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Is board recertification worth it?
I passed the neurology boards, for the first time, in 1998. Then again in 2009, and most recently in 2019.
So I’m up again in 2029. Regrettably, I missed grandfathering in for life by a few years.
Some people don’t study for them, but I’m a little too compulsive not to. I’d guess I put 40-50 hours into doing so in the 3 months beforehand. I didn’t want to fail and have to pay a hefty fee to retake them (the test fee for once is enough as it is).
I’ll be 63 when my next certification is due.
So I wonder (if I’m still in practice) will it even be worthwhile to do it all again? I like what I do, but certainly don’t plan on practicing forever.
Board certification looks good on paper, but certainly isn’t a requirement to practice. One of the best cardiologists I know has never bothered to get his board certification and I don’t think any less of him for it. He also isn’t wanting for patients, and those he has think he’s awesome.
That said, there are things, like being involved in research and legal work, where board certification is strongly recommended, if not mandatory. Since I do both, I certainly wouldn’t want to do anything that might affect my participating in them – if I’m still doing this in 8 years.
By the same token, my office lease runs out when I’m 62. At that point I’ll have been in the same place for 17 years. I don’t consider that a bad thing. I like my current office, and will be perfectly happy to wrap up my career here.
It brings up the same question, though, with logistics that are an even bigger PIA. The last thing I want to do is move my office as my career is winding down. But a lease extension for a few years can be negotiated, a board certification can’t.
I can’t help but wonder: If I’ve already passed it three times, hopefully that means I know what I’m doing. One side will argue that it’s purely greed, as the people who run the boards need money and a way to justify their existence. On the other side are those who argue that maintenance of certification, while not perfect, is the only way we have of making sure practicing physicians are staying up to snuff.
The truth, as always, is somewhere in between.
But it still raises a question that I, fortunately, have another 8 years to think about. Because I’m not in a position to debate if it’s right or wrong, I just have to play by the rules.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
I passed the neurology boards, for the first time, in 1998. Then again in 2009, and most recently in 2019.
So I’m up again in 2029. Regrettably, I missed grandfathering in for life by a few years.
Some people don’t study for them, but I’m a little too compulsive not to. I’d guess I put 40-50 hours into doing so in the 3 months beforehand. I didn’t want to fail and have to pay a hefty fee to retake them (the test fee for once is enough as it is).
I’ll be 63 when my next certification is due.
So I wonder (if I’m still in practice) will it even be worthwhile to do it all again? I like what I do, but certainly don’t plan on practicing forever.
Board certification looks good on paper, but certainly isn’t a requirement to practice. One of the best cardiologists I know has never bothered to get his board certification and I don’t think any less of him for it. He also isn’t wanting for patients, and those he has think he’s awesome.
That said, there are things, like being involved in research and legal work, where board certification is strongly recommended, if not mandatory. Since I do both, I certainly wouldn’t want to do anything that might affect my participating in them – if I’m still doing this in 8 years.
By the same token, my office lease runs out when I’m 62. At that point I’ll have been in the same place for 17 years. I don’t consider that a bad thing. I like my current office, and will be perfectly happy to wrap up my career here.
It brings up the same question, though, with logistics that are an even bigger PIA. The last thing I want to do is move my office as my career is winding down. But a lease extension for a few years can be negotiated, a board certification can’t.
I can’t help but wonder: If I’ve already passed it three times, hopefully that means I know what I’m doing. One side will argue that it’s purely greed, as the people who run the boards need money and a way to justify their existence. On the other side are those who argue that maintenance of certification, while not perfect, is the only way we have of making sure practicing physicians are staying up to snuff.
The truth, as always, is somewhere in between.
But it still raises a question that I, fortunately, have another 8 years to think about. Because I’m not in a position to debate if it’s right or wrong, I just have to play by the rules.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
I passed the neurology boards, for the first time, in 1998. Then again in 2009, and most recently in 2019.
So I’m up again in 2029. Regrettably, I missed grandfathering in for life by a few years.
Some people don’t study for them, but I’m a little too compulsive not to. I’d guess I put 40-50 hours into doing so in the 3 months beforehand. I didn’t want to fail and have to pay a hefty fee to retake them (the test fee for once is enough as it is).
I’ll be 63 when my next certification is due.
So I wonder (if I’m still in practice) will it even be worthwhile to do it all again? I like what I do, but certainly don’t plan on practicing forever.
Board certification looks good on paper, but certainly isn’t a requirement to practice. One of the best cardiologists I know has never bothered to get his board certification and I don’t think any less of him for it. He also isn’t wanting for patients, and those he has think he’s awesome.
That said, there are things, like being involved in research and legal work, where board certification is strongly recommended, if not mandatory. Since I do both, I certainly wouldn’t want to do anything that might affect my participating in them – if I’m still doing this in 8 years.
By the same token, my office lease runs out when I’m 62. At that point I’ll have been in the same place for 17 years. I don’t consider that a bad thing. I like my current office, and will be perfectly happy to wrap up my career here.
It brings up the same question, though, with logistics that are an even bigger PIA. The last thing I want to do is move my office as my career is winding down. But a lease extension for a few years can be negotiated, a board certification can’t.
I can’t help but wonder: If I’ve already passed it three times, hopefully that means I know what I’m doing. One side will argue that it’s purely greed, as the people who run the boards need money and a way to justify their existence. On the other side are those who argue that maintenance of certification, while not perfect, is the only way we have of making sure practicing physicians are staying up to snuff.
The truth, as always, is somewhere in between.
But it still raises a question that I, fortunately, have another 8 years to think about. Because I’m not in a position to debate if it’s right or wrong, I just have to play by the rules.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
The fax that got under my skin
I got an interesting fax recently.
It started with how tough things have been for small practices during the pandemic (like I need reminding) and suggests it has solutions for my practice to stay afloat.
I’m used to all kinds of these approaches, and was going to toss the fax, but decided to read on out of curiosity. I assumed it was an advertisement for a loan company, or to sell vitamins out of my office.
This one, surprisingly, suggested I buy gadgets that would allow me to “balance uneven skin tones,” “shrink pores,” “eliminate freckles and stretch marks,” and do “laser vaginal resurfacing”
Are you kidding me?
First of all, I try very hard to stay in my lane. I’m a neurologist, hopefully a competent one, and have no desire to go beyond that. Imagine how bad this would look in a legal case: I’d be pretty hard pressed to convince a malpractice lawyer and jury that “eliminating stretch marks” and “laser vaginal resurfacing” are within the scope and training of your average neurologist.
Second, I don’t see this sort of thing as reflecting well on me. Patients come here to be treated for Parkinson’s disease, strokes, and epilepsy. If I tried to change the appointment’s topic to “those issues are minor, let’s talk about your stretch marks” I’m pretty sure they’d be looking for a new neurologist. And, when it got back to the physician who referred them, so would she.
Third, my patients are tightening their belts like everyone else in this pandemic-associated economic downturn. Suddenly trying to sell them on a pricey cash-pay procedure, let alone one that’s pretty far out of my field, isn’t going to fly. Like my own family they’re watching every penny right now and shrinking pores is at the bottom of their financial priorities. If they really want that done I’d to happy to refer them to a dermatologist.
Not surprisingly, I tossed the fax. Caring for my patients is challenging enough when I stick to what I do best.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
I got an interesting fax recently.
It started with how tough things have been for small practices during the pandemic (like I need reminding) and suggests it has solutions for my practice to stay afloat.
I’m used to all kinds of these approaches, and was going to toss the fax, but decided to read on out of curiosity. I assumed it was an advertisement for a loan company, or to sell vitamins out of my office.
This one, surprisingly, suggested I buy gadgets that would allow me to “balance uneven skin tones,” “shrink pores,” “eliminate freckles and stretch marks,” and do “laser vaginal resurfacing”
Are you kidding me?
First of all, I try very hard to stay in my lane. I’m a neurologist, hopefully a competent one, and have no desire to go beyond that. Imagine how bad this would look in a legal case: I’d be pretty hard pressed to convince a malpractice lawyer and jury that “eliminating stretch marks” and “laser vaginal resurfacing” are within the scope and training of your average neurologist.
Second, I don’t see this sort of thing as reflecting well on me. Patients come here to be treated for Parkinson’s disease, strokes, and epilepsy. If I tried to change the appointment’s topic to “those issues are minor, let’s talk about your stretch marks” I’m pretty sure they’d be looking for a new neurologist. And, when it got back to the physician who referred them, so would she.
Third, my patients are tightening their belts like everyone else in this pandemic-associated economic downturn. Suddenly trying to sell them on a pricey cash-pay procedure, let alone one that’s pretty far out of my field, isn’t going to fly. Like my own family they’re watching every penny right now and shrinking pores is at the bottom of their financial priorities. If they really want that done I’d to happy to refer them to a dermatologist.
Not surprisingly, I tossed the fax. Caring for my patients is challenging enough when I stick to what I do best.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
I got an interesting fax recently.
It started with how tough things have been for small practices during the pandemic (like I need reminding) and suggests it has solutions for my practice to stay afloat.
I’m used to all kinds of these approaches, and was going to toss the fax, but decided to read on out of curiosity. I assumed it was an advertisement for a loan company, or to sell vitamins out of my office.
This one, surprisingly, suggested I buy gadgets that would allow me to “balance uneven skin tones,” “shrink pores,” “eliminate freckles and stretch marks,” and do “laser vaginal resurfacing”
Are you kidding me?
First of all, I try very hard to stay in my lane. I’m a neurologist, hopefully a competent one, and have no desire to go beyond that. Imagine how bad this would look in a legal case: I’d be pretty hard pressed to convince a malpractice lawyer and jury that “eliminating stretch marks” and “laser vaginal resurfacing” are within the scope and training of your average neurologist.
Second, I don’t see this sort of thing as reflecting well on me. Patients come here to be treated for Parkinson’s disease, strokes, and epilepsy. If I tried to change the appointment’s topic to “those issues are minor, let’s talk about your stretch marks” I’m pretty sure they’d be looking for a new neurologist. And, when it got back to the physician who referred them, so would she.
Third, my patients are tightening their belts like everyone else in this pandemic-associated economic downturn. Suddenly trying to sell them on a pricey cash-pay procedure, let alone one that’s pretty far out of my field, isn’t going to fly. Like my own family they’re watching every penny right now and shrinking pores is at the bottom of their financial priorities. If they really want that done I’d to happy to refer them to a dermatologist.
Not surprisingly, I tossed the fax. Caring for my patients is challenging enough when I stick to what I do best.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Reminders of our mortality can come when physicians least expect it
This time of year I spend weekend afternoons in my hot tub, catching up on medical journals, CME, paperbacks, and generally anything worth reading that shows up in my mailbox.
One of those items was the alumni news from my medical school. As usual, I leafed through it, reading articles of interest and glancing at updates on any classmates that were featured.
Then I stopped.
There, in the back of the magazine, was an obituary on the first of my classmates to pass (that I’m aware of).
I reread it a few times in disbelief. Maybe it was on her taking a new job or being promoted, and was in the wrong section. Nope.
I put the magazine down. She was 1 year younger than me and had gone into internal medicine. Not someone I’d kept in touch with, but certainly was friendly with during those 4 years and frequently chatted with in hallways or between classes. I remember meeting her during the first week of school, when I got her name mixed up with another girl’s in our class. I saw her at parties, meetings, and I think even played doubles tennis with her once, though who we played against I have no idea anymore.
She was at our 20th reunion, and we’d talked for a few minutes. We caught up on our lives since graduation and, as people do at these things, moved on to chat with others.
No details were given as to her death, and it really doesn’t matter.
. For most of each day it’s a fact in the back of our minds, behind the daily activities of working, shopping, doing laundry, commuting, and cooking dinner. After all, it’s really what we do while here that matters, no matter how mundane it may seem.
But sometimes something will push that realization to the front, and make us remember how important every minute really is.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
This time of year I spend weekend afternoons in my hot tub, catching up on medical journals, CME, paperbacks, and generally anything worth reading that shows up in my mailbox.
One of those items was the alumni news from my medical school. As usual, I leafed through it, reading articles of interest and glancing at updates on any classmates that were featured.
Then I stopped.
There, in the back of the magazine, was an obituary on the first of my classmates to pass (that I’m aware of).
I reread it a few times in disbelief. Maybe it was on her taking a new job or being promoted, and was in the wrong section. Nope.
I put the magazine down. She was 1 year younger than me and had gone into internal medicine. Not someone I’d kept in touch with, but certainly was friendly with during those 4 years and frequently chatted with in hallways or between classes. I remember meeting her during the first week of school, when I got her name mixed up with another girl’s in our class. I saw her at parties, meetings, and I think even played doubles tennis with her once, though who we played against I have no idea anymore.
She was at our 20th reunion, and we’d talked for a few minutes. We caught up on our lives since graduation and, as people do at these things, moved on to chat with others.
No details were given as to her death, and it really doesn’t matter.
. For most of each day it’s a fact in the back of our minds, behind the daily activities of working, shopping, doing laundry, commuting, and cooking dinner. After all, it’s really what we do while here that matters, no matter how mundane it may seem.
But sometimes something will push that realization to the front, and make us remember how important every minute really is.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
This time of year I spend weekend afternoons in my hot tub, catching up on medical journals, CME, paperbacks, and generally anything worth reading that shows up in my mailbox.
One of those items was the alumni news from my medical school. As usual, I leafed through it, reading articles of interest and glancing at updates on any classmates that were featured.
Then I stopped.
There, in the back of the magazine, was an obituary on the first of my classmates to pass (that I’m aware of).
I reread it a few times in disbelief. Maybe it was on her taking a new job or being promoted, and was in the wrong section. Nope.
I put the magazine down. She was 1 year younger than me and had gone into internal medicine. Not someone I’d kept in touch with, but certainly was friendly with during those 4 years and frequently chatted with in hallways or between classes. I remember meeting her during the first week of school, when I got her name mixed up with another girl’s in our class. I saw her at parties, meetings, and I think even played doubles tennis with her once, though who we played against I have no idea anymore.
She was at our 20th reunion, and we’d talked for a few minutes. We caught up on our lives since graduation and, as people do at these things, moved on to chat with others.
No details were given as to her death, and it really doesn’t matter.
. For most of each day it’s a fact in the back of our minds, behind the daily activities of working, shopping, doing laundry, commuting, and cooking dinner. After all, it’s really what we do while here that matters, no matter how mundane it may seem.
But sometimes something will push that realization to the front, and make us remember how important every minute really is.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Mental health illness needs appropriate care
The January 2021 issue of JAMA Neurology had an article that stated that the current U.S. spending on emergency room (ER) and inpatient costs for patients with functional neurological disorders is $1.2 billion and climbing. That doesn’t include, obviously, the costs of treating functional disorders in other specialties.
Now, $1.2 billion is a pittance when you compare it with, say, the total costs of Alzheimer’s disease ($277 billion/year), but it’s still a lot of money. Especially when you consider that, unlike Alzheimer’s disease, a lot of the spending associated with functional disorders is avoidable.
The problem is that getting good psychiatric care isn’t easy, and that’s what many of these people really need. A lot of psychiatrists, including the excellent one my son sees, don’t take insurance. We’re fortunate to be able to pay for the visits, but most people aren’t. So the psychiatrists and mental health professionals who do accept insurance get rapidly overwhelmed and burned out, end up seeing their own psychiatrists, and then drop insurance plans, too.
Not only that, but insurers are willing to pay for these patients to go to ER and get labs and pricey imaging. At the same time mental health benefits are often limited or nonexistent, even when considerably less costly than the ER visits and imaging.
I don’t fault the ER doctors or hospitalists for ordering expensive tests on these patients. They often don’t know the patient and have to take them at face value. I’ve been there, too, when I’ve taken inpatient call. Someone comes in with a group of symptoms. You may be 99.999% sure they’re functional, but at the same time it’s not worth risking your medical license or malpractice premiums to just say that. Defensive medicine will always win that argument.
The trouble is that ER, and the inpatient setting, are often the worst possible places to be managing functional disorders. This is really a case where a stitch in time saves nine. The cost of their getting appropriate care to prevent underlying issues from driving them to ER is going to be less than the inevitable visit when they don’t.
That’s not to say these people might have a legitimate medical issue that should be evaluated – sometimes urgently. But once that’s off the table repeated ER visits and testing quickly become an exercise in futility and diminishing returns.
Many health care system payers need to recognize that, so these people can be treated appropriately from the beginning, and not end up shuttling between ERs, looking for an answer and help they aren’t equipped to provide at a cost that’s not sustainable.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
The January 2021 issue of JAMA Neurology had an article that stated that the current U.S. spending on emergency room (ER) and inpatient costs for patients with functional neurological disorders is $1.2 billion and climbing. That doesn’t include, obviously, the costs of treating functional disorders in other specialties.
Now, $1.2 billion is a pittance when you compare it with, say, the total costs of Alzheimer’s disease ($277 billion/year), but it’s still a lot of money. Especially when you consider that, unlike Alzheimer’s disease, a lot of the spending associated with functional disorders is avoidable.
The problem is that getting good psychiatric care isn’t easy, and that’s what many of these people really need. A lot of psychiatrists, including the excellent one my son sees, don’t take insurance. We’re fortunate to be able to pay for the visits, but most people aren’t. So the psychiatrists and mental health professionals who do accept insurance get rapidly overwhelmed and burned out, end up seeing their own psychiatrists, and then drop insurance plans, too.
Not only that, but insurers are willing to pay for these patients to go to ER and get labs and pricey imaging. At the same time mental health benefits are often limited or nonexistent, even when considerably less costly than the ER visits and imaging.
I don’t fault the ER doctors or hospitalists for ordering expensive tests on these patients. They often don’t know the patient and have to take them at face value. I’ve been there, too, when I’ve taken inpatient call. Someone comes in with a group of symptoms. You may be 99.999% sure they’re functional, but at the same time it’s not worth risking your medical license or malpractice premiums to just say that. Defensive medicine will always win that argument.
The trouble is that ER, and the inpatient setting, are often the worst possible places to be managing functional disorders. This is really a case where a stitch in time saves nine. The cost of their getting appropriate care to prevent underlying issues from driving them to ER is going to be less than the inevitable visit when they don’t.
That’s not to say these people might have a legitimate medical issue that should be evaluated – sometimes urgently. But once that’s off the table repeated ER visits and testing quickly become an exercise in futility and diminishing returns.
Many health care system payers need to recognize that, so these people can be treated appropriately from the beginning, and not end up shuttling between ERs, looking for an answer and help they aren’t equipped to provide at a cost that’s not sustainable.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
The January 2021 issue of JAMA Neurology had an article that stated that the current U.S. spending on emergency room (ER) and inpatient costs for patients with functional neurological disorders is $1.2 billion and climbing. That doesn’t include, obviously, the costs of treating functional disorders in other specialties.
Now, $1.2 billion is a pittance when you compare it with, say, the total costs of Alzheimer’s disease ($277 billion/year), but it’s still a lot of money. Especially when you consider that, unlike Alzheimer’s disease, a lot of the spending associated with functional disorders is avoidable.
The problem is that getting good psychiatric care isn’t easy, and that’s what many of these people really need. A lot of psychiatrists, including the excellent one my son sees, don’t take insurance. We’re fortunate to be able to pay for the visits, but most people aren’t. So the psychiatrists and mental health professionals who do accept insurance get rapidly overwhelmed and burned out, end up seeing their own psychiatrists, and then drop insurance plans, too.
Not only that, but insurers are willing to pay for these patients to go to ER and get labs and pricey imaging. At the same time mental health benefits are often limited or nonexistent, even when considerably less costly than the ER visits and imaging.
I don’t fault the ER doctors or hospitalists for ordering expensive tests on these patients. They often don’t know the patient and have to take them at face value. I’ve been there, too, when I’ve taken inpatient call. Someone comes in with a group of symptoms. You may be 99.999% sure they’re functional, but at the same time it’s not worth risking your medical license or malpractice premiums to just say that. Defensive medicine will always win that argument.
The trouble is that ER, and the inpatient setting, are often the worst possible places to be managing functional disorders. This is really a case where a stitch in time saves nine. The cost of their getting appropriate care to prevent underlying issues from driving them to ER is going to be less than the inevitable visit when they don’t.
That’s not to say these people might have a legitimate medical issue that should be evaluated – sometimes urgently. But once that’s off the table repeated ER visits and testing quickly become an exercise in futility and diminishing returns.
Many health care system payers need to recognize that, so these people can be treated appropriately from the beginning, and not end up shuttling between ERs, looking for an answer and help they aren’t equipped to provide at a cost that’s not sustainable.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
How much is enough?
How much do I make compared with other doctors?
I see questions like that on surveys I get, asking me to fill something out on the Internet, then I’ll get back a list of how well other docs in my field/city/state/blood type are doing.
Nah. I’ll pass.
Realistically, why? So I can feel I’m superior or inferior to others? Isn’t keeping up with the Joneses the purpose of the doctors’ parking lot at the hospital? (Actually, the number of pricey cars there has dropped off over time).
I really don’t want to know how much others make. It’s probably more than what I make, but that’s the trade-off I accepted when I went with a small solo practice instead of a large group 20 years ago.
We become so obsessed with the question of “how much money should I be making?” and comparing it with the salaries of others that we lose track of the real question: “How much money do I need?”
That should be the real number to look at. How much money do I really need to pay for a comfortable home, support my family, pay for my kids’ education, fund my retirement?
Enough should be as good as a feast.
Yet, even when content we get caught in the trap of comparing ourselves with others. This is human nature. We’re programmed to be competitive to survive. Whether that means anything when we don’t have to be hunters and gatherers is irrelevant. It is who we are.
But we’re also intelligent enough to realize that. I for one, don’t want to know, or care, how much money the neurologist down the street is earning.
To quote Sheryl Crow, “it’s not having what you want, it’s wanting what you’ve got.”
So I’ll skip the comparisons and focus on the only people that really matter to me.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
How much do I make compared with other doctors?
I see questions like that on surveys I get, asking me to fill something out on the Internet, then I’ll get back a list of how well other docs in my field/city/state/blood type are doing.
Nah. I’ll pass.
Realistically, why? So I can feel I’m superior or inferior to others? Isn’t keeping up with the Joneses the purpose of the doctors’ parking lot at the hospital? (Actually, the number of pricey cars there has dropped off over time).
I really don’t want to know how much others make. It’s probably more than what I make, but that’s the trade-off I accepted when I went with a small solo practice instead of a large group 20 years ago.
We become so obsessed with the question of “how much money should I be making?” and comparing it with the salaries of others that we lose track of the real question: “How much money do I need?”
That should be the real number to look at. How much money do I really need to pay for a comfortable home, support my family, pay for my kids’ education, fund my retirement?
Enough should be as good as a feast.
Yet, even when content we get caught in the trap of comparing ourselves with others. This is human nature. We’re programmed to be competitive to survive. Whether that means anything when we don’t have to be hunters and gatherers is irrelevant. It is who we are.
But we’re also intelligent enough to realize that. I for one, don’t want to know, or care, how much money the neurologist down the street is earning.
To quote Sheryl Crow, “it’s not having what you want, it’s wanting what you’ve got.”
So I’ll skip the comparisons and focus on the only people that really matter to me.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
How much do I make compared with other doctors?
I see questions like that on surveys I get, asking me to fill something out on the Internet, then I’ll get back a list of how well other docs in my field/city/state/blood type are doing.
Nah. I’ll pass.
Realistically, why? So I can feel I’m superior or inferior to others? Isn’t keeping up with the Joneses the purpose of the doctors’ parking lot at the hospital? (Actually, the number of pricey cars there has dropped off over time).
I really don’t want to know how much others make. It’s probably more than what I make, but that’s the trade-off I accepted when I went with a small solo practice instead of a large group 20 years ago.
We become so obsessed with the question of “how much money should I be making?” and comparing it with the salaries of others that we lose track of the real question: “How much money do I need?”
That should be the real number to look at. How much money do I really need to pay for a comfortable home, support my family, pay for my kids’ education, fund my retirement?
Enough should be as good as a feast.
Yet, even when content we get caught in the trap of comparing ourselves with others. This is human nature. We’re programmed to be competitive to survive. Whether that means anything when we don’t have to be hunters and gatherers is irrelevant. It is who we are.
But we’re also intelligent enough to realize that. I for one, don’t want to know, or care, how much money the neurologist down the street is earning.
To quote Sheryl Crow, “it’s not having what you want, it’s wanting what you’ve got.”
So I’ll skip the comparisons and focus on the only people that really matter to me.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Dealing with an anti-masker
Recently I got a referral from another office and skimmed through it, as I always do, to make sure it’s something I handle in my little practice.
Overall it seemed pretty straightforward, but on page 3 were multiple notes that the patient adamantly refused to wear a mask to visits, or took one off as soon as she got back to an exam room and refused to put it back on. She also insisted on in-person, not video, visits. Staff members had documented that she told them masks were “stupid and worthless” and called people who insisted on them “idiots.”
I looked at the notes for a minute, then flagged them to indicate she is someone who shouldn’t be scheduled if she calls, forwarded them to my secretary, and moved on to my next patient.
Some might say this is discrimination, but I disagree. Although studies vary on the degree of efficacy, the overall data show that masks help prevent the wearer from spreading COVID-19 to others, to a lesser degree protect you from catching it from others, and are safe to use.
So The data on COVID-19 spreading through asymptomatic people is pretty solid, so those who say “I feel fine, so I don’t need to wear a mask” are only endangering others.
Certainly, people have the right to refuse masks, but currently the laws in my area require them in public, and I definitely require them in my little practice. I’m not calling the police if someone doesn’t wear one, but I’m not going to see them in my practice, either.
Like all other doctors, health care workers, and patients, I’m as susceptible to infectious disease as everyone else. If I’m sick, I can’t take care of others.
I’m not refusing to see the sick—far from it—but if I’m going to try to help you get better, then you should be willing to wear a mask to help protect me, too.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Recently I got a referral from another office and skimmed through it, as I always do, to make sure it’s something I handle in my little practice.
Overall it seemed pretty straightforward, but on page 3 were multiple notes that the patient adamantly refused to wear a mask to visits, or took one off as soon as she got back to an exam room and refused to put it back on. She also insisted on in-person, not video, visits. Staff members had documented that she told them masks were “stupid and worthless” and called people who insisted on them “idiots.”
I looked at the notes for a minute, then flagged them to indicate she is someone who shouldn’t be scheduled if she calls, forwarded them to my secretary, and moved on to my next patient.
Some might say this is discrimination, but I disagree. Although studies vary on the degree of efficacy, the overall data show that masks help prevent the wearer from spreading COVID-19 to others, to a lesser degree protect you from catching it from others, and are safe to use.
So The data on COVID-19 spreading through asymptomatic people is pretty solid, so those who say “I feel fine, so I don’t need to wear a mask” are only endangering others.
Certainly, people have the right to refuse masks, but currently the laws in my area require them in public, and I definitely require them in my little practice. I’m not calling the police if someone doesn’t wear one, but I’m not going to see them in my practice, either.
Like all other doctors, health care workers, and patients, I’m as susceptible to infectious disease as everyone else. If I’m sick, I can’t take care of others.
I’m not refusing to see the sick—far from it—but if I’m going to try to help you get better, then you should be willing to wear a mask to help protect me, too.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Recently I got a referral from another office and skimmed through it, as I always do, to make sure it’s something I handle in my little practice.
Overall it seemed pretty straightforward, but on page 3 were multiple notes that the patient adamantly refused to wear a mask to visits, or took one off as soon as she got back to an exam room and refused to put it back on. She also insisted on in-person, not video, visits. Staff members had documented that she told them masks were “stupid and worthless” and called people who insisted on them “idiots.”
I looked at the notes for a minute, then flagged them to indicate she is someone who shouldn’t be scheduled if she calls, forwarded them to my secretary, and moved on to my next patient.
Some might say this is discrimination, but I disagree. Although studies vary on the degree of efficacy, the overall data show that masks help prevent the wearer from spreading COVID-19 to others, to a lesser degree protect you from catching it from others, and are safe to use.
So The data on COVID-19 spreading through asymptomatic people is pretty solid, so those who say “I feel fine, so I don’t need to wear a mask” are only endangering others.
Certainly, people have the right to refuse masks, but currently the laws in my area require them in public, and I definitely require them in my little practice. I’m not calling the police if someone doesn’t wear one, but I’m not going to see them in my practice, either.
Like all other doctors, health care workers, and patients, I’m as susceptible to infectious disease as everyone else. If I’m sick, I can’t take care of others.
I’m not refusing to see the sick—far from it—but if I’m going to try to help you get better, then you should be willing to wear a mask to help protect me, too.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Lost time amid COVID-19
At the end of my second year of medical school was what I call “The Lost Month.”
Between the end of classes and USMLE-1 we had 30 days to study for an 800-question, 2-day test that covered the entirety of the first 2 years. If you failed it once, you had to retake it. If you failed it twice you were out of medical school.
It was understandably stressful and I felt like every minute counted. I stopped shaving for the month to free up a few extra minutes each day. I unplugged my TV and put it in a closet.
Every day was the same. I was up at 7:00, had corn flakes, walked to Creighton, and found an empty library room. I took 30 minutes off at lunch and dinner to get something from the student union to eat outside (the only chance I had to enjoy sunlight), then study again until 1:00-2:00 in the morning.
The whole month become a blur. Days of the week were meaningless, only the number left until boards. Saturday or Tuesday, my life was the same. I don’t remember many specifics.
That was “The Lost Month.”
Now, somewhere in the middle of my attendinghood, I’ve come to 2020 (and likely beyond) which is, “The Lost Year.”
The days of the week have a bit more meaning now, as I still go to my office for a few hours and am home on weekends. But the weeks and months blend together. I’m home most of the time, I busy myself with working, and I have meal breaks with my family. There are no vacations or parties or movies. Even the holidays aren’t that different from the weekends—there isn’t much else to do to pass the time. And the stress is still there (in the early 90s it was academic, today it’s financial).
At least now I still try to shave regularly.
Thirty years ago I passed the boards and moved on to where I am today. My fear of failing out of medical school never materialized.
Today I try to remain optimistic. Vaccines are coming. Our learning curve on treating COVID-19 is getting better. Hopefully, The Lost Year will gradually become a memory as life goes on and normalizes.
Like the The Lost Month, I have to view 2020 as bump in the road. If this is the worst crisis I and my loved ones have to go through, I can deal with that. I know we’re fortunate compared with others. I try to remember that every time I pass a Salvation Army kettle or canned food drive, and donate.
In 1990 I had a specific date when The Lost Month would be over, and it was coming up way too fast. In 2020 no such date exists, now or in the immediate future.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
At the end of my second year of medical school was what I call “The Lost Month.”
Between the end of classes and USMLE-1 we had 30 days to study for an 800-question, 2-day test that covered the entirety of the first 2 years. If you failed it once, you had to retake it. If you failed it twice you were out of medical school.
It was understandably stressful and I felt like every minute counted. I stopped shaving for the month to free up a few extra minutes each day. I unplugged my TV and put it in a closet.
Every day was the same. I was up at 7:00, had corn flakes, walked to Creighton, and found an empty library room. I took 30 minutes off at lunch and dinner to get something from the student union to eat outside (the only chance I had to enjoy sunlight), then study again until 1:00-2:00 in the morning.
The whole month become a blur. Days of the week were meaningless, only the number left until boards. Saturday or Tuesday, my life was the same. I don’t remember many specifics.
That was “The Lost Month.”
Now, somewhere in the middle of my attendinghood, I’ve come to 2020 (and likely beyond) which is, “The Lost Year.”
The days of the week have a bit more meaning now, as I still go to my office for a few hours and am home on weekends. But the weeks and months blend together. I’m home most of the time, I busy myself with working, and I have meal breaks with my family. There are no vacations or parties or movies. Even the holidays aren’t that different from the weekends—there isn’t much else to do to pass the time. And the stress is still there (in the early 90s it was academic, today it’s financial).
At least now I still try to shave regularly.
Thirty years ago I passed the boards and moved on to where I am today. My fear of failing out of medical school never materialized.
Today I try to remain optimistic. Vaccines are coming. Our learning curve on treating COVID-19 is getting better. Hopefully, The Lost Year will gradually become a memory as life goes on and normalizes.
Like the The Lost Month, I have to view 2020 as bump in the road. If this is the worst crisis I and my loved ones have to go through, I can deal with that. I know we’re fortunate compared with others. I try to remember that every time I pass a Salvation Army kettle or canned food drive, and donate.
In 1990 I had a specific date when The Lost Month would be over, and it was coming up way too fast. In 2020 no such date exists, now or in the immediate future.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
At the end of my second year of medical school was what I call “The Lost Month.”
Between the end of classes and USMLE-1 we had 30 days to study for an 800-question, 2-day test that covered the entirety of the first 2 years. If you failed it once, you had to retake it. If you failed it twice you were out of medical school.
It was understandably stressful and I felt like every minute counted. I stopped shaving for the month to free up a few extra minutes each day. I unplugged my TV and put it in a closet.
Every day was the same. I was up at 7:00, had corn flakes, walked to Creighton, and found an empty library room. I took 30 minutes off at lunch and dinner to get something from the student union to eat outside (the only chance I had to enjoy sunlight), then study again until 1:00-2:00 in the morning.
The whole month become a blur. Days of the week were meaningless, only the number left until boards. Saturday or Tuesday, my life was the same. I don’t remember many specifics.
That was “The Lost Month.”
Now, somewhere in the middle of my attendinghood, I’ve come to 2020 (and likely beyond) which is, “The Lost Year.”
The days of the week have a bit more meaning now, as I still go to my office for a few hours and am home on weekends. But the weeks and months blend together. I’m home most of the time, I busy myself with working, and I have meal breaks with my family. There are no vacations or parties or movies. Even the holidays aren’t that different from the weekends—there isn’t much else to do to pass the time. And the stress is still there (in the early 90s it was academic, today it’s financial).
At least now I still try to shave regularly.
Thirty years ago I passed the boards and moved on to where I am today. My fear of failing out of medical school never materialized.
Today I try to remain optimistic. Vaccines are coming. Our learning curve on treating COVID-19 is getting better. Hopefully, The Lost Year will gradually become a memory as life goes on and normalizes.
Like the The Lost Month, I have to view 2020 as bump in the road. If this is the worst crisis I and my loved ones have to go through, I can deal with that. I know we’re fortunate compared with others. I try to remember that every time I pass a Salvation Army kettle or canned food drive, and donate.
In 1990 I had a specific date when The Lost Month would be over, and it was coming up way too fast. In 2020 no such date exists, now or in the immediate future.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Twenty years later, two gambles that paid off
Amidst the pandemic and election, two anniversaries passed almost unnoticed in early November.
On Nov. 2, 2020, we reached 20 years since the first crew moved into the International Space Station (ISS). This may seem like a minor anniversary to some, but it means a lot if you think about it. From humble beginnings, and scattered launches in different craft between 1961 and 1999, it’s now been over a generation since people weren’t living in space. We certainly aren’t on the starship Enterprise yet, or even going to Mars, but today’s college kids have never known a world where people didn’t live and work in the void upstairs. That’s something to think about.
Equally important, but of significance to far fewer, is that on Nov. 6, 2020, my little solo practice also reached its 20-year anniversary.
To the central person involved, me, this is a pretty big deal. In early 2000, when I made the decision to leave a large practice, I was confident but still nervous. I’d developed a decent referral base while working for the other group, but still didn’t know what would happen. I was 33. My oldest kid was 1 and my wife and I had twins on the way.
Now, it’s 20 years later. All three kids grew up and went off to college, but in the strange circle of the pandemic, they are now back home. Granted they’re not waking us up at night when they’re hungry (they have microwave popcorn – lots of it – for that).
Some things have changed. I’m now across the street from the office I started in. My hospital work, which in 2000 was about 50% of my practice, is now down to 0% for the time being. My medical assistant is still the same one, and my secretary has been with me since 2004. I’m lucky to have such a long-lasting team. Even in 2020, when they’re working from home, we’re still doing a great job of keeping it running.
After 20 years I’m heavier and my hair is thinning and gray, but I still like this job. I still try to do the very best I can for my patients. I sometimes read the personal statement I wrote in the summer of 1987 for my medical school application, trying to keep in touch with who I was then when I started out.
Looking back after 20 years, going solo, like building the ISS, was a big gamble. But both have worked out. My job has allowed me to support and raise a family, to care for patients (contrary to the impression one gets from medical blogs, the vast majority of them are good, decent, people) and get to know them for who they are, and to work with my two terrific long-time office staff who, like my wife, kids, and dogs, still put up with me and my quirks. And all the while I am still doing something that I found I loved in my first week of residency.
Looking forward another 20 years, who knows where I (or the ISS) will be? I probably won’t want to be working full time then, but if I still enjoy medicine I doubt I’ll want to be completely retired, either. Looking back, I’ve been fortunate that I found this one.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Amidst the pandemic and election, two anniversaries passed almost unnoticed in early November.
On Nov. 2, 2020, we reached 20 years since the first crew moved into the International Space Station (ISS). This may seem like a minor anniversary to some, but it means a lot if you think about it. From humble beginnings, and scattered launches in different craft between 1961 and 1999, it’s now been over a generation since people weren’t living in space. We certainly aren’t on the starship Enterprise yet, or even going to Mars, but today’s college kids have never known a world where people didn’t live and work in the void upstairs. That’s something to think about.
Equally important, but of significance to far fewer, is that on Nov. 6, 2020, my little solo practice also reached its 20-year anniversary.
To the central person involved, me, this is a pretty big deal. In early 2000, when I made the decision to leave a large practice, I was confident but still nervous. I’d developed a decent referral base while working for the other group, but still didn’t know what would happen. I was 33. My oldest kid was 1 and my wife and I had twins on the way.
Now, it’s 20 years later. All three kids grew up and went off to college, but in the strange circle of the pandemic, they are now back home. Granted they’re not waking us up at night when they’re hungry (they have microwave popcorn – lots of it – for that).
Some things have changed. I’m now across the street from the office I started in. My hospital work, which in 2000 was about 50% of my practice, is now down to 0% for the time being. My medical assistant is still the same one, and my secretary has been with me since 2004. I’m lucky to have such a long-lasting team. Even in 2020, when they’re working from home, we’re still doing a great job of keeping it running.
After 20 years I’m heavier and my hair is thinning and gray, but I still like this job. I still try to do the very best I can for my patients. I sometimes read the personal statement I wrote in the summer of 1987 for my medical school application, trying to keep in touch with who I was then when I started out.
Looking back after 20 years, going solo, like building the ISS, was a big gamble. But both have worked out. My job has allowed me to support and raise a family, to care for patients (contrary to the impression one gets from medical blogs, the vast majority of them are good, decent, people) and get to know them for who they are, and to work with my two terrific long-time office staff who, like my wife, kids, and dogs, still put up with me and my quirks. And all the while I am still doing something that I found I loved in my first week of residency.
Looking forward another 20 years, who knows where I (or the ISS) will be? I probably won’t want to be working full time then, but if I still enjoy medicine I doubt I’ll want to be completely retired, either. Looking back, I’ve been fortunate that I found this one.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Amidst the pandemic and election, two anniversaries passed almost unnoticed in early November.
On Nov. 2, 2020, we reached 20 years since the first crew moved into the International Space Station (ISS). This may seem like a minor anniversary to some, but it means a lot if you think about it. From humble beginnings, and scattered launches in different craft between 1961 and 1999, it’s now been over a generation since people weren’t living in space. We certainly aren’t on the starship Enterprise yet, or even going to Mars, but today’s college kids have never known a world where people didn’t live and work in the void upstairs. That’s something to think about.
Equally important, but of significance to far fewer, is that on Nov. 6, 2020, my little solo practice also reached its 20-year anniversary.
To the central person involved, me, this is a pretty big deal. In early 2000, when I made the decision to leave a large practice, I was confident but still nervous. I’d developed a decent referral base while working for the other group, but still didn’t know what would happen. I was 33. My oldest kid was 1 and my wife and I had twins on the way.
Now, it’s 20 years later. All three kids grew up and went off to college, but in the strange circle of the pandemic, they are now back home. Granted they’re not waking us up at night when they’re hungry (they have microwave popcorn – lots of it – for that).
Some things have changed. I’m now across the street from the office I started in. My hospital work, which in 2000 was about 50% of my practice, is now down to 0% for the time being. My medical assistant is still the same one, and my secretary has been with me since 2004. I’m lucky to have such a long-lasting team. Even in 2020, when they’re working from home, we’re still doing a great job of keeping it running.
After 20 years I’m heavier and my hair is thinning and gray, but I still like this job. I still try to do the very best I can for my patients. I sometimes read the personal statement I wrote in the summer of 1987 for my medical school application, trying to keep in touch with who I was then when I started out.
Looking back after 20 years, going solo, like building the ISS, was a big gamble. But both have worked out. My job has allowed me to support and raise a family, to care for patients (contrary to the impression one gets from medical blogs, the vast majority of them are good, decent, people) and get to know them for who they are, and to work with my two terrific long-time office staff who, like my wife, kids, and dogs, still put up with me and my quirks. And all the while I am still doing something that I found I loved in my first week of residency.
Looking forward another 20 years, who knows where I (or the ISS) will be? I probably won’t want to be working full time then, but if I still enjoy medicine I doubt I’ll want to be completely retired, either. Looking back, I’ve been fortunate that I found this one.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Do general neurologists fall victim to a plethora of treatment options?
In 1993 I graduated from medical school. That same year Betaseron (interferon beta-1b) came to market as the first treatment specifically approved for multiple sclerosis (MS). This was a groundbreaker at the time, as there’d been little besides steroids and other potent immunosuppressants to try. Now we had a real drug to offer patients.
The demand for Betaseron was huge, so much so that a lottery system was used to determine which patients would get it first, as there simply wasn’t enough to go around. In the next several years a few more agents jumped into the ring – Avonex (interferon beta-1a), Copaxone (glatiramer acetate), Novantrone (mitoxantrone), and Rebif (interferon beta-1a) – before things went quiet for a while.
In 2006 the first monoclonal antibody for MS – Tysabri (natalizumab) – came out, then almost just as quickly vanished again, not returning until 2009.
Since then we’ve had a gradual explosion of new treatments for MS – like watching kernels become popcorn – first one, then two, then a deluge filling up the basket.
So here we are, approaching the end of 2020, with a remarkable collection of monoclonal antibodies, S1P modulators, fumarates, immunosuppressants, and one symptomatic treatment, many of which weren’t even imagined in 1993. Not to mention the original ABCR (Avonex, Betaseron, Copaxone, Rebif) agents, though they’re riding into the sunset.
A friend and I were talking about this remarkable success story. MS certainly hasn’t been cured, but its treatments have had a dramatic improvement in efficacy over the last quarter century.
He made a point though: that this selection of treatments may be relegating MS from the province of a general neurologist to that of the fellowship-trained MS subspecialist.
Not that that is such a bad thing, as MS is a very challenging disease. But the point is well taken. As treatments become increasingly complicated, and numerous, it becomes harder to know which one is best. Most of us likely choose orals first and monoclonal antibodies second, but the question of “which one?” arises for each category. They each have their own risks, side effects, initiation protocols, and peculiarities. In a disease of heterogeneous presentations and courses, there are no clear data on which agent to start first for what patient type. To a general neurologist, also juggling migraines, strokes, Parkinson’s disease, dementia, and neuropathy (and many other disorders) in the course of a day, it becomes tricky to keep up on such.
At some point do general neurologists become a victim of this success? Maybe, but probably not. Just as there are more general practitioners than neurologists, there are more general neurologists than MS subspecialists. Their knowledge and training should be reserved for those patients not responding to our first- (and second-) line treatments, presentations that are atypical, and more complex issues outside the scope of those of us practicing whatever-comes-to-the-door neurology.
It would, however, be nice to have a good consensus on how to best use this array of treatments. Solid guidelines, breaking disease subtypes and treatments down by patient types, drugs, and mechanisms of action, would help those of us on the neurology frontlines to better care for those who need us.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
In 1993 I graduated from medical school. That same year Betaseron (interferon beta-1b) came to market as the first treatment specifically approved for multiple sclerosis (MS). This was a groundbreaker at the time, as there’d been little besides steroids and other potent immunosuppressants to try. Now we had a real drug to offer patients.
The demand for Betaseron was huge, so much so that a lottery system was used to determine which patients would get it first, as there simply wasn’t enough to go around. In the next several years a few more agents jumped into the ring – Avonex (interferon beta-1a), Copaxone (glatiramer acetate), Novantrone (mitoxantrone), and Rebif (interferon beta-1a) – before things went quiet for a while.
In 2006 the first monoclonal antibody for MS – Tysabri (natalizumab) – came out, then almost just as quickly vanished again, not returning until 2009.
Since then we’ve had a gradual explosion of new treatments for MS – like watching kernels become popcorn – first one, then two, then a deluge filling up the basket.
So here we are, approaching the end of 2020, with a remarkable collection of monoclonal antibodies, S1P modulators, fumarates, immunosuppressants, and one symptomatic treatment, many of which weren’t even imagined in 1993. Not to mention the original ABCR (Avonex, Betaseron, Copaxone, Rebif) agents, though they’re riding into the sunset.
A friend and I were talking about this remarkable success story. MS certainly hasn’t been cured, but its treatments have had a dramatic improvement in efficacy over the last quarter century.
He made a point though: that this selection of treatments may be relegating MS from the province of a general neurologist to that of the fellowship-trained MS subspecialist.
Not that that is such a bad thing, as MS is a very challenging disease. But the point is well taken. As treatments become increasingly complicated, and numerous, it becomes harder to know which one is best. Most of us likely choose orals first and monoclonal antibodies second, but the question of “which one?” arises for each category. They each have their own risks, side effects, initiation protocols, and peculiarities. In a disease of heterogeneous presentations and courses, there are no clear data on which agent to start first for what patient type. To a general neurologist, also juggling migraines, strokes, Parkinson’s disease, dementia, and neuropathy (and many other disorders) in the course of a day, it becomes tricky to keep up on such.
At some point do general neurologists become a victim of this success? Maybe, but probably not. Just as there are more general practitioners than neurologists, there are more general neurologists than MS subspecialists. Their knowledge and training should be reserved for those patients not responding to our first- (and second-) line treatments, presentations that are atypical, and more complex issues outside the scope of those of us practicing whatever-comes-to-the-door neurology.
It would, however, be nice to have a good consensus on how to best use this array of treatments. Solid guidelines, breaking disease subtypes and treatments down by patient types, drugs, and mechanisms of action, would help those of us on the neurology frontlines to better care for those who need us.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
In 1993 I graduated from medical school. That same year Betaseron (interferon beta-1b) came to market as the first treatment specifically approved for multiple sclerosis (MS). This was a groundbreaker at the time, as there’d been little besides steroids and other potent immunosuppressants to try. Now we had a real drug to offer patients.
The demand for Betaseron was huge, so much so that a lottery system was used to determine which patients would get it first, as there simply wasn’t enough to go around. In the next several years a few more agents jumped into the ring – Avonex (interferon beta-1a), Copaxone (glatiramer acetate), Novantrone (mitoxantrone), and Rebif (interferon beta-1a) – before things went quiet for a while.
In 2006 the first monoclonal antibody for MS – Tysabri (natalizumab) – came out, then almost just as quickly vanished again, not returning until 2009.
Since then we’ve had a gradual explosion of new treatments for MS – like watching kernels become popcorn – first one, then two, then a deluge filling up the basket.
So here we are, approaching the end of 2020, with a remarkable collection of monoclonal antibodies, S1P modulators, fumarates, immunosuppressants, and one symptomatic treatment, many of which weren’t even imagined in 1993. Not to mention the original ABCR (Avonex, Betaseron, Copaxone, Rebif) agents, though they’re riding into the sunset.
A friend and I were talking about this remarkable success story. MS certainly hasn’t been cured, but its treatments have had a dramatic improvement in efficacy over the last quarter century.
He made a point though: that this selection of treatments may be relegating MS from the province of a general neurologist to that of the fellowship-trained MS subspecialist.
Not that that is such a bad thing, as MS is a very challenging disease. But the point is well taken. As treatments become increasingly complicated, and numerous, it becomes harder to know which one is best. Most of us likely choose orals first and monoclonal antibodies second, but the question of “which one?” arises for each category. They each have their own risks, side effects, initiation protocols, and peculiarities. In a disease of heterogeneous presentations and courses, there are no clear data on which agent to start first for what patient type. To a general neurologist, also juggling migraines, strokes, Parkinson’s disease, dementia, and neuropathy (and many other disorders) in the course of a day, it becomes tricky to keep up on such.
At some point do general neurologists become a victim of this success? Maybe, but probably not. Just as there are more general practitioners than neurologists, there are more general neurologists than MS subspecialists. Their knowledge and training should be reserved for those patients not responding to our first- (and second-) line treatments, presentations that are atypical, and more complex issues outside the scope of those of us practicing whatever-comes-to-the-door neurology.
It would, however, be nice to have a good consensus on how to best use this array of treatments. Solid guidelines, breaking disease subtypes and treatments down by patient types, drugs, and mechanisms of action, would help those of us on the neurology frontlines to better care for those who need us.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Is the troll tracker crying wolf?
I’m a big believer in my state’s Prescription Monitoring Program (PMP), perhaps more commonly known as the troll tracker. The ability to quickly access a patient’s controlled prescription records across pharmacies has been enormously helpful in my everyday practice. I rely on it and check it often.
With it I can see if my patients are getting the same drug from other prescribers, pharmacy-shopping, or carrying out other concerning activities. The database helpfully sends me emails alerting me to such conflicts, so I can take prompt action on them.
Unfortunately, the threshold for such emails has gradually crept lower, to where I now get maybe 10 a week.
A lady to whom I gave two Valium tablets to get her through a lumbar spine MRI also got 20 Percocet for the same back pain from her internist … and I get an alert email.
A long-established patient for whom I’ve been prescribing Ativan and Tramadol for years, fills them both every month … and I get an alert email every month (and I’m the only prescriber who has written for him in the last 10 years).
A patient who suffered a painful vertebral fracture, got 10 Norco in the ED, follows with up with me 5 days later, and I write her for 20 more … and I get an email.
Now, I understand what the program is trying to do – and wholeheartedly agree with it – but the problem is that the more email warnings I get the less likely I am to have time to investigate each one. It’s like the boy who cried “wolf!” In fact, it’s probably been over a year since a warning email from the PMP told me something I didn’t already know.
Granted, these emails are sent by a computer, following a rigid set of parameters to do so. The machine doesn’t know I’m aware of the situation, or keep track of case nuances, or even notice that I’m the only prescriber of all the medications involved. It just does what it’s set to do. And the warnings all make it clear that they’re just warnings, and that the treatment is still left to physician’s discretion.
Arizona currently has roughly 18,000 practicing physicians. Granted, not all of them are routinely prescribing controlled agents, but I’d guess at least two-thirds of them are. So it’s safe to assume at least 12,000 doctors here are receiving email warnings with varying degrees of frequency.
At some point, with all the other tasks and hats your average doctor goes through in a day, too many of these warnings – the vast majority of them meaningless – become part of the background noise.
There are only so many hours in a day to see patients, write notes, send prescriptions, review tests, return calls, fill out forms, and all the other things that are part of our days. Having to log into the PMP website to see what’s up every time you get an email from them, especially when the last 20 (or more) warnings that you received were meaningless, gets pushed farther and farther onto the back burner. So when a real warning shows up, it may not got noticed much at all.
Like I said, I believe in and routinely use the state PMP. But it may be time to take a second look at the criteria under which its email warning system operates.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
I’m a big believer in my state’s Prescription Monitoring Program (PMP), perhaps more commonly known as the troll tracker. The ability to quickly access a patient’s controlled prescription records across pharmacies has been enormously helpful in my everyday practice. I rely on it and check it often.
With it I can see if my patients are getting the same drug from other prescribers, pharmacy-shopping, or carrying out other concerning activities. The database helpfully sends me emails alerting me to such conflicts, so I can take prompt action on them.
Unfortunately, the threshold for such emails has gradually crept lower, to where I now get maybe 10 a week.
A lady to whom I gave two Valium tablets to get her through a lumbar spine MRI also got 20 Percocet for the same back pain from her internist … and I get an alert email.
A long-established patient for whom I’ve been prescribing Ativan and Tramadol for years, fills them both every month … and I get an alert email every month (and I’m the only prescriber who has written for him in the last 10 years).
A patient who suffered a painful vertebral fracture, got 10 Norco in the ED, follows with up with me 5 days later, and I write her for 20 more … and I get an email.
Now, I understand what the program is trying to do – and wholeheartedly agree with it – but the problem is that the more email warnings I get the less likely I am to have time to investigate each one. It’s like the boy who cried “wolf!” In fact, it’s probably been over a year since a warning email from the PMP told me something I didn’t already know.
Granted, these emails are sent by a computer, following a rigid set of parameters to do so. The machine doesn’t know I’m aware of the situation, or keep track of case nuances, or even notice that I’m the only prescriber of all the medications involved. It just does what it’s set to do. And the warnings all make it clear that they’re just warnings, and that the treatment is still left to physician’s discretion.
Arizona currently has roughly 18,000 practicing physicians. Granted, not all of them are routinely prescribing controlled agents, but I’d guess at least two-thirds of them are. So it’s safe to assume at least 12,000 doctors here are receiving email warnings with varying degrees of frequency.
At some point, with all the other tasks and hats your average doctor goes through in a day, too many of these warnings – the vast majority of them meaningless – become part of the background noise.
There are only so many hours in a day to see patients, write notes, send prescriptions, review tests, return calls, fill out forms, and all the other things that are part of our days. Having to log into the PMP website to see what’s up every time you get an email from them, especially when the last 20 (or more) warnings that you received were meaningless, gets pushed farther and farther onto the back burner. So when a real warning shows up, it may not got noticed much at all.
Like I said, I believe in and routinely use the state PMP. But it may be time to take a second look at the criteria under which its email warning system operates.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
I’m a big believer in my state’s Prescription Monitoring Program (PMP), perhaps more commonly known as the troll tracker. The ability to quickly access a patient’s controlled prescription records across pharmacies has been enormously helpful in my everyday practice. I rely on it and check it often.
With it I can see if my patients are getting the same drug from other prescribers, pharmacy-shopping, or carrying out other concerning activities. The database helpfully sends me emails alerting me to such conflicts, so I can take prompt action on them.
Unfortunately, the threshold for such emails has gradually crept lower, to where I now get maybe 10 a week.
A lady to whom I gave two Valium tablets to get her through a lumbar spine MRI also got 20 Percocet for the same back pain from her internist … and I get an alert email.
A long-established patient for whom I’ve been prescribing Ativan and Tramadol for years, fills them both every month … and I get an alert email every month (and I’m the only prescriber who has written for him in the last 10 years).
A patient who suffered a painful vertebral fracture, got 10 Norco in the ED, follows with up with me 5 days later, and I write her for 20 more … and I get an email.
Now, I understand what the program is trying to do – and wholeheartedly agree with it – but the problem is that the more email warnings I get the less likely I am to have time to investigate each one. It’s like the boy who cried “wolf!” In fact, it’s probably been over a year since a warning email from the PMP told me something I didn’t already know.
Granted, these emails are sent by a computer, following a rigid set of parameters to do so. The machine doesn’t know I’m aware of the situation, or keep track of case nuances, or even notice that I’m the only prescriber of all the medications involved. It just does what it’s set to do. And the warnings all make it clear that they’re just warnings, and that the treatment is still left to physician’s discretion.
Arizona currently has roughly 18,000 practicing physicians. Granted, not all of them are routinely prescribing controlled agents, but I’d guess at least two-thirds of them are. So it’s safe to assume at least 12,000 doctors here are receiving email warnings with varying degrees of frequency.
At some point, with all the other tasks and hats your average doctor goes through in a day, too many of these warnings – the vast majority of them meaningless – become part of the background noise.
There are only so many hours in a day to see patients, write notes, send prescriptions, review tests, return calls, fill out forms, and all the other things that are part of our days. Having to log into the PMP website to see what’s up every time you get an email from them, especially when the last 20 (or more) warnings that you received were meaningless, gets pushed farther and farther onto the back burner. So when a real warning shows up, it may not got noticed much at all.
Like I said, I believe in and routinely use the state PMP. But it may be time to take a second look at the criteria under which its email warning system operates.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.