Hitting a Nerve

In the Nov. 1, 2019, issue of JAMA Neurology, an editorial argues that it’s time for neurologists to start managing high blood pressure.

GlobalStock/Getty Images

It makes some very valid points: that targeting a systolic blood pressure of less than 120 mm Hg results in lower rates of cardiovascular events and all causes of mortality, that poorly controlled hypertension leads to debilitating neurologic conditions, and that high blood pressure is the most common modifiable risk factor for stroke.

All are strong points. I agree with them and definitely believe that more can and should be done to control hypertension.

The editorial then goes on to say that “first and foremost we are charging neurologists with actively diagnosing hypertension and prescribing medications when appropriate.”

Uh, no. I’m not going to be the one managing hypertension, nor should any outpatient neurologist.

Outpatient hypertension treatment has historically been, and should remain, the province of general practitioners, cardiologists, and nephrologists. Too many cooks, as they say, spoils the broth. I don’t want to be in a situation where two (or more) doctors are simultaneously trying to treat the same condition. On that path lies danger.

This doesn’t mean I ignore blood pressure. On the contrary, I take it (myself) at every patient visit, and put it in my note. In most cases I do nothing further, as nothing further needs to be done. On occasion, though, if it’s concerningly high, I’ll write it down for the patient and direct them to call the physician handling it. I also fax a note about it to that office, and if it’s dangerously high will call the doctor myself.

But try to manage it? No. Elevated readings definitely overlap with my world, but treating them shouldn’t.

The article says that, for some chronic patients, neurologists are their de facto internist. Perhaps for a few, but when a patient calls with concerns about a respiratory ailment, gastrointestinal problem, or other nonneurologic issue, I tell them to call their general practitioner. If they don’t have one I’m happy to give them the names and phone numbers of colleagues who practice that field, or even urgent care and emergency department information if needed. Just because I see them for their neurologic problems doesn’t qualify me to practice another branch of medicine.

Beyond the dangers of having more than one doctor involved, as a specialist it’s not practical for me to know the antihypertensive medications – possibly the largest group of agents on the market, – in detail, with their mechanisms of action, side effects, and contraindications. Yes, I do keep a handful in mind, since they’re needed off label for migraines and tremors, but not in the kind of detail a cardiologist would. I have to keep track of enough medications in my specialty as it is.

I wouldn’t try to handle blood pressure any more than I’d expect a nephrologist to treat epilepsy. It’s just looking for trouble.

Even when covering the hospital, I’ll stay out of that arena. This doesn’t mean I ignore blood pressure in such serious conditions as stroke or posterior reversible encephalopathy syndrome. I’m more than happy to provide guidelines and parameters. But as far as choosing the medications and doses? No.

Like driving, we all have to share the road. We may even be focused on the same journey (or patient). But part of practicing medicine and handling traffic is knowing when to stay in your lane.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

In the Nov. 1, 2019, issue of JAMA Neurology, an editorial argues that it’s time for neurologists to start managing high blood pressure.

GlobalStock/Getty Images

It makes some very valid points: that targeting a systolic blood pressure of less than 120 mm Hg results in lower rates of cardiovascular events and all causes of mortality, that poorly controlled hypertension leads to debilitating neurologic conditions, and that high blood pressure is the most common modifiable risk factor for stroke.

All are strong points. I agree with them and definitely believe that more can and should be done to control hypertension.

The editorial then goes on to say that “first and foremost we are charging neurologists with actively diagnosing hypertension and prescribing medications when appropriate.”

Uh, no. I’m not going to be the one managing hypertension, nor should any outpatient neurologist.

Outpatient hypertension treatment has historically been, and should remain, the province of general practitioners, cardiologists, and nephrologists. Too many cooks, as they say, spoils the broth. I don’t want to be in a situation where two (or more) doctors are simultaneously trying to treat the same condition. On that path lies danger.

This doesn’t mean I ignore blood pressure. On the contrary, I take it (myself) at every patient visit, and put it in my note. In most cases I do nothing further, as nothing further needs to be done. On occasion, though, if it’s concerningly high, I’ll write it down for the patient and direct them to call the physician handling it. I also fax a note about it to that office, and if it’s dangerously high will call the doctor myself.

But try to manage it? No. Elevated readings definitely overlap with my world, but treating them shouldn’t.

The article says that, for some chronic patients, neurologists are their de facto internist. Perhaps for a few, but when a patient calls with concerns about a respiratory ailment, gastrointestinal problem, or other nonneurologic issue, I tell them to call their general practitioner. If they don’t have one I’m happy to give them the names and phone numbers of colleagues who practice that field, or even urgent care and emergency department information if needed. Just because I see them for their neurologic problems doesn’t qualify me to practice another branch of medicine.

Beyond the dangers of having more than one doctor involved, as a specialist it’s not practical for me to know the antihypertensive medications – possibly the largest group of agents on the market, – in detail, with their mechanisms of action, side effects, and contraindications. Yes, I do keep a handful in mind, since they’re needed off label for migraines and tremors, but not in the kind of detail a cardiologist would. I have to keep track of enough medications in my specialty as it is.

I wouldn’t try to handle blood pressure any more than I’d expect a nephrologist to treat epilepsy. It’s just looking for trouble.

Even when covering the hospital, I’ll stay out of that arena. This doesn’t mean I ignore blood pressure in such serious conditions as stroke or posterior reversible encephalopathy syndrome. I’m more than happy to provide guidelines and parameters. But as far as choosing the medications and doses? No.

Like driving, we all have to share the road. We may even be focused on the same journey (or patient). But part of practicing medicine and handling traffic is knowing when to stay in your lane.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

In the Nov. 1, 2019, issue of JAMA Neurology, an editorial argues that it’s time for neurologists to start managing high blood pressure.

GlobalStock/Getty Images

It makes some very valid points: that targeting a systolic blood pressure of less than 120 mm Hg results in lower rates of cardiovascular events and all causes of mortality, that poorly controlled hypertension leads to debilitating neurologic conditions, and that high blood pressure is the most common modifiable risk factor for stroke.

All are strong points. I agree with them and definitely believe that more can and should be done to control hypertension.

The editorial then goes on to say that “first and foremost we are charging neurologists with actively diagnosing hypertension and prescribing medications when appropriate.”

Uh, no. I’m not going to be the one managing hypertension, nor should any outpatient neurologist.

Outpatient hypertension treatment has historically been, and should remain, the province of general practitioners, cardiologists, and nephrologists. Too many cooks, as they say, spoils the broth. I don’t want to be in a situation where two (or more) doctors are simultaneously trying to treat the same condition. On that path lies danger.

This doesn’t mean I ignore blood pressure. On the contrary, I take it (myself) at every patient visit, and put it in my note. In most cases I do nothing further, as nothing further needs to be done. On occasion, though, if it’s concerningly high, I’ll write it down for the patient and direct them to call the physician handling it. I also fax a note about it to that office, and if it’s dangerously high will call the doctor myself.

But try to manage it? No. Elevated readings definitely overlap with my world, but treating them shouldn’t.

The article says that, for some chronic patients, neurologists are their de facto internist. Perhaps for a few, but when a patient calls with concerns about a respiratory ailment, gastrointestinal problem, or other nonneurologic issue, I tell them to call their general practitioner. If they don’t have one I’m happy to give them the names and phone numbers of colleagues who practice that field, or even urgent care and emergency department information if needed. Just because I see them for their neurologic problems doesn’t qualify me to practice another branch of medicine.

Beyond the dangers of having more than one doctor involved, as a specialist it’s not practical for me to know the antihypertensive medications – possibly the largest group of agents on the market, – in detail, with their mechanisms of action, side effects, and contraindications. Yes, I do keep a handful in mind, since they’re needed off label for migraines and tremors, but not in the kind of detail a cardiologist would. I have to keep track of enough medications in my specialty as it is.

I wouldn’t try to handle blood pressure any more than I’d expect a nephrologist to treat epilepsy. It’s just looking for trouble.

Even when covering the hospital, I’ll stay out of that arena. This doesn’t mean I ignore blood pressure in such serious conditions as stroke or posterior reversible encephalopathy syndrome. I’m more than happy to provide guidelines and parameters. But as far as choosing the medications and doses? No.

Like driving, we all have to share the road. We may even be focused on the same journey (or patient). But part of practicing medicine and handling traffic is knowing when to stay in your lane.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I recently had an unusual patient call. A woman I’ve seen for many years for migraines called to tell me her son was being hospitalized for appendicitis. He was scheduled for surgery in the morning.

pinkomelet/Thinkstock

She called because she’d recently seen a news report about how people without an appendix may have a higher rate of Parkinson’s disease as they age. She was, understandably, concerned about the long-term risks the procedure could pose.

On the surface, as a medical professional, the call sounds frivolous and silly. The risks of untreated acute appendicitis, such as peritonitis and death, are pretty well documented. Surgery offers the best possibility for a cure without recurrence. Compared with the long-term, uncertain, risk of Parkinson’s disease, the benefit-to-risk ratio and options are pretty obvious.

The question of the GI tract’s involvement in neurologic diseases is a legitimate one that needs to be answered. It may provide new insight into their causes and potential treatments. The research she brought up raises some interesting points.

But that doesn’t mean there should be any delay in treating something as easily cured – and potentially serious – as acute appendicitis.

My patient called to ask questions, and I have no issue with that. To someone with no medical training, it’s a legitimate concern. But not everyone will call to ask.

This is a hazard of early stages of medical research making it into the lay press. It may be right, it may be wrong, but it’s too early to tell either way. We have years of training to help us recognize the uncertainties of preliminary data, but the general public doesn’t. Stories like this create interest and raise questions in the medical literature and fear and anxiety in the lay press.

I’m a strong supporter of freedom of the press, and certainly they have every right to air or publish such stories. But they should also be put in perspective at the beginning, not the bottom, and make it clear the findings are far from proven.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I recently had an unusual patient call. A woman I’ve seen for many years for migraines called to tell me her son was being hospitalized for appendicitis. He was scheduled for surgery in the morning.

pinkomelet/Thinkstock

She called because she’d recently seen a news report about how people without an appendix may have a higher rate of Parkinson’s disease as they age. She was, understandably, concerned about the long-term risks the procedure could pose.

On the surface, as a medical professional, the call sounds frivolous and silly. The risks of untreated acute appendicitis, such as peritonitis and death, are pretty well documented. Surgery offers the best possibility for a cure without recurrence. Compared with the long-term, uncertain, risk of Parkinson’s disease, the benefit-to-risk ratio and options are pretty obvious.

The question of the GI tract’s involvement in neurologic diseases is a legitimate one that needs to be answered. It may provide new insight into their causes and potential treatments. The research she brought up raises some interesting points.

But that doesn’t mean there should be any delay in treating something as easily cured – and potentially serious – as acute appendicitis.

My patient called to ask questions, and I have no issue with that. To someone with no medical training, it’s a legitimate concern. But not everyone will call to ask.

This is a hazard of early stages of medical research making it into the lay press. It may be right, it may be wrong, but it’s too early to tell either way. We have years of training to help us recognize the uncertainties of preliminary data, but the general public doesn’t. Stories like this create interest and raise questions in the medical literature and fear and anxiety in the lay press.

I’m a strong supporter of freedom of the press, and certainly they have every right to air or publish such stories. But they should also be put in perspective at the beginning, not the bottom, and make it clear the findings are far from proven.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I recently had an unusual patient call. A woman I’ve seen for many years for migraines called to tell me her son was being hospitalized for appendicitis. He was scheduled for surgery in the morning.

pinkomelet/Thinkstock

She called because she’d recently seen a news report about how people without an appendix may have a higher rate of Parkinson’s disease as they age. She was, understandably, concerned about the long-term risks the procedure could pose.

On the surface, as a medical professional, the call sounds frivolous and silly. The risks of untreated acute appendicitis, such as peritonitis and death, are pretty well documented. Surgery offers the best possibility for a cure without recurrence. Compared with the long-term, uncertain, risk of Parkinson’s disease, the benefit-to-risk ratio and options are pretty obvious.

The question of the GI tract’s involvement in neurologic diseases is a legitimate one that needs to be answered. It may provide new insight into their causes and potential treatments. The research she brought up raises some interesting points.

But that doesn’t mean there should be any delay in treating something as easily cured – and potentially serious – as acute appendicitis.

My patient called to ask questions, and I have no issue with that. To someone with no medical training, it’s a legitimate concern. But not everyone will call to ask.

This is a hazard of early stages of medical research making it into the lay press. It may be right, it may be wrong, but it’s too early to tell either way. We have years of training to help us recognize the uncertainties of preliminary data, but the general public doesn’t. Stories like this create interest and raise questions in the medical literature and fear and anxiety in the lay press.

I’m a strong supporter of freedom of the press, and certainly they have every right to air or publish such stories. But they should also be put in perspective at the beginning, not the bottom, and make it clear the findings are far from proven.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

“Why didn’t you see that patient?”

TongRo Images/Thinkstock

The hospitalist on the phone was angry. He’d wanted the patient seen by neurology and cleared for discharge. Apparently, I hadn’t complied.

Actually, that isn’t true. I was on call, so I had dutifully dragged myself in (with the help of some coffee), reviewed the chart, and gone in to see the fellow.

The patient, however, had other ideas. He said he was sick of doctors, didn’t like them, didn’t want to see me, and asked me to leave. So I did.

This threw off the hospitalist’s well-choreographed day of admissions and discharges. Without me seeing the patient, he had to either discharge him on his own decision or find another neurologist who would do it.

Sorry, but I’m not going to force this issue. If a patient doesn’t want to see me, it’s not worth fighting over. Believe me, I get paid to see patients, so I don’t have much incentive to just walk away.

But at the same time I have to respect patients’ decisions. While a neurology consult is pretty noninvasive, it’s still a part of medicine. If a patient doesn’t want to see me, I’m not going to force them to.

Granted, there are exceptions. Obviously, if the patient is fairly demented or otherwise not mentally competent to make such a decision, I’ll see them. In those cases, their deteriorating mental status is likely the reason for the consult.

But the fellow that day seemed alert and reasonable, and there was nothing in the chart about confusion. So I’m going to assume he knew what he was doing when he told me to go away.

The hospitalist didn’t see this as an issue, but I did. Doing a consult on a patient who doesn’t want one seems, at least to me, like harassment. I’m sorry if it messes up the discharge planning, but that’s not my fault. It’s the patient’s decision.

While I may disagree at times with patients’ decisions, their autonomy is still central to medicine. I respect and believe in that, even if it makes things more difficult for those around them.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

“Why didn’t you see that patient?”

TongRo Images/Thinkstock

The hospitalist on the phone was angry. He’d wanted the patient seen by neurology and cleared for discharge. Apparently, I hadn’t complied.

Actually, that isn’t true. I was on call, so I had dutifully dragged myself in (with the help of some coffee), reviewed the chart, and gone in to see the fellow.

The patient, however, had other ideas. He said he was sick of doctors, didn’t like them, didn’t want to see me, and asked me to leave. So I did.

This threw off the hospitalist’s well-choreographed day of admissions and discharges. Without me seeing the patient, he had to either discharge him on his own decision or find another neurologist who would do it.

Sorry, but I’m not going to force this issue. If a patient doesn’t want to see me, it’s not worth fighting over. Believe me, I get paid to see patients, so I don’t have much incentive to just walk away.

But at the same time I have to respect patients’ decisions. While a neurology consult is pretty noninvasive, it’s still a part of medicine. If a patient doesn’t want to see me, I’m not going to force them to.

Granted, there are exceptions. Obviously, if the patient is fairly demented or otherwise not mentally competent to make such a decision, I’ll see them. In those cases, their deteriorating mental status is likely the reason for the consult.

But the fellow that day seemed alert and reasonable, and there was nothing in the chart about confusion. So I’m going to assume he knew what he was doing when he told me to go away.

The hospitalist didn’t see this as an issue, but I did. Doing a consult on a patient who doesn’t want one seems, at least to me, like harassment. I’m sorry if it messes up the discharge planning, but that’s not my fault. It’s the patient’s decision.

While I may disagree at times with patients’ decisions, their autonomy is still central to medicine. I respect and believe in that, even if it makes things more difficult for those around them.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

“Why didn’t you see that patient?”

TongRo Images/Thinkstock

The hospitalist on the phone was angry. He’d wanted the patient seen by neurology and cleared for discharge. Apparently, I hadn’t complied.

Actually, that isn’t true. I was on call, so I had dutifully dragged myself in (with the help of some coffee), reviewed the chart, and gone in to see the fellow.

The patient, however, had other ideas. He said he was sick of doctors, didn’t like them, didn’t want to see me, and asked me to leave. So I did.

This threw off the hospitalist’s well-choreographed day of admissions and discharges. Without me seeing the patient, he had to either discharge him on his own decision or find another neurologist who would do it.

Sorry, but I’m not going to force this issue. If a patient doesn’t want to see me, it’s not worth fighting over. Believe me, I get paid to see patients, so I don’t have much incentive to just walk away.

But at the same time I have to respect patients’ decisions. While a neurology consult is pretty noninvasive, it’s still a part of medicine. If a patient doesn’t want to see me, I’m not going to force them to.

Granted, there are exceptions. Obviously, if the patient is fairly demented or otherwise not mentally competent to make such a decision, I’ll see them. In those cases, their deteriorating mental status is likely the reason for the consult.

But the fellow that day seemed alert and reasonable, and there was nothing in the chart about confusion. So I’m going to assume he knew what he was doing when he told me to go away.

The hospitalist didn’t see this as an issue, but I did. Doing a consult on a patient who doesn’t want one seems, at least to me, like harassment. I’m sorry if it messes up the discharge planning, but that’s not my fault. It’s the patient’s decision.

While I may disagree at times with patients’ decisions, their autonomy is still central to medicine. I respect and believe in that, even if it makes things more difficult for those around them.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Another solo-practice neurologist and I were talking last week. He’s understandably worried about the local hospital starting construction on a new “neuroscience center” down the street from us. They have ambitious plans for it, which apparently don’t include those of us who’ve served the community for 20-30 years.

Whatever. I’ve been in a large practice before, and don’t want to be a part of one again.

His concern, which I have, too, is that the hospital center will drive us little guys out of business. This seems to be a common medical practice model these days.

I hope not. I’ve been doing this for a long time, and am happy with my little world. I also believe, perhaps naively, that there’s still a place for a small practice.

My staff and I know my patients. We’re generally tuned in to who needs what, or how much time. We return all calls within a few hours (or less) and try be on top of getting medication refills and records requests done the same day they come in.

While a large practice has some advantages, based on my time with one I’d have to say we didn’t do those things as well there. Messages often weren’t relayed, or were sent to the wrong doctor. Here there’s only me.

I may not make as much, but my appointment times and intervals aren’t dictated by an accountant. This allows me to generally spend as much time as needed with each person and not feel rushed as the day goes on. I hope patients still desire that in a physician, as opposed to a place advertising “20 neurologists, no waiting!” on a sign that would fit in on the Vegas strip.

Obviously, I can’t control what the hospital will do. I can only manage my own little world. I’ll continue doing that as best I can, as long as I’m able.

Time spent worrying about things I can’t change isn’t productive and is bad for one’s blood pressure. So I’ll focus on what I can do, and try not to worry about the rest.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Another solo-practice neurologist and I were talking last week. He’s understandably worried about the local hospital starting construction on a new “neuroscience center” down the street from us. They have ambitious plans for it, which apparently don’t include those of us who’ve served the community for 20-30 years.

Whatever. I’ve been in a large practice before, and don’t want to be a part of one again.

His concern, which I have, too, is that the hospital center will drive us little guys out of business. This seems to be a common medical practice model these days.

I hope not. I’ve been doing this for a long time, and am happy with my little world. I also believe, perhaps naively, that there’s still a place for a small practice.

My staff and I know my patients. We’re generally tuned in to who needs what, or how much time. We return all calls within a few hours (or less) and try be on top of getting medication refills and records requests done the same day they come in.

While a large practice has some advantages, based on my time with one I’d have to say we didn’t do those things as well there. Messages often weren’t relayed, or were sent to the wrong doctor. Here there’s only me.

I may not make as much, but my appointment times and intervals aren’t dictated by an accountant. This allows me to generally spend as much time as needed with each person and not feel rushed as the day goes on. I hope patients still desire that in a physician, as opposed to a place advertising “20 neurologists, no waiting!” on a sign that would fit in on the Vegas strip.

Obviously, I can’t control what the hospital will do. I can only manage my own little world. I’ll continue doing that as best I can, as long as I’m able.

Time spent worrying about things I can’t change isn’t productive and is bad for one’s blood pressure. So I’ll focus on what I can do, and try not to worry about the rest.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Another solo-practice neurologist and I were talking last week. He’s understandably worried about the local hospital starting construction on a new “neuroscience center” down the street from us. They have ambitious plans for it, which apparently don’t include those of us who’ve served the community for 20-30 years.

Whatever. I’ve been in a large practice before, and don’t want to be a part of one again.

His concern, which I have, too, is that the hospital center will drive us little guys out of business. This seems to be a common medical practice model these days.

I hope not. I’ve been doing this for a long time, and am happy with my little world. I also believe, perhaps naively, that there’s still a place for a small practice.

My staff and I know my patients. We’re generally tuned in to who needs what, or how much time. We return all calls within a few hours (or less) and try be on top of getting medication refills and records requests done the same day they come in.

While a large practice has some advantages, based on my time with one I’d have to say we didn’t do those things as well there. Messages often weren’t relayed, or were sent to the wrong doctor. Here there’s only me.

I may not make as much, but my appointment times and intervals aren’t dictated by an accountant. This allows me to generally spend as much time as needed with each person and not feel rushed as the day goes on. I hope patients still desire that in a physician, as opposed to a place advertising “20 neurologists, no waiting!” on a sign that would fit in on the Vegas strip.

Obviously, I can’t control what the hospital will do. I can only manage my own little world. I’ll continue doing that as best I can, as long as I’m able.

Time spent worrying about things I can’t change isn’t productive and is bad for one’s blood pressure. So I’ll focus on what I can do, and try not to worry about the rest.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I don’t want to rule the world.

Some doctors do, albeit in a non–Attila-the-Hun sort of way. They want to have offices on every street corner, in every suburb of a given city, sometimes more than one city. Like the Starbucks of medicine.

That’s not me. I’m happy in my little one-office world.

Maybe I just don’t have the ambition, or the business mindset, or whatever it takes to want to do that. I understand it’s all part of wanting to be successful, and obviously those doctors are more driven in that direction than I am. The more offices, the more patients can be seen, and the more money you make.

It’s not quite that simple, though. No one can be in more than one place at the same time, so to see more patients at more places you need more doctors. To pay more doctors requires more money, which in turn requires more patients.

There’s nothing wrong with taking over the world (or at least a suburb) if you like that sort of thing. But to me, more money brings more headaches. More offices to rent, more staff to hire, more people to handle billing, IT, HR, payroll, accounting, contracts, and so on.

You can have it. I’ve taken over all the world I want, in my case a 1,200-square-foot suite on the second floor of a small-to-medium-size medical building. To some that may sound unambitious, but to me, it’s perfect.

I know where my Keurig, Sodastream, and office supplies are. Except for my secretary and her cheerfully rambunctious young daughter, I don’t have to worry about sharing stuff here, or if anyone wants a different carpet color, or what’s going on at a satellite office halfway across town.

If other doctors want to try and take over the world, more power to them, but I’m happy with this. Enough is as good as a feast.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I don’t want to rule the world.

Some doctors do, albeit in a non–Attila-the-Hun sort of way. They want to have offices on every street corner, in every suburb of a given city, sometimes more than one city. Like the Starbucks of medicine.

That’s not me. I’m happy in my little one-office world.

Maybe I just don’t have the ambition, or the business mindset, or whatever it takes to want to do that. I understand it’s all part of wanting to be successful, and obviously those doctors are more driven in that direction than I am. The more offices, the more patients can be seen, and the more money you make.

It’s not quite that simple, though. No one can be in more than one place at the same time, so to see more patients at more places you need more doctors. To pay more doctors requires more money, which in turn requires more patients.

There’s nothing wrong with taking over the world (or at least a suburb) if you like that sort of thing. But to me, more money brings more headaches. More offices to rent, more staff to hire, more people to handle billing, IT, HR, payroll, accounting, contracts, and so on.

You can have it. I’ve taken over all the world I want, in my case a 1,200-square-foot suite on the second floor of a small-to-medium-size medical building. To some that may sound unambitious, but to me, it’s perfect.

I know where my Keurig, Sodastream, and office supplies are. Except for my secretary and her cheerfully rambunctious young daughter, I don’t have to worry about sharing stuff here, or if anyone wants a different carpet color, or what’s going on at a satellite office halfway across town.

If other doctors want to try and take over the world, more power to them, but I’m happy with this. Enough is as good as a feast.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I don’t want to rule the world.

Some doctors do, albeit in a non–Attila-the-Hun sort of way. They want to have offices on every street corner, in every suburb of a given city, sometimes more than one city. Like the Starbucks of medicine.

That’s not me. I’m happy in my little one-office world.

Maybe I just don’t have the ambition, or the business mindset, or whatever it takes to want to do that. I understand it’s all part of wanting to be successful, and obviously those doctors are more driven in that direction than I am. The more offices, the more patients can be seen, and the more money you make.

It’s not quite that simple, though. No one can be in more than one place at the same time, so to see more patients at more places you need more doctors. To pay more doctors requires more money, which in turn requires more patients.

There’s nothing wrong with taking over the world (or at least a suburb) if you like that sort of thing. But to me, more money brings more headaches. More offices to rent, more staff to hire, more people to handle billing, IT, HR, payroll, accounting, contracts, and so on.

You can have it. I’ve taken over all the world I want, in my case a 1,200-square-foot suite on the second floor of a small-to-medium-size medical building. To some that may sound unambitious, but to me, it’s perfect.

I know where my Keurig, Sodastream, and office supplies are. Except for my secretary and her cheerfully rambunctious young daughter, I don’t have to worry about sharing stuff here, or if anyone wants a different carpet color, or what’s going on at a satellite office halfway across town.

If other doctors want to try and take over the world, more power to them, but I’m happy with this. Enough is as good as a feast.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Kernohan’s notch false localizing sign. PPRF. The 7th nerve fascicle wraps around the 6th nerve nucleus. (Or is it the other way around?)
 

Yes, I’m studying for my 10-year boards.

It’s funny how many of these details you forget over time. I used to be able to rattle off names, syndromes, and pathways at the dreaded Thursday morning differential conference in residency. To not know them would get you a dreaded glare from the chairman. Now ... not as much.

Granted, the names of such things become less important over time. What’s important is the instinctive understanding of them that comes with experience. Remembering the specific name of a neural pathway becomes less relevant compared to recognizing where the problem is when you see that patient, and translating that into appropriate testing and treatment.

But, every 10 years, I have to go back to the books. Relearn the faded details of enzyme pathways, miscellaneous receptor actions, and courses of nerve tracts.

A lot of it is done on my iPad, a gadget I never imagined back in medical school, but it’s still the same routine I knew so well back then: Reading a page, staring blankly off to commit some point to memory, taking a practice test, and reviewing the answers. Occasionally, wandering off to get a can of soda or make tea.

Of course, today I have to work that around my family and job, concerns I didn’t have to split my time with in medical school. I had classmates who were married and had kids, and this always gives me a new respect for how they managed it.

Does knowing these details again make me a better doctor? I have no idea. I understand the idea that we need some way of showing we’re still on top of things after 20 years in the field. I’m not sure the current maintenance of certification practices are the best way to do that, but admittedly I don’t have any better ideas.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Kernohan’s notch false localizing sign. PPRF. The 7th nerve fascicle wraps around the 6th nerve nucleus. (Or is it the other way around?)
 

Yes, I’m studying for my 10-year boards.

It’s funny how many of these details you forget over time. I used to be able to rattle off names, syndromes, and pathways at the dreaded Thursday morning differential conference in residency. To not know them would get you a dreaded glare from the chairman. Now ... not as much.

Granted, the names of such things become less important over time. What’s important is the instinctive understanding of them that comes with experience. Remembering the specific name of a neural pathway becomes less relevant compared to recognizing where the problem is when you see that patient, and translating that into appropriate testing and treatment.

But, every 10 years, I have to go back to the books. Relearn the faded details of enzyme pathways, miscellaneous receptor actions, and courses of nerve tracts.

A lot of it is done on my iPad, a gadget I never imagined back in medical school, but it’s still the same routine I knew so well back then: Reading a page, staring blankly off to commit some point to memory, taking a practice test, and reviewing the answers. Occasionally, wandering off to get a can of soda or make tea.

Of course, today I have to work that around my family and job, concerns I didn’t have to split my time with in medical school. I had classmates who were married and had kids, and this always gives me a new respect for how they managed it.

Does knowing these details again make me a better doctor? I have no idea. I understand the idea that we need some way of showing we’re still on top of things after 20 years in the field. I’m not sure the current maintenance of certification practices are the best way to do that, but admittedly I don’t have any better ideas.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Kernohan’s notch false localizing sign. PPRF. The 7th nerve fascicle wraps around the 6th nerve nucleus. (Or is it the other way around?)
 

Yes, I’m studying for my 10-year boards.

It’s funny how many of these details you forget over time. I used to be able to rattle off names, syndromes, and pathways at the dreaded Thursday morning differential conference in residency. To not know them would get you a dreaded glare from the chairman. Now ... not as much.

Granted, the names of such things become less important over time. What’s important is the instinctive understanding of them that comes with experience. Remembering the specific name of a neural pathway becomes less relevant compared to recognizing where the problem is when you see that patient, and translating that into appropriate testing and treatment.

But, every 10 years, I have to go back to the books. Relearn the faded details of enzyme pathways, miscellaneous receptor actions, and courses of nerve tracts.

A lot of it is done on my iPad, a gadget I never imagined back in medical school, but it’s still the same routine I knew so well back then: Reading a page, staring blankly off to commit some point to memory, taking a practice test, and reviewing the answers. Occasionally, wandering off to get a can of soda or make tea.

Of course, today I have to work that around my family and job, concerns I didn’t have to split my time with in medical school. I had classmates who were married and had kids, and this always gives me a new respect for how they managed it.

Does knowing these details again make me a better doctor? I have no idea. I understand the idea that we need some way of showing we’re still on top of things after 20 years in the field. I’m not sure the current maintenance of certification practices are the best way to do that, but admittedly I don’t have any better ideas.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

The EHR system at the hospital occasionally argues with me about my orders.

kokouu/iStockphoto

I may order a brain MRI, or CT angiography, or pretty much anything, and when I click to submit it a box pops up, telling me I shouldn’t be ordering that.

Sometimes it’s based on cost, saying that the MRI is more expensive than a CT, and according to some internal algorithm I should do that instead. Other times it says the test isn’t appropriate given the patient’s condition, age, zodiac sign, whatever. It might also say the test is redundant, because the patient just had a brain MRI during an admission last month.

I ignore them. There’s an override button to close the box and order the test, and that’s what I always click.

I have no objection to a reasonable review, but neither the computer nor its algorithms went through medical school, or residency, or read journals regularly, or have 20 years of experience in this field. I’d like to think (or hope) I know what I’m doing.

I don’t take this job lightly. When I order a test it’s because I’m trying to do the right thing for the patient. To find out what’s going on. To see what I can do to treat them. In short, to help as much as I can within the limitations of modern medical practice. Sometimes those things don’t always involve saving the insurance company money, or trying to get by with a previous study’s results.

Medicine is not a cookbook. While guidelines can be useful, every patient is different, and treatment plans have to be adjusted accordingly. It would be nice if this was the one-size-fits-all world the computer algorithms would like, but patient care is anything but.

I’d also rather “overcare” than “undercare.” To me, that’s just good practice. If I follow the computer’s advice and provide less care than needed and miss something, I’m pretty sure “because the computer told me not to” isn’t going to stand up as a defense in court.

I’m going to just keep on practicing medicine using, as one of my past attendings would say, “clinical correlation” and keeping what’s best for the patient in mind. Anything less may be fine for the computer, but not for me, and certainly not for those I’m trying to help.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

The EHR system at the hospital occasionally argues with me about my orders.

kokouu/iStockphoto

I may order a brain MRI, or CT angiography, or pretty much anything, and when I click to submit it a box pops up, telling me I shouldn’t be ordering that.

Sometimes it’s based on cost, saying that the MRI is more expensive than a CT, and according to some internal algorithm I should do that instead. Other times it says the test isn’t appropriate given the patient’s condition, age, zodiac sign, whatever. It might also say the test is redundant, because the patient just had a brain MRI during an admission last month.

I ignore them. There’s an override button to close the box and order the test, and that’s what I always click.

I have no objection to a reasonable review, but neither the computer nor its algorithms went through medical school, or residency, or read journals regularly, or have 20 years of experience in this field. I’d like to think (or hope) I know what I’m doing.

I don’t take this job lightly. When I order a test it’s because I’m trying to do the right thing for the patient. To find out what’s going on. To see what I can do to treat them. In short, to help as much as I can within the limitations of modern medical practice. Sometimes those things don’t always involve saving the insurance company money, or trying to get by with a previous study’s results.

Medicine is not a cookbook. While guidelines can be useful, every patient is different, and treatment plans have to be adjusted accordingly. It would be nice if this was the one-size-fits-all world the computer algorithms would like, but patient care is anything but.

I’d also rather “overcare” than “undercare.” To me, that’s just good practice. If I follow the computer’s advice and provide less care than needed and miss something, I’m pretty sure “because the computer told me not to” isn’t going to stand up as a defense in court.

I’m going to just keep on practicing medicine using, as one of my past attendings would say, “clinical correlation” and keeping what’s best for the patient in mind. Anything less may be fine for the computer, but not for me, and certainly not for those I’m trying to help.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

The EHR system at the hospital occasionally argues with me about my orders.

kokouu/iStockphoto

I may order a brain MRI, or CT angiography, or pretty much anything, and when I click to submit it a box pops up, telling me I shouldn’t be ordering that.

Sometimes it’s based on cost, saying that the MRI is more expensive than a CT, and according to some internal algorithm I should do that instead. Other times it says the test isn’t appropriate given the patient’s condition, age, zodiac sign, whatever. It might also say the test is redundant, because the patient just had a brain MRI during an admission last month.

I ignore them. There’s an override button to close the box and order the test, and that’s what I always click.

I have no objection to a reasonable review, but neither the computer nor its algorithms went through medical school, or residency, or read journals regularly, or have 20 years of experience in this field. I’d like to think (or hope) I know what I’m doing.

I don’t take this job lightly. When I order a test it’s because I’m trying to do the right thing for the patient. To find out what’s going on. To see what I can do to treat them. In short, to help as much as I can within the limitations of modern medical practice. Sometimes those things don’t always involve saving the insurance company money, or trying to get by with a previous study’s results.

Medicine is not a cookbook. While guidelines can be useful, every patient is different, and treatment plans have to be adjusted accordingly. It would be nice if this was the one-size-fits-all world the computer algorithms would like, but patient care is anything but.

I’d also rather “overcare” than “undercare.” To me, that’s just good practice. If I follow the computer’s advice and provide less care than needed and miss something, I’m pretty sure “because the computer told me not to” isn’t going to stand up as a defense in court.

I’m going to just keep on practicing medicine using, as one of my past attendings would say, “clinical correlation” and keeping what’s best for the patient in mind. Anything less may be fine for the computer, but not for me, and certainly not for those I’m trying to help.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Around once a month I go to the cemetery to visit my Dad. Although this was difficult 6 years ago when I started, it’s become easier thanks to that great healer, time.

germi_p/Thinkstock

His grave is a short distance from the parking spot, so I have to walk past a number of others to get there. As a result you see these change over time.

A few times in the last several years I’ve noticed a new grave marker that, to my surprise, has the name of one of my (former) patients on it. Granted, a lot of my practice is the above-75 crowd, and they wouldn’t be coming to me if they didn’t have health issues.

But still, it jolts me a bit when it happens. I may not have thought about them for a while, but suddenly I see the marker and realize why that person hadn’t been in recently. I can usually picture them, too, and remember something they may have said that concerned me or just made me laugh.

Obviously, regardless of age we all end up there, and I certainly don’t consider this a personal medical failing on my part. It’s the nature of life on Earth, no matter how good a job we do as physicians.

But it still surprises me. If it was a patient I have fond memories of, I’ll often stop and say a few words to them, too. To date no one has answered, but I suspect there’s something therapeutic for me in doing so. The cemetery is generally peaceful, and certainly not a place where I feel rushed.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Around once a month I go to the cemetery to visit my Dad. Although this was difficult 6 years ago when I started, it’s become easier thanks to that great healer, time.

germi_p/Thinkstock

His grave is a short distance from the parking spot, so I have to walk past a number of others to get there. As a result you see these change over time.

A few times in the last several years I’ve noticed a new grave marker that, to my surprise, has the name of one of my (former) patients on it. Granted, a lot of my practice is the above-75 crowd, and they wouldn’t be coming to me if they didn’t have health issues.

But still, it jolts me a bit when it happens. I may not have thought about them for a while, but suddenly I see the marker and realize why that person hadn’t been in recently. I can usually picture them, too, and remember something they may have said that concerned me or just made me laugh.

Obviously, regardless of age we all end up there, and I certainly don’t consider this a personal medical failing on my part. It’s the nature of life on Earth, no matter how good a job we do as physicians.

But it still surprises me. If it was a patient I have fond memories of, I’ll often stop and say a few words to them, too. To date no one has answered, but I suspect there’s something therapeutic for me in doing so. The cemetery is generally peaceful, and certainly not a place where I feel rushed.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Around once a month I go to the cemetery to visit my Dad. Although this was difficult 6 years ago when I started, it’s become easier thanks to that great healer, time.

germi_p/Thinkstock

His grave is a short distance from the parking spot, so I have to walk past a number of others to get there. As a result you see these change over time.

A few times in the last several years I’ve noticed a new grave marker that, to my surprise, has the name of one of my (former) patients on it. Granted, a lot of my practice is the above-75 crowd, and they wouldn’t be coming to me if they didn’t have health issues.

But still, it jolts me a bit when it happens. I may not have thought about them for a while, but suddenly I see the marker and realize why that person hadn’t been in recently. I can usually picture them, too, and remember something they may have said that concerned me or just made me laugh.

Obviously, regardless of age we all end up there, and I certainly don’t consider this a personal medical failing on my part. It’s the nature of life on Earth, no matter how good a job we do as physicians.

But it still surprises me. If it was a patient I have fond memories of, I’ll often stop and say a few words to them, too. To date no one has answered, but I suspect there’s something therapeutic for me in doing so. The cemetery is generally peaceful, and certainly not a place where I feel rushed.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Is dementia a diagnosis?

I use it myself, although I find that some neurologists consider this blasphemy.

alexdans/Thinkstock

The problem is that there aren’t many terms to cover cognitive disorders beyond mild cognitive impairment (MCI). Phrases like “cortical degeneration” and “frontotemporal disorder” are difficult for families and patients. They aren’t medically trained and want something easy to write down.

“Alzheimer’s,” or – as one patient’s family member says, “the A-word” – is often more accurate, but has stigma attached to it that many don’t want, especially at a first visit. It also immediately conjures up feared images of nursing homes, wheelchairs, and bed-bound people.

So I use a diagnosis of dementia with many families, at least initially. Since, with occasional exceptions, we tend to perform a work-up of all cognitive disorders the same way, I don’t have a problem with using a more generic blanket term. As I sometimes try to simplify things, I’ll say, “It’s like squares and rectangles. Alzheimer’s disease is a dementia, but not all dementias are Alzheimer’s disease.”

I don’t do this to avoid confrontation, be dishonest, mislead patients and families, or avoid telling the truth. I still make it very clear that this is a progressive neurologic illness that will cause worsening cognitive problems over time. But many times families aren’t ready for “the A-word” early on, or there’s a concern the patient will harm themselves while they still have that capacity. Sometimes, it’s better to use a different phrase.

It may all be semantics, but on a personal level, a word can make a huge difference.

So I say dementia. In spite of some editorials I’ve seen saying we should retire the phrase, I argue that in many circumstances it’s still valid and useful.

It may not be a final, or even specific, diagnosis, but it is often the best and most socially acceptable one at the beginning of the doctor-patient-family relationship. When you’re trying to build rapport with them, that’s equally critical when you know what’s to come down the road.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Is dementia a diagnosis?

I use it myself, although I find that some neurologists consider this blasphemy.

alexdans/Thinkstock

The problem is that there aren’t many terms to cover cognitive disorders beyond mild cognitive impairment (MCI). Phrases like “cortical degeneration” and “frontotemporal disorder” are difficult for families and patients. They aren’t medically trained and want something easy to write down.

“Alzheimer’s,” or – as one patient’s family member says, “the A-word” – is often more accurate, but has stigma attached to it that many don’t want, especially at a first visit. It also immediately conjures up feared images of nursing homes, wheelchairs, and bed-bound people.

So I use a diagnosis of dementia with many families, at least initially. Since, with occasional exceptions, we tend to perform a work-up of all cognitive disorders the same way, I don’t have a problem with using a more generic blanket term. As I sometimes try to simplify things, I’ll say, “It’s like squares and rectangles. Alzheimer’s disease is a dementia, but not all dementias are Alzheimer’s disease.”

I don’t do this to avoid confrontation, be dishonest, mislead patients and families, or avoid telling the truth. I still make it very clear that this is a progressive neurologic illness that will cause worsening cognitive problems over time. But many times families aren’t ready for “the A-word” early on, or there’s a concern the patient will harm themselves while they still have that capacity. Sometimes, it’s better to use a different phrase.

It may all be semantics, but on a personal level, a word can make a huge difference.

So I say dementia. In spite of some editorials I’ve seen saying we should retire the phrase, I argue that in many circumstances it’s still valid and useful.

It may not be a final, or even specific, diagnosis, but it is often the best and most socially acceptable one at the beginning of the doctor-patient-family relationship. When you’re trying to build rapport with them, that’s equally critical when you know what’s to come down the road.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Is dementia a diagnosis?

I use it myself, although I find that some neurologists consider this blasphemy.

alexdans/Thinkstock

The problem is that there aren’t many terms to cover cognitive disorders beyond mild cognitive impairment (MCI). Phrases like “cortical degeneration” and “frontotemporal disorder” are difficult for families and patients. They aren’t medically trained and want something easy to write down.

“Alzheimer’s,” or – as one patient’s family member says, “the A-word” – is often more accurate, but has stigma attached to it that many don’t want, especially at a first visit. It also immediately conjures up feared images of nursing homes, wheelchairs, and bed-bound people.

So I use a diagnosis of dementia with many families, at least initially. Since, with occasional exceptions, we tend to perform a work-up of all cognitive disorders the same way, I don’t have a problem with using a more generic blanket term. As I sometimes try to simplify things, I’ll say, “It’s like squares and rectangles. Alzheimer’s disease is a dementia, but not all dementias are Alzheimer’s disease.”

I don’t do this to avoid confrontation, be dishonest, mislead patients and families, or avoid telling the truth. I still make it very clear that this is a progressive neurologic illness that will cause worsening cognitive problems over time. But many times families aren’t ready for “the A-word” early on, or there’s a concern the patient will harm themselves while they still have that capacity. Sometimes, it’s better to use a different phrase.

It may all be semantics, but on a personal level, a word can make a huge difference.

So I say dementia. In spite of some editorials I’ve seen saying we should retire the phrase, I argue that in many circumstances it’s still valid and useful.

It may not be a final, or even specific, diagnosis, but it is often the best and most socially acceptable one at the beginning of the doctor-patient-family relationship. When you’re trying to build rapport with them, that’s equally critical when you know what’s to come down the road.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

About once a week, along with all the other junk mail, I get a glossy brochure for some university’s online courses to “become a leader in medicine.”

phototechno/Thinkstock

They extol the virtues of their programs: How they equip me to “change the health care system,” “harness market forces to improve medical care,” “empower the next generation of physicians,” and other statements that were almost certainly not written by a doctor.

I’m sure some people are interested in this sort of thing. Maybe they’re ready for a career change from the exam room to the boardroom. But me? I have, pretty much, zero desire to do that. I don’t want to be a corporate leader in medicine. I didn’t come here to sit at a table and watch PowerPoint slides. I didn’t work to get into, and through, medical school, residency, and fellowship to debate earnings ratios and procedure costs with accountants.

I’m here for the patients. I’m sure there are some who became attending physicians, realized this wasn’t for them, and went off to do something else. That’s fine. I have nothing against it.

But, after 20 years in practice, I’m happy where I am. Like most others, I wish I made more money, or that my overhead was less, but I’m overall content with my little world. I have a great staff, a relaxed office, and the majority of my patients are good people.

I have no interest in trading that to be a leader in medicine. In the game of trying to make the world a better place, I’ve found my calling. I can do good for others far more effectively at my second-floor office than in a corporate tower.

And if doing my best for patients day in and day out doesn’t make me a leader in medicine, I don’t know what does.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

About once a week, along with all the other junk mail, I get a glossy brochure for some university’s online courses to “become a leader in medicine.”

phototechno/Thinkstock

They extol the virtues of their programs: How they equip me to “change the health care system,” “harness market forces to improve medical care,” “empower the next generation of physicians,” and other statements that were almost certainly not written by a doctor.

I’m sure some people are interested in this sort of thing. Maybe they’re ready for a career change from the exam room to the boardroom. But me? I have, pretty much, zero desire to do that. I don’t want to be a corporate leader in medicine. I didn’t come here to sit at a table and watch PowerPoint slides. I didn’t work to get into, and through, medical school, residency, and fellowship to debate earnings ratios and procedure costs with accountants.

I’m here for the patients. I’m sure there are some who became attending physicians, realized this wasn’t for them, and went off to do something else. That’s fine. I have nothing against it.

But, after 20 years in practice, I’m happy where I am. Like most others, I wish I made more money, or that my overhead was less, but I’m overall content with my little world. I have a great staff, a relaxed office, and the majority of my patients are good people.

I have no interest in trading that to be a leader in medicine. In the game of trying to make the world a better place, I’ve found my calling. I can do good for others far more effectively at my second-floor office than in a corporate tower.

And if doing my best for patients day in and day out doesn’t make me a leader in medicine, I don’t know what does.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

About once a week, along with all the other junk mail, I get a glossy brochure for some university’s online courses to “become a leader in medicine.”

phototechno/Thinkstock

They extol the virtues of their programs: How they equip me to “change the health care system,” “harness market forces to improve medical care,” “empower the next generation of physicians,” and other statements that were almost certainly not written by a doctor.

I’m sure some people are interested in this sort of thing. Maybe they’re ready for a career change from the exam room to the boardroom. But me? I have, pretty much, zero desire to do that. I don’t want to be a corporate leader in medicine. I didn’t come here to sit at a table and watch PowerPoint slides. I didn’t work to get into, and through, medical school, residency, and fellowship to debate earnings ratios and procedure costs with accountants.

I’m here for the patients. I’m sure there are some who became attending physicians, realized this wasn’t for them, and went off to do something else. That’s fine. I have nothing against it.

But, after 20 years in practice, I’m happy where I am. Like most others, I wish I made more money, or that my overhead was less, but I’m overall content with my little world. I have a great staff, a relaxed office, and the majority of my patients are good people.

I have no interest in trading that to be a leader in medicine. In the game of trying to make the world a better place, I’ve found my calling. I can do good for others far more effectively at my second-floor office than in a corporate tower.

And if doing my best for patients day in and day out doesn’t make me a leader in medicine, I don’t know what does.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.