The Country Neurologist

Beyond the Edge of Chaos

May 27th, 2024
By Eduardo Garcia, MD

Memory the warder of the brain—William Shakespeare

The other day we were asked to see a gentleman in his late 50’s for altered mental status. Bread and butter Neurology, I told my students. As we dove into the patient’s medical records we found, well… nothing! The patient was one of those healthy individuals who had not seen a doctor in 20 years! Without the usual navigational tools—like past medical history, prior medications, allergies, previous lab work, and imaging—I felt as though we were flying into a storm with no instruments. In the practice of 21st-century medicine, data is king. Data allows physicians to prepare Mental Predictive Models* that help narrow the differential diagnosis before setting eyes on the patient. Thankfully, we could still ascertain a trove of information using the time-honored history and physical exam.

When we entered the patient’s room we found a pleasant middle-aged man who greeted us with a big smile. His wife sat on a chair across his bed. I introduced myself and my team and asked what brought him to the hospital. Without wasting time, his wife explained how she had noticed some alarming changes in her husband’s behavior over the preceding weeks. He had become more irritable. She also noticed he had problems expressing himself, coming up with words, articulating his thoughts, and recalling recent events. She was also concerned about his driving which had become aggressive and erratic. Lastly, she remarked on how her husband had become uncharacteristically disorganized. His office, which had always been spotless and organized, had become a mess in a few weeks. To the extent that he could no longer keep up with bills and orders.

As the interview unfolded, I could not help but notice how the patient sat on his bed contemplating the exchange between his wife and the author, much like a spectator in a tennis match. I turned to the patient and asked if he had anything else to add—he didn’t. “Any headaches, fevers, chills, weight loss, or neck stiffness? I asked. “No doctor” he replied parsimoniously. He also denied any tick or insect bites, rashes, recent foreign travel, new medications, or abusing alcohol, or other substances. His wife denied any abnormal movements, staring spells, or weakness. His toxicology screen, routine labs, and head CT on admission had all been reported as normal.

On examination, our patient was a medium build middle-aged Caucasian male. He was shaven and coiffed. His comportment was normal, albeit somewhat withdrawn. He otherwise had good eye contact and followed commands appropriately. He knew who the US president was. He knew he was in a hospital, but could name the hospital, or the city where it is located. He knew the year, but could not tell me the date, or the day of the week. He could only retain 1 of the 3 words I gave him to memorize. He could not name the months of the year backward and had effortful and at times garbled speech. His strength was otherwise normal and symmetric, sensation was intact, as were his reflexes. His gait was normal.

When evaluating a patient I tell my students to keep seven guiding principles in mind: 1. Do your homework, and comb through the records for clues that may help solve the problem. 2. Listen to what the patient (or family) has to say, you can learn a wealth of information about the circumstances that led to the patient’s admissions, symptoms, educational background, and psychosocial situation, all just by listening! 3. Do a thorough exam, do not cut corners. 4. Localize the lesion, meaning, try to ascertain if the lesion involves the peripheral nervous system (nerves, plexus, or nerve root), central nervous system (spinal cord, brain stem, or brain), or both. Don’t forget supratentorial or functional disorders. 5. Remember Occam’s razor, that is, common things are common—if you hear hoofbeats outside your window, think of horses, not zebras! But don’t forget Hickam’s dictum, the principle in medicine that suggests that “patients can have as many diseases as they damn well please.” Once common things have been ruled out (including atypical presentations of common illnesses) you can go on your safari expedition. 6 . Think of the thing(s) you can not afford to miss and rule them out. Lastly, 7. Give the patient the benefit of the doubt, in other words, don’t judge a book by its cover.

As I finished examining the patient I knew we were dealing with a process involving the central nervous system. It also became clear that his presentation was atypical, it could still be a horse, but it looked more like a zebra—so much for bread and butter! It appeared we were dealing with a rapidly progressive neurological process. A process involving several cognitive domains including, working and episodic memory, attention, executive function, and language. The areas of the brain subservient to such domains included a large swath of valuable real estate including, the prefrontal cortex, thalamus, temporal, and parietal lobes.

Several mental representations played out in my mind. We still had to rule out stroke in keeping with our second heuristic**. To be sure, there was an element of aphasia in his exam. However, the subacute and progressive nature of his illness, along with his cognitive decline, and nonfocal exam, argued for a rapidly progressive dementia. The differential diagnosis of which includes, autoimmune encephalitides, paraneoplastic syndromes, and the most dreaded, prion disease. I recommended a brain MRI and lumbar puncture and started him on aspirin and atorvastatin in the off chance he had a stroke.

The human brain with its 100 billion neurons and more than 100 trillion synapses, or connections may be regarded as the mother of all complex systems. To put this in perspective, it is said that the number of synapses or connections in the human brain may exceed the number of stars in the observable universe! So what exactly is a complex system? A complex system consists of interacting components that exhibit emergent properties such as patterns or behaviors seen in an ant colony, a flock of birds, or consciousness. The components within the system are highly interconnected in both direct and indirect ways which can lead to feedback loops. The relationship between the components in the system is nonlinear, and the Complex loops can adapt to changing conditions, which may contribute to the system’s ability to self-organize¹.

Chaos theory, a branch of mathematics that deals with the behavior of complex and nonlinear systems, states that a small change in the initial condition may lead to different and difficult-to-predict outcomes. Think, The butterfly effect—a metaphor coined by meteorologist Edward Norton Lorenz, who illustrated how the flapping of a butterfly’s wings in Brazil could ultimately lead to a tornado in Texas².

Between order and chaos lies a dynamic state that facilitates information processing and adaptability, this Goldilocks state is referred to as “The Edge of Chaos.³“ The healthy human brain operates in such optimal complexity state. However, too much order, and the system malfunctions, too much chaos, and the system may run amok. An epileptic seizure is a perfect example of too much order, where networks of neurons fire simultaneously thus lowering the system’s entropy, or randomness. On the other hand, dementias increase the system’s entropy due to the breakdown in the brain’s organized structures and systems from misfolding proteins which disrupt the brain’s normal function.

The following morning I received an alert in my inbox, our patient’s brain MRI showed significant abnormalities in the basal ganglia—a cluster of neurons located deep within each brain hemisphere—, and cerebral cortex—the outer layer of the brain—concerning for Creutzfeldt Jacob Disease. Creutzfeldt-Jacob Disease, or CJD, is a fatal neurodegenerative disorder caused by abnormal proteins called prions⁴. Prions can trigger the misfolding of normal brain proteins which can spread like wildfire. This results in the accumulation of amyloid plaques that lead to cognitive decline, personality changes, rigidity, muscle twitches called myoclonus, and seizures. Most patients succumb within a year.

Our patient underwent a lumbar puncture before discharge and the cerebrospinal fluid was sent for analysis. We ordered the standard lab tests, as well as, autoimmune encephalitis panel, Protein 14-3-3, and Real-time quacking-induced conversion or RT-QuIC, a sensitive test that detects prion proteins. I never saw our patient again, as we referred him to a memory disorders clinic at an academic medical center downtown. However, a few weeks later I learned his Rt-QuIC had come back positive.

*Mental Predictive models are cognitive processes through which individuals create mental representations of future scenarios, events, or outcomes.

**Heuristic is a mental shortcut that helps one make decisions quickly and efficiently.

Reference:
1. Ladyman, J. Lambert, J. Weisener, K. What is a Complex System? European Journal for Philosophy and Science, June 2013.
2. Lorenz, EN. Deterministic Nonperiodic Flow, J. of Atmosph Sci, Vol 20, 130-141, 1963
3. Kitzbichler, ML, Smith, ML, Bullmore, ET Broadband Criticality of Human Brain Network Synchronization PLOS Computational Biology 2009.
4. Appleby, BS, Cohen, ML, Creutzfeld-Jakob disease Up to Date
State of Non Existence

February 21st, 2024

Last night I came across a video by Neil DeGrasse Tyson on the afterlife (or lack thereof). During the short video he explained how there was no scientific evidence to support the existence of a an afterlife. He called this state after death, a state of non existence. Such state, he said, is no different than the state prior to our formation (nothingness). Just imagine the likelihood of being a conscious living being in the universe! The known universe is 13.8 billion years old, or 1.38 x 10^10. The average human life expectancy in the US is 79.3 for females and 73.5 for men. The point being, do what you love, and love what you do, as we only dance this dance!
Back in the Trenches

July 30th, 2023

“Your work is going to fill a large part of your life, and the only way to be truly satisfied is to do what you believe is great work” — Steve Jobs

I was happy to be back on the floors after a month in the monotonous outpatient clinic factory line. I welcomed the somewhat controlled chaos in the wards, where you never know what will come your way. Sometimes you get a steady yet manageable barrage of pages, others—like yesterday— you get page after page until 5 PM, at which point you can start seeing your patients. Yesterday morning started quietly, we rounded on our patients from the day before and even had some time for teaching. But come noontime, all hell broke loose! No sooner had I called back the last requesting clinician than I would get another page. Thankfully, I had the Neuro Team to fall back on. Our team was no Jumbo Visma!—only a 4th year medical student and a PA student— but what we lacked in number we more than made up for in speed, attention to detail, and stealth. Why stealth? the reader may ask! Well, when a consultant gets called in to the ER, she better make sure she moves at lightning speed lest she ends up with 3 more “oh by the way” consults! Alas, notwithstanding spooky action at a distance that day we got hit with 2 more consults when we went down to the ER to see a patient.

Another reason I relish being in the wards is teaching! I have worked in other hospitals without medical students, residents, or physician assistant students, and believe me it’s not as fun. Moreover, students keep you on your toes! If a student asks you a question, you can not just go “we see that!” you have to stay up to date. Teaching also helps you find your weaknesses and correct them. I find that if I can not explain a concept clearly, it’s time to go back to the drawing board. As Richard Feynman said, “The first principle is that you must not fool yourself—and you are the easiest person to fool.” All in all I find teaching an essential antidote to physician burnout!

Lastly, I welcome the challenge of seeing patients with Neurological problems outside my area of expertise. In his book “Peak, Secrets from the New Science of Expertise” author Anders Ericsson makes a compelling case for stepping out of one’s comfort zone to achieve expertise. You may have heard of Ericsson’s 10,000-hour rule, in which he suggests that it takes about 10,000 hours of deliberate practice* to achieve expertise in a particular field.

One such case was Joe, an 85 year-old man who I was asked to see in the Intensive Care Unit (ICU) for worsening weakness and shortness of breath. Joe had a longstanding history of Myasthenia Gravis (MG), a chronic autoimmune condition associated with weakness and fatigue of skeletal muscles. He had been getting weaker and weaker over the preceding days to admission, right around the time his Neurologist lowered his mycophenolate—an immunomodulator used in chronic MG. It sounded like myasthenic crisis, a potentially life threatening exacerbation of MG.

When I first meet students doing their Neurology clerkship, I go over what I call “The Rules of Engagement” with them. These are a set of principles I have found very useful in my practice over the years. One of these principles is Win stay, lose shift, a heuristic** I use to adapt my decision-making based on past experiences. That is, if patient x has done well on medication y at dose z STAY! why change it? Irrespective of why Joe’s mycophenolate dose was changed, now we were confronted with impending respiratory failure. The patient’s last forced vital capacities (FVC)—a measurement of lung function that can help determine when a patient needs to be intubated—were tanking. To complicate matters, he had had side effects to plasmapheresis and IVIG in the past, both of which are the mainstay in the treatment Myasthenic crisis! Moreover, prednisone, another treatment option can sometimes be associated with worsening weakness that may throw the patient into respiratory failure. I did have one last card up my sleeve, pyridostigmine! I will digress to explain the mechanism of MG so as to illustrate how pyridostigmine works. Muscles are activated or turned on by a neurotransmitter called acetyl choline (ACh). Acetyl choline is released by nerve endings connecting to the muscle, only the connection is a virtual one. In fact, there is a cleft, or space between the nerve ending and the muscle. Vesicles or quanta of ACh travel through this synaptic cleft to attach to its receptor in the muscle. This in turn contracts the muscle.

In MG antibodies latch on to the ACh receptors like gum in a key hole, prohibiting ACh (the key) to enter its receptor (the key hole). Now, our bodies recycle the ACh in the synaptic cleft. Pyridostigmine inhibits or stops Acetylcholinesterase, the enzyme responsible for recycling ACh, allowing more ACh to be available to latch on to what remaining unobstructed key holes are left in the muscle.

Joe was not on pyridostigmine on account of giving him bradycardia (low heart rate). Of the two choices I was left with: 1. Prednisone, which could potentially worsen his weakness and land him on a ventilator, or 2. Pyridostigmine, that could make him bradycardic, the latter seemed the more sensible one (you can always give him something to prop up his heat rate). Thus we started him on low dose pyridostigmine. Over the ensuing days his FVC’s started going up, and his strength improved. By midweek he was discharged home on low dose pyridostigmine and his previous dose of mycophenolate. The morale of the story, If it ain’t broke, don’t fix it!

*Deliberate practice is a type of practice that involves focusing on improving specific skills, receiving feedback, and continuously pushing oneself beyond your current capabilities.

**Heuristics are mental shortcuts or rules of thumb that people often use when faced with complex or uncertain situations.
Gotcha!

June 25th, 2023

“Voodoo,” [Cootie] whispered. “Some peoples saying Henrietta’s sickness and them cells was man or woman-made, others say sit was doctor-made”—Rebecca Skloot

It started off one morning as a minor itch in my throat that was followed by what felt like a minor reactive cough, no biggie! That evening though—as my wife and I were walking downtown—my legs felt heavy, as if I were walking in molasses! “Perhaps I’m just overtired from the trip overseas” I thought to myself. It was not until the following morning that things really started going south. I woke up with a throbbing headache and generalized malaise. “This is it, you finally got me you cheeky bastard!” I thought to myself. Three years of washing my hands like an OCD person, gowning up multiple times a day to see patients, donning those suffocating N95 masks, wearing surgical masks, and goggles for hours on end, multiple vaccines, and their side effects, and yet there I was.

That morning my partner was about to go visit her elderly parents, when I offered testing myself before leaving. Most of our test kits were expired, except one! I opened the kit and carefully placed it on a desk, making sure I only touched the edges. I placed the reagent in one of two perforations on the card, got the swab, and started the process of turning the swab in one nostril 5 times clockwise and 5 times counter clockwise. I repeated the process in the other nostril. I introduced the swab in the lower of two orifices in the card, and turned it 3 times, closed the card, and set my watch timer for 15 minutes. After the 15 minutes I opened the card and voila! two red bars appeared on the strip, I had tested positive for COVID-19. This came as no surprise to me or my partner. I told her I was sorry! She would remain asymptomatic for three more days before testing positive herself. I must have gotten it in one of the airports or planes on my way back from a trip the week before. It really did not matter les jeux sont faits!

On the other hand, had I been infected in 2020 before the advent of the mRNA vaccines or Paxlovid, I could have been another statistic, one of 921,000 dead in the US according to the CDC. I called my Chief to switch my patients from in-person to virtual for the following week and spent the rest of the day in bed. By night fall I was warm and achy. I called a colleague in the ER, and asked his thoughts on Paxlovid—an FDA approved antiviral medication against SARS CoV2. “Unless you are over 65 and are not healthy, I would pass on it, he said.” I was on the fence about starting the antiviral in any case, who wants rebound COVID! I went upstairs locked myself in a room and got back to reading “La Peste” by Albert Camus.
Masks off

May 15th, 2023

“Without wearing any mask we are conscious of, we have a special face for each friend”—Oliver Wendell Holmes

Last Thursday at work my hand kept reaching for a mask every time I got up from my desk to greet a patient, only there was no mask to be found. On Thursday 05/11/23 the public health emergency was officially over, and with it the mask mandate at our institution. It was weird to see people walking maskless down the hospital corridors. Seems like only yesterday we were scrounging for N95 masks and reusing them often several times because of the PPE shortage. The idiocy surrounding the mask debate also comes to mind. Crazy how a simple mask was weaponized by politicians to create discord and divide people. Bonkers how some people would risk their lives and that of others around them in defense of “their rights!” And what about people’s right to live? Citizenship, The common good.

Only a few times in the history of our nation have we been asked to make sacrifices, think of the American Revolution, the Civil War, the World Wars, and 911. Americans didn’t flinch to serve their country in those trying times, yet when our generation was only asked to wear a mask to protect ourselves, our families, and neighbors, a good many declined and even took to arms (think Michigan). Wearing a mask was not a big ask! We were not summoned to land on Omaha Beach under a rain of bullets! Nonetheless politicians saw this as an opportunity to score political points, and in the process debunk science, and expertise!

Will I miss wearing mask? Probably not, nor will it be the last time I gown up and wear PPE. A small price to pay to stay healthy and stop the spread of infectious diseases, but that’s just me, a poor country neurologist.

Disclaimer: The views and opinions expressed in this blog are those of the author and do not necessarily reflect the views or positions of any entities they represent.
Coming of Age

May 7th, 2023

This past weekend I picked up my son at the airport. He was coming from Toronto, where he spent the week with his girlfriend—a small reward for his hard work in his last weeks of college. In the preceding weeks he took his finals, defended his thesis (and aced it), packed all his bags, subleted his apartment, and managed to get very high marks in the process. As he walked towards the car outside the terminal, I couldn’t help to notice a change in him, for starters he was wearing the blazer I got him, but he also appeared more mature. This was not the 18 year-old boy I dropped off at his residence, Shirreff Hall, the motto of which befittingly reads Esse Quam Videri (To Be Rather Than to Seem). Nor was he the chap I helped move into his first apartment a year later. This was a man, who had (with a little help) adapted and succeeded in his environment. He is a man, who actually loves what he studied, and is quite knowledgeable at it. His thesis reads like it was written by a professional (and I read the whole thing!). “My son is ready!” I thought to myself, as he opened the door with a smile and greeted me, hi dad!
Everybody is an Expert

April 30th, 2023

True intuitive expertise is learned from prolonged experience with good feedback on mistakes —David Kahneman

Not long ago I saw my cousin Frank at a family barbecue. It had been over 30 years since I last saw him, so there was lots of catching up to do as we stood by the grill sharing food and drink. Frank was in his early 60’s, but you would never know, he looked at least a decade younger. He stood around 5’10”, was medium built, and had a calm demeanor to him. As we stood by the grill his brother—who had joined with others—asked me if I was a Neurosurgeon. I told him I was a Neurologist and explained the difference between the two specialties, namely around $500K. “Anyway, do you know Frank has Parkinson’s?” he said. I stepped back in disbelief, how could it have eluded me? I had been chatting with the guy for a good 20 minutes! “Are you being treated for it?” I asked Frank. “Yes I have been on levodopa for the last ten years” he replied. At closer inspection the picture became more clear to me. He had not moved his left arm much for the time we were chatting. He also had mild dyskinetic head movements, and was slightly stooped. Otherwise, his blink rate was symmetric, he had normal facial expression, and had no resting tremor. “I’ll be darned!” I said. “Your doctor is doing a heck of a job, so just keep doing what you are doing” I told Frank. No sooner had I said this, than uncle Joe—a bright and opinionated engineer—jumped into the conversation. “So Frank, I hope you bought a lottery ticket” he said. Everyone in the group looked perplexed. “Why yes, everyone knows Parkinson’s is an old man’s disease” He said “just ask the Neurologist here!” he added, as his gaze fixed on mine seeking validation. “Well, Late-onset Parkinson’s disease, the most common type, occurs after the age of 50, so Frank is within the age bracket to have it.” I replied.

Curiously enough, I had just finished reading the book “The Death of Expertise” by Tom Nichols, which delves into the concerted attack on expertise and rise of anti-intellectualism as a consequence of the so-called democratization of knowledge. I see this all too often in clinic, when patients present with self diagnosed MS or ALS (the two biggies) based on “their research!” To this I kindly explain the difference between “a Google search” and actual scientific research, and add—tongue-in-cheek—that “thankfully a Google search is no match for a medical education and clinical experience*.” I also mention to patients that if you want to find evidence in the internet that the earth is flat, you will find it! Thus perpetuating that person’s confirmation bias. After all, search engines are nothing more than confirmation bias algorithms, “Pizzagate” being a prime example.

Ten thousand hours is frequently quoted as the time of deliberate practice needed for someone to achieve expertise in a given domain. The idea of the “10,000 hour expertise” is based on the work of psychologist Anders Ericsson, who conducted research on the development of expert performance. Deliberate practice involves intentionally focusing on improving specific aspects of performance, seeking feedback, and constantly pushing oneself to improve. Yet with the internet more and more experts appear to be coming out of the woodworks! From Lyme disease to COVID-19 vaccines, there is no shortage of “experts.”

As I was ready to leave the barbecue, another cousin approached me “Hey cuz, can I ask you a question about my mother? You know she was diagnosed with Alzheimer’s disease!” My brother who was with me immediately, and without hesitation interjected “so sorry to hear about auntie, but you know there is nothing to do, right!” said my sibling, as he turned towards me seeking affirmation. I looked at my cousin and said “the lawyer is right!” I turned around and left the party.

*According to Google “Med-PaLM2 its medical large language model or LLM was able to perform an expert test-taker level performance on the MedQA dataset of the US Medical licensing examination (USMLE) -style questions, reaching 85%+accuracy.”
How Commercial Insurance (and my practice manager) Killed the Most Innovative Advancement in the Practice of Medicine

March 26th, 2023

“He that will not apply new remedies must expect new evils, for time is the great innovator.”— Francis Bacon

Jack is a 79 year-old man who I saw in follow up for his Neurological troubles. He was accompanied by his wife, who supplemented the history. “How are you Jack?” I asked. “Hanging in there” he replied in a soft voice. Jack appeared frail, he had lost more weight since his last visit. He sat still as wife updated me on his condition. “Any hallucinations?” I asked. “He still sees little kids, but they don’t seem to bother him” replied his wife. I asked Jack where he was. He looked around the room, but could not answer my question. I asked him what the date was, but he was equally lost. “Jack, what do you call this?” I asked him, as I showed him a tennis ball. He looked at me with a blank stare for a few seconds and finally replied “a ball.” Then I showed him a pen “what about this, what do you call this?”I asked him “a pencil.” He said. “Can you repeat the words apple, table, penny for me” He did. “Can you repeat them again.” He could only recall apple. “I will ask you again what the words are in a minute.” Can you spell the word world backwards for me. “D, R, ….” he stopped. “What are the words I asked you to remember?” I asked. “Don’t know.” He said. “Can you repeat no ifs ands or buts about it” I asked him. He got stuck after no ifs. “Thanks Jack, can you lift your hands in front of you and tap your index fingers against your thumbs at the same time” I asked. He slowly lifted his hands and started tapping his fingers. The left appeared slower, and the amplitude was lower compared to the right. “Jack, can you get up from your chair with your arms crossed?” I asked. He tried, but every time he attempted to get up, he would fall back onto the chair, until his wife finally propped him up. I had him walk down the hall with his walker, but he could not initiate his gait—it was as if his feet were glued to the floor—. After a few tries he finally got going. He shuffled as he walked away. He had a stooped posture, and it took several steps for him to pivot back towards me. “Thank you Jack, you can sit down now” I said.

Jack suffers from dementia with Lewy Bodies (DLB), a neurodegenerative disorder characterized by the accumulation of Lewy bodies in the brain. The late actor Robin Williams was diagnosed with this condition. Lewy bodies are abnormal protein deposits that develop inside neurons, and they are associated with the degeneration of these cells in specific areas of the brain. The exact cause of DLB is not fully understood, but it is believed to involve a combination of genetic and environmental factors. Clinically DLB is associated with the triad of memory impairment, visual hallucinations, and Parkinsonism. We do not have a cure, but we can manage the symptoms and improve the patient’s quality of life. Following our interview we were able to ascertain the progression or Jack’s condition, make medication adjustments, and make other recommendations, all without leaving the comfort of his home via Telehealth.

In the spring of 2020, at the height of the COVID-19 pandemic, our practice switched from 100% in-person visits to 100% remote or virtual visits. Thanks to advances in computing and telecommunications we were able to evaluate, diagnose, and treat patients like Jack through a computer screen. As vaccines became more readily available we switched to a hybrid model, in which some patients were seen in person, while others were seen remotely.

A Brief History of Telemedicine

Telemedicine—the use of telecommunications and digital technology to deliver health care services remotely—is not new. There are reports going as far back as the 1870s describing the use of telephone calls to determine if a baby had croup.In the 1920’s the radio was used to provide medical advice to clinics on ships (Nesbitt, 2012). In 1968 the Massachusetts General Hospital established a medical station at Logan Airport in Boston staffed by nurses and linked via microwave to provide emergency services.In 1976 Memorial University of Newfoundland established the Telemedicine Centre which provided remote health care and education to rural areas.

The National Aeronautics and Space Administration (NASA) also played a pivotal role in the development of telemedicine. The STARPAHC (Space Technology Applied to Rural Papago Advanced Health Care) program was a project implemented by NASA and the Indian Health Service (IHS) in the 1980s to improve healthcare services for the Native American community in the Papago Reservation in Arizona. The project aimed to bring advanced healthcare technologies and telemedicine services to remote and underserved areas using satellite communications. The project included the installation of medical equipment and technology, such as telemedicine systems, ultrasound machines, and remote monitoring devices, in the Papago Reservation. These technologies allowed healthcare providers to remotely diagnose and treat patients, share medical information, and collaborate with specialists in other locations. In 1993 the American Telemedicine Association was created, its mission: To promote and expand Telehealth technology companies as a way of increasing patient access to care*.

Follow the money!

In the 1990’s Telehealth programs in the US were mostly funded by federal grants through agencies like the Office for the Advancement of Telehealth and the U.S. Department of Agriculture. The Telemedicine Development Act of 1996 was sponsored by then California state senator Mike Thompson. The law among other things requires insurance providers to reimburse telemedicine services at the same rate as in-person services, as long as the telemedicine services meet certain criteria.

Then came the Balanced Budget Act of 1997 (BBA) a US federal law that had a significant impact on Telehealth. The law included several provisions related to Telehealth, including, Medicare reimbursement of Telehealth services in rural areas under certain conditions, such as the use of interactive audio and video technology. However, the law also included some restrictions that limited the adoption of telehealth services, and subsequent legislation was aimed to expand access to telehealth and remove some of these limitations.

In the wake of the 2008 financial crisis, the federal government passed the American Recovery and Reinvestment Act (ARRA) of 2009, which also had a significant impact on the adoption and expansion of Telehealth services in the country. The law provided funding for healthcare providers and organizations to implement electronic health records (EHRs) and other health information technology (HIT) tools, including Telehealth. One of the key provisions related to telehealth was the establishment of the Health Information Technology for Economic and Clinical Health (HITECH) Act. The HITECH Act provided funding to support the adoption and use of electronic health records (EHRs) by healthcare providers. EHRs can facilitate the exchange of patient information between healthcare providers, which can be especially important in the context of telehealh

In addition to supporting the adoption of EHRs, the ARRA also included funding to support the development of telehealth infrastructure and programs. This funding was intended to help expand access to telehealth services, particularly in rural and underserved areas where access to healthcare services may be limited. The ARRA also provided funding to support research on the effectiveness of telehealth services. This research was intended to help determine the best ways to use Telehealth to improve patient outcomes and reduce healthcare costs.

Finally, in response to the COVID-19 pandemic, Chapter 260 of the Acts of 2020 was enacted. The Massachusetts state law’s purpose was to increase access to healthcare services through Telehealth. Under the law, healthcare providers in Massachusetts are allowed to offer telehealth services to patients without first establishing an in-person relationship. Additionally, insurers are required to cover telehealth services in the same way that they cover in-person services, with certain exceptions.

Back to the office

One evening, more than two years after the successful implementation of the hybrid model in our practice, my boss showed up in my office with a big grin on his face “well, everybody is going back to the office!” he said. The comment was in reference to the inexorable return to the old paradigm of the practice of medicine. A model that can be traced back to Imhotep—the first physician in recorded history Ca. 2600 years BCE. In the old paradigm the infirm would travel—at times great distances and at great cost— to seek care from a medicine man, shaman, or doctor. However, in the spring of 2020 the COVID-19 pandemic upended the status quo. Decades of technological innovations in telecommunications coupled with progressive legislation had culminated in a new paradigm which promised to break barriers to care and physician burnout. For a brief moment, the future looked bright for both patients and physicians, that is until one day, one of the major payers announced they would stop paying parity for specialty visits. At which point practice managers and other suits did not hesitate to crack their whips and bring everyone back to their offices. Not long after the aforesaid healthcare behemoth made its announcement, the so called big three followed suit, killing any hope for a return of the more benevolent model we had been living with for almost 3 years. Thus, it is incumbent upon us as physicians to do everything in our power to maintain Medicare reimbursement at parity and convince commercial insurance to do the same. Telehealth is the future, so talk to your institutions, talk to your state medical society, talk to your legislators in congress, and never, ever, ever give up.

*For more on the history of Telehealth, please refer to the Chapter on History of Telehealth by Thomas S. Nesbitt. Understanding Telehealth, 2018 McGraw Hill.

Disclaimer: The views and opinions expressed in this blog are those of the author and do not necessarily reflect the views or positions of any entities they represent.
On Advocacy

March 12th, 2023

“Every moment is an organizing opportunity, every person a potential activist, every minute a chance to change the word” — Dolores Huerta

Kaitlyn is a 35 year-old otherwise healthy woman. She lives with her two young children and boyfriend in a middle class neighborhood in the area. She works part-time at a school cafeteria to supplement the family income. She does not drink, or smoke cigarettes, but she does smoke cannabis “to calm her nerves.”

One morning Kaitlyn woke up with blood in her mouth and aching all over her body. She later described the feeling “as if I got hit by a Mack truck!” She Googled her symptoms and proceeded to the Emergency Room to get checked out. When the medical students and I saw her in the ER she appeared distraught, she was fidgety, and her speech was pressured as she related her story. On further questioning, she mentioned memory problems and “weird spells” over the previous couple of years “like a rush going from my body to my head!” This feeling was usually preceded by recalling a familiar dream, or déjà vu. Her sibling, who was in attendance, confirmed the story and added “yes, and she looks like a deer in the headlights for a few seconds!” Her spells were happening several times a day, but she chucked her symptoms to her anxiety. She denied any risk factors for seizures, such as, head injuries with loss of consciousness, family history of epilepsy, or seizures with fevers as a child. Her physical and neurological exams were otherwise normal, save for bites on each side of her tongue. “I think you are right, it looks like you had a generalized tonic-clonic seizure” I told her.

Kaitlyn was admitted and by the following morning she had had an EEG—a brainwave test to look for abnormal electrical activity in the brain—and a brain MRI. The former showed interictal epileptiform discharges (IEDs) arising from the right temporal lobe. The presence of IEDs can help confirm the diagnosis of epilepsy, and where seizures are coming from (Chabolla and Cascino 2006). The brain MRI showed a bright and shrunken right hippocampus—the most medial portion of the temporal lobe—which can be seen in patients with drug resistant temporal lobe epilepsy. As I explained to Kaitlyn, her history, EEG and MRI findings were all consistent with temporal lobe epilepsy coming from the right side of her brain. She was terrified, but at the same time expressed relief to know “she wasn’t going crazy.”

We started her on an antiseizure medication called levetiracetam, informed her that she would not be able to drive for 6 months as per state law, and discharged her home with a follow up appointment in 2 weeks. The following week I received a message from Kaitlyn, she was irritable and she was “snapping at her kids and boyfriend a lot!” I explained to her that this was likely a side effect of levetiracetam, and we switched her to another antiseizure medication called Vimpat (lacosamide). When I saw her in follow up she stated feeling much better, she had no side effects to the medication, and the number of episodes had decreased dramatically.

In her next visit Kaitlyn reported feeling more like her old self, even her memory was better! She had just gone back to driving and no longer depended on rides to go to work or pick up groceries. It seemed she was finally turning the corner. That is, until one day when she received a letter from her health insurance stating Vimpat—the very medication that had finally controlled her seizures—was no longer covered by her plan and that she would need to contact her doctor. At around the same time I received a prior authorization from her pharmacy benefit manager.

Prior Authorizations, Prior Auths, or PAs are used by pharmacy benefit managers (PBMs)* to determine if a treatment or service will be covered. The origin of Prior Auths can be traced back to utilization reviews by Medicare and Medicaid in the 1960s. These were ostensibly used to reduce over utilization of resources and identify waste. Over time the utilization review model was widely adopted by health insurance plans and evolved into what we now know as prior auths. I find PAs a draconian instrument widely used by PBMs to deter clinicians from ordering certain medications, studies, or procedures. It breaks down like this: Clinician orders prescription X for condition A. If prescription X is not in formulary—meaning, the PBM contracted with the health insurance plan does not have a special deal to get prescription X cheap—the PBM will send the clinician a Prior Auth. The lengthy document, which not infrequently needs to be filled by hand and faxed back over to the PBM, will recommend other treatment options for condition A, like say prescription Y. Here is the kicker, the pharmaceutical maker of prescription Y has a deal with the PBM for a cheaper price than prescription X! Therefore, the PBM will push for prescription Y, regardless of whether the patient is doing well on prescription X or not! How does the PBM know whether the patient will do well on prescription Y? You may ask. Well, that’s the problem, they don’t! For all we know the patient could have a fatal reaction to medication Y or condition A could run amok! The decision is purely economical with no regard to the patient’s health or condition.

Can the clinician then appeal the PBM for medication X? The answer is yes, but not infrequently before trying prescription Y, so called step therapy. In case the clinician attempts to forgo prescription Y all together, he/she/they would need to fill the prior auth in which the clinician would have to answer questions such as: When was the patient diagnosed with the condition? has the patient been hospitalized for such condition, and if so which dates?, when was the patient started on prescription X?, has the patient tried other medications? if so name the medications, and the dates they were tried? you get the gist…

The rate limiting steps in this equation are time, man power, and of course money! With dozens of PAs a day, some practices have resorted to hiring people—in cases whole departments—just to fill out PAs. Others have given clinicians admin days to fill PAs and clear the junk from their inboxes, this in turn results in less access to care! Moreover, the clinicians or practices, many of which operate on tight margins, are not reimbursed for the time it takes to fill prior auths. So where is the cost savings? One may ask!

Lastly, the decision making by the PBM once the information is ascertained and faxed or entered, may take as long as two weeks. Yet, 90% of Prior Auths are approved. So why go through this exercise in futility? As I said before, to deter us from ordering certain medications, tests, or procedures.

Back to Kaitlyn, once we were slapped with the Prior Auth, we had to move fast, as she only had enough medication for three days. Withholding antiseizure medication, even one dose, may lead to a recurrent seizure, which could in turn lead to another 6 months of no driving, loss of wages, injury, or even death. Unfortunately, there was no generic lacosamide in the market—only brand name was available at the time. Since brand name medications are more expensive than generics, PBMs make it exquisitely painful to approve. In the end, in spite of our best efforts, we were unable to secure the medication in time, and ended up switching her to another antiseizure medication. She had some side effects to her new medication, and she had some breakthrough auras as well, but she did not have any further generalized tonic-clinic seizures. When Vimpat finally went generic we were able to switch her back and she is now stable and doing better.

I wish I could say this scenario is rare, but it happens all too often. That is why it is important to advocate for our patients and for the practice of Neurology. We should not be told by an RN or doctor in the other side of the line, which medication is best for our patients. Almost every year since 2015 I have made the pilgrimage to DC to participate in Neurology on the Hill where a bunch of concerned Neurologists take the time off their busy schedules to talk to their elected representatives in congress to advocate for issues such as Prior Authorizations and the unnecessary burden they create on an already stressed system.

*Pharmacy benefit managers through specialty pharmacy services such as CVS Caremark, or Optum Rx are contracted with commercial health insurance plans, self-insured employer plans, Federal Employees health benefit plans, and other to negotiate prices from drug manufacturers, and encourage use of generic medication.

Disclaimer: The views and opinions expressed in this blog are those of the author and do not necessarily reflect the views or positions of any entities they represent.
Employed or in private practice?

February 26th, 2023

I remember distinctly how one day our group met with one of the many hospital presidents that have come and gone in my time. The first thing he asked was not how are you? but rather “are you employed or in private practice? “Why is this relevant?” I asked myself, aren’t we all doctors taking care of patients? or are we? In this article we will explore the differences (and similarities) between Neurologists in private practice v those employed by a hospital or healthcare system.

According to the American Academy of Neurology (AAN) 2020 Insights Report, in 2019 49% of its US members were employed by a hospital, 22% were employed by a practice, and 13% were owners or partners. In the same report the percentage of members in solo practice fell from 18% in 2008 to 11% in 2019. In the same period Neurologists in a Neurology Group went up from 20% to 27%, you get the gist.

If the trend continues solo practices will soon relegated to a display in a museum of natural history along with other extinct species like the T-Rex, and the Dodo. I’m not saying that is a good or a bad thing, it’s just evolution. The practice of medicine in the US has become too costly and impossibly complicated for a solo practitioner to bare alone. I myself am employed by a Neurology private practice, and while we are probably in the endangered species list, we are still game in this mass extinction of private practice.

So are you employed or in private practice? Let’s face it, regardless of whether you work for a Neurology group practice or a behemoth healthcare system, most of us are already employed. As such, the autonomy train has long left the station!

So how do you define autonomy? In my mind autonomy implies the ability to decide your work hours, vacations, and taking time off for emergencies. From what I have seen the larger the group the harder it gets for one to decide his/her hours. That said, smaller practices are subject to other types of pressures (i.e. man power) that may make your 4th of July getaway as elusive! So now that the autonomy issue has been settled—meaning we ain’t got any!—we can continue with our exercise.

What is your salary? According to Doximty the estimated compensation for Neurologist in my area is $208,000, where the median home price is $496,500. Are we being compensated enough? I am afraid the answer is a resolute negativo. So what drives our salaries? you may ask. Our salaries are driven in part by CMS (Centers for Medicare and Medicaid) and by market forces, such as geographic location, years in practice, and other. So how does CMS determine your pay? It starts when you bill the appropriate code, CPT (current procedural terminology) code, followed by coding the appropriate diagnosis or ICD (International Classification of Diseases) code. Finally, a determination of payment is made based on RBVRS (resource based relative value scale) of which RVUs (relative value unit) are an important part.

So what is an RVU? An RVU is a measure of value used by CMS to calculate physician reimbursement (Baadh et al. 2016). Prior to the creation of the RVU, CMS reimbursed physicians using a “usual, customary, and reasonable” rate which led to payment variability (Uwe Reinhardt 2010). Currently for each service provided, the payment formula contains 3 RVUs, one for physician work (~52%), one for practice expense (~44%), and one for malpractice expense (~4%).

The 3 RVUs are each multiplied by a GPCI or geographic practice cost index, so called GPCI adjustment. The sum of the three RVU components adjusted by their GPCIs is then multiplied by the Medicare conversion factor (CV) for the final price or Fee for service Medicare pays for one overall RVU. The formula looks something like this:

Fee(z) = (Work RVU2 x Work GPCI + PE RVU2 x PE GPCI + PLI RVU2 x PLI GPCI) x CV

In paper CMS regularly adjusts RVUs (i.e. due to advances in technology, etc.) In reality adjustments in RVUs are made by an elite group of 29 physicians, the Seal Team 6 if you will, within the AMA known as the Specialty Society Relative Value Scale Update or RUC. The RUC has such punch that CMS follows the RUC’s recommendations 90% of the time! (Uwe Reinhardt 2010). So AMA where are you?

Other forces that determine your compensation include, you guessed it, Location, Location, Location! So if you want to work in NY, one of the states with the highest concentration of jobs according to the US Bureau of Labor statistics, well… it’s going to cost you, whether you are in private practice or employed by a healthcare system.

Other factors that may influence your compensation include, years of experience, level of training, discipline within Neurology (procedure v. non-procedure based), performance, and other. N.B many of these factors are subject to change with Obamacare.

Can someone say benefits? Benefits, are the third metric I will analyze in our exercise. What are your benefits? Typical benefits packages include, healthcare, dental, disability, and malpractice insurance, paid vacation, CME stipend, licensing fees, personal days, and 401K matching. Anything short of the above is a nonstarter! But provided you get the above said bare minimum, the quality of benefits will vary from employer to employer. Big organizations have more clout and can therefore negotiate better contracts with health insurances, while others will try to sell you their homegrown plans (whether better or worse).

Quality of Life (QOL), our last metric of the day, a metric that is hardly considered by those deciding between a life in private practice v employed. QOL is also difficult to measure. How do you measure your work related QOL? Inevitably, one of the first things that come to my mind is burnout! Yes indeed, the dreaded “B word,” subject of much lip service, especially by large conglomerates which bolster on meaningless campaigns like “the joy of medicine, or the joy in practice.” Campaigns devised by the medical industrial complex to appease our ever increasing number of charred Neurologists while accomplishing nothing. So what are some of the drivers of burnout in your practice? Administrative burden (i.e. prior-authorizations, forms), patient load, time per patient, call schedule, COVID-19? So what can be done about the burnout crisis? Well firstly, I would argue we need more time with our patients. This however, is in direct opposition with the current business model of medicine, in which doctors’ and other practitioners’ salaries are dependent on number of patients/procedures they generate. Secondly, we need smarter technology, while voice recognition and electronic medical records are improving, we are a long way from opening a chart and having AI warn us that patient so and so is at imminent risk of a stroke, or patient x has had an uptick in her seizures over the last month. I would argue at least half the time we spend with our patients we are just doing data entry! Is this what the industry calls “working at the top of our license”? Hardly; Lastly, we need to be better compensated whether it is monetarily, in time, or other.

Well there you have it, my 2 cents on private practice v employed. In the end whether your work for the largest employer in the state or are in an old fashion moms and pops solo practice, we are all working class Neurologists!

Disclaimer: The views and opinions expressed in this blog are those of the author and do not necessarily reflect the views or positions of any entities they represent.