“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.