Is Clinical Neurology Dead?
Looking backward and forward
I started my training in July 1959 at Montreal, Canada. Fifty-six years have passed since I entered neurology. Essentially, I am a clinical neurologist with interests in the welfare of patients, especially in patient care, in clinical diagnosis and teaching. I follow Sir William Osler's ober dictum—placing research after the above are done.
Neurology has changed like everything else. The biggest change has been brought about by imaging techniques such as computed tomographic imaging, magnetic resonance imaging (MRI), functional magnetic resonance, and positron emission tomographic scans; all of them have revolutionized the way we practice neurology. However, every good thing brings with it bad news. Today, physicians are more interested in the MRI findings than in their clinical expertise and in spending time with patients.
A radiologist, who has never seen the patient and depends on your inputs, reads the MRI scan. If the MRI findings do not agree with your clinical findings, go back to the bedside and start all over again. A new specialty emerging around the world is MRI-Negative Neurology, that is, "something is wrong with the patient but the MRI is normal!" Remember, in 30% of your cases, your clinical findings are more important than the laboratory findings.
Therefore, it is necessary to develop good clinical methods, which include the following:
The new slogan relevant today is: Please listen to the patients, as they are trying to tell you the diagnosis.
Let me quote Rober Wartenberg, the famous neurologist, who escaped from the Nazi persecution and settled in the United States—"Repeated history taking and physical examination are time consuming. It is the busy physician who will rely and delegate the diagnosis to the laboratory, in the vain hope of saving time. Too many investigations only confuse and cloud the issue, whereas a detailed clinical examination would have paid greater dividends. If your laboratory findings do not agree with your clinical findings, go back to the bedside."
In our vast country, there are 27 languages, 650 dialects, and 8 religions. Of these, language plays a role of greater importance. Even in South India, there are four distinct languages. Remember, in neurology, the diagnosis is made from the history.
In our out-patient setup, every patient is accompanied by at least four people, and some of them have no formal education. Therefore, it is important that if you are not familiar with the language, you must develop patience, use an interpreter, if required, and get an eye witness who has observed the patient's clinical condition over time, even if it takes 2 days to find one. The people who accompany the patient may simply come along to see the town and may have no personal knowledge about the patient!
Finally, a proper management is essential to provide benefit for the patient, and how tactful you are will pay dividends. Have a small bag with proper equipment, which should include the following:
Learn about developmental assessment so that one can examine a child with competence and care.
Avoid overprescribing medicines, as they are expensive for the lower-income group and sometimes unnecessary for the higher-income group. Tailor the medicines according to your clinical assessment.
The message here is that patient care is far more important than any other help you are giving; if you run several tests, you are caring about the results and not the patient. In a majority of patients, a part of the problem lies in the patient's mind; therefore, addressing the maladies in the patient's mind is of paramount importance. Always establish therapy with a team of competent therapists. Neurology is teamwork, and one must remember that no individual can solve any problem working alone.
The following quotation is from Dr. McDonald Critchley, who taught me clinical neurology at National Hospital, Queen Square, London, UK, in 1961, 1962, and 1963. While talking about Sir William Gowers, he stated, "Once again he would go over the points in the history, elucidating, and elaborating. His own examination would follow—full, detailed, but without the tedious slowness of some other neurologists. A clinical point, or any unusual symptom or sign would attract his attention. He would perhaps send for a copy of his manual to verify an observation. Often he would produce his pocket-book and make some shorthand memorandum which at home would be simplified and indexed for later reference.
The basis of his assessment of the problem was, therefore, solid and substantial. Aided by an adequate knowledge of neuropathology as it stood in his day, and by a thorough grounding in neuroanatomy, he interpreted his observations scientifically. Hence he did not have to rely on clinical memory, or clinical "instinct"—useful though they were to him. There was nothing flashy or meretricious, therefore, in his bedside technique. Hence it was that his diagnostic accuracy proved uncanny."
I joined the Neurological Society of India as a member in December 1996. The photograph shown here was taken in Bangalore with late Prof. B. Ramamurthy, late Prof. Baldev Singh, and Prof. Prakash Tandon [Figure 1]. I was a young man of 33 years when this photograph was taken. The photograph is important because I was associated with Prof. Ramamurthy from the time I was a medical student. I worked in Delhi at Safdarjung Hospital from 1957 to 1959 and was taught by Prof. Baldev Singh, who inspired me. Prof. Prakash Tandon is a good friend of mine; when I was an examiner for DM (Neurology) at AIIMS, I used to meet him regularly.
When the Annual Meeting of the Neurological Society of India, 2016 will be held in December in Chennai, I will complete 50 years as a member of this society. It has been a long journey, and I have made many friends. I have been attending the Neurological Society of India meetings reasonably regularly. When I became the Founder President of the Indian Academy of Neurology in the early 1990s, I divided my time between these two societies. In December 2009, in Lucknow, I was made an Honorary Member of the Neurological Society of India and honored with the Lifetime Achievement Award.
I will end this section with the following quotation by Sir William Osler:
"The Past is always with us, never to be forgotten. Sometimes, we live too much for the Present and too much for the Future." We should remember Prof. B. Ramamurthy (Chennai), Prof. R. S. Gindey (Mumbai), and Prof. Jacob Chandy (Vellore) to whom we owe the origins of this society.