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Hello and welcome to the neuro transmitters, a podcast about everything related to clinical neurology uh with the goal of reducing your neur a phobia. I'm fortunate to be joined today by Doctor Ethan Meltzer, a neurologist at the University of Texas. Thank you so much for joining me today. I really appreciate it. Yeah, thank you for having me. So, uh the reason I asked you on was uh you had this book come out earlier this year called Very Appropriately How To Think like a Neurologist, which I, I really love that title. Uh It's very on the Nose and it has just enough cheekiness. But uh but tell me a little bit about kind of how you got started in neurology and then what uh what the path was that led you to kind of publishing this book. Yeah. So, you know, my path to neurology, um I guess it, it goes pretty far back. Um, you know, as a child, I was always interested in sciences, um and eventually found my way to medicine and, you know, the brain just fascinates me. You know, it's, you know, you know, as people say, it's the last frontier of medicine in the sense of, you know, there's so much that we don't yet know. Um, and, you know, it's just something that, that, um, I think it's very easy for me to see and to get it excited about. Um, you know, there's someone, you know, I don't know if it's saying, or someone has told this to me once. Uh, but I really like it. Which is that, um, you know, neurology and I guess psychiatry as well. It's the only specialty in medicine where the organ actually tells you what's wrong. Uh, you know, uh which I really like, you know, you know, if someone, you know, the liver can't speak to the heart, can't speak to you, but you can actually ask the, the organ that is having the disease, what it's experiencing, um, which I think is just wild. I'm gonna steal that one. Yeah, I still look from someone I can't remember who otherwise I would give the credit. So, so you've been obviously, you know, gone through training uh fellowship, etcetera. And, you know, and now you're, you're teaching neurology yourself and you know, what uh what was it that you saw when you're, when you're teaching new trainees about neurology that uh that kind of led you to write an entire book on the subject? Yeah. Um, you know, so the book How To Think like a neurologist, um, is, you know, it was really inspired by, you know, what I think of is trying to, to really tap into what is really the challenge of neurology or what's the skill that neurologists have? Um And, you know, it doesn't exist in isolation and, you know, obviously, it's inspired by my own training and the people that I learned from. Um and I'll, you know, give a quick anecdote. Um You know, so I got the privilege of attending um one of the new England Journal um CPCS Grand rounds when I was a resident, um where Dr Marty Samuels um was presented a case and it was this case that was incredibly complex guy with a very complex medical history. And he's having essentially every known neurologic symptom to, you know, that that can be described, it's progressing very quickly over the course of about three weeks and then he dies. Um And um the only other information that was really relevant is there was an inflammatory spinal fluid and you had some fever, but it's just, it's very, very, very quickly progressing syndrome. And I remember sitting in the audience and there and, you know, they're reading this history or, you know, they're presenting him this history, you know, like what you would read in the, you know, what the paper actually looks like when it ends up getting published. And there's so much information at the end of it, you know, he puts up a single slide where he's taking all of this and he says this is a rapidly progressive fatal mening go encephalitis. And, you know, it was, you know, basically that what, you know, five or six words, he's taken about 1000 words made into five or six words. And he says this really probably can't be much else besides amoeba. Um, and it was amoebic encephalitis. Um, and, you know, it's one of these things that, that looks like magic if you don't really know what he's doing. Um And so that was really kind of the basis of the book is that, that shouldn't be magic. Um It should be something that seems attainable to trainees um to even to non neurologists, which is how does someone get this, you know, two pages of information to still it to five words and then say, and then formulate a differential diagnosis based off of that. Um And I think that that's really, you know, when I think back about my training in residency and, you know, I learned lumbar puncture is, you know, you learn to do Botox, you know, you do learn discrete skills, but probably the most important skill I think I learned was how to get a history, get an exam and then translate that into meaningful data um that defines a clinical syndrome and then I can make a differential diagnosis. Um And it's something that really is not taught. I think for the most part in earlier parts of medical training, um you know, students are given you know the exam question and it already has distilled, it, it's already to find the syndrome in the exam question. And then when they come to the wards, you know, they struggle because they aren't presented with that information already that and you know, so being able to generate that, you know, I think that's, that was really the impetus for the book. Yeah. And one of the things I, I really like is your emphasis on and I think this, you referenced his book a couple times, uh Doctor Erin Berkowitz's uh Clinical Neurology and your anatomy, which actually came out just before the year or two before I took my boards. I used it from my anatomy review for, for board exams, uh which is great, but he talks about imaging negative neurology which, you know, I know there's uh let's just say uh neuro haters out there and um like, what do we need to, you know, do that? We can just get an MRI, right? But uh but there are so many things in neurology where the MRI, you know, maybe it's red herring or it doesn't tell you anything useful at all. And uh you know, really drilling down on like the thought process and if you would be so kind as to uh talk a little bit about kind of your approach to generating your neurologic differential diagnosis. Yeah. Um you know, it's, you know, very apt to bring up uh Aaron's book um you know, I know him well and, and, you know, you know, I, you know, he was one of my attendings. And so again, you know, these ideas aren't in isolation. And, and so, you know, really the idea of the book was to try and codify in a way that at least I hadn't seen before. And, you know, I think, you know, one of the little blurb for the book is really trying to flip kind of the case narrative on his head where it's, you know, the case is not the, that's not what we're focused on. We're not, you know, the, you know, I tell the readers, you know, this is not a book where you're, you're gonna be learning clinical diseases, you know, hopefully not because it's a lot of zebras, a lot of real things aren't too relevant for most of medical training. Um And so the end payout is not necessarily getting it right. Um The end payout is the, you know, is the journey is the way to get there. And so unlike a typical case book where the focus is on the actual pathology, um you know, if, if you look to the book, you know, the pathology, it's not necessarily throw away, but it's a small little paragraph um for the most part at the end of any case and really the meat of it is trying to define the clinical syndrome. And so, you know, kind of going back to that, defining that term a little bit here. Um, you know, I think about it, it's the one liner in the assessment for neurology. And that's, that's what I tell medical students when I'm rotating is, you know, your neurology assessment, you know, shouldn't be, you know, 25 year old comes in with a MC A stroke. Um, you know, the, you know, that first line is, you know, a 25 year old comes on with an abrupt or acute or hyper whatever term you want to use, you know, acute onset of aphasia and right sided weakness, you know, and then differential stems from that in terms of what the actual pathology is. And so a lot of the book talks about using the history and particularly um what I've used of the term as the pace, other people would use the word tempo, but essentially how quickly something comes on. Um And then also the localization where within the neuraxis is it and combining those two things, um is what I think of when I think of as the clinical syndrome. So, yeah, and you know, that's what, you know, Marty did and, you know, in that grand rounds is, you know, rapidly progressive fatal mening go encephalitis. Um And, you know, it's, you know, that's the syndrome. Um and there's no, no, you know, you don't necessarily need any sort of book knowledge. Now you need neuro anatomy course, you need to go to get a history, you know, so it's not that there are any skills that are needed, but you don't necessarily need to have an encyclopedic knowledge of every disease that's out there. If you can get the syndrome, you're probably about 95% of the way there in terms of the diagnosis. Right? I think that's, yeah, a lot of the work up that sometimes you'll see, you know, if, if there has been a work up before you are asked to see a patient, um, it seems almost haphazard uh in terms of like imaging obtained, like I can't, I can't count how many times I've been asked to see someone who's been having like, you know, difficulty walking or leg weakness or, you know, quote unquote leg weakness and there's a lumbar MRI on file, like, well, that doesn't, that doesn't fit this presentation at all, like that's just a wasted test. Um And so, you know, I, I somewhat in jest with, uh, with the residents and students who, with me, it's like, you know, sometimes part of the job is just telling people where to point the scan. Er, right. Um, but, and, you know, to that point, I'll get one unit dose but, you know, to that point when I think of value based care, especially in neurology. Um and it's interesting, you know, because, you know, we have these discussions often in our morning reports, you know, value, you know, there's a lot of value based care there, right? Because it is, you know, getting unnecessary tests, um, you know, lab tests, Mri's has a huge cost. Um, you know, to the patient, you know, you have the potential for false diagnoses. And so, you know, think about how many memories of the lumbar spine for difficulty walking could be avoided. Um, you know, with, you know, a simple, you know, what's the pace, what's the localization? Oh, you know that, you know, that seems like parkinsonism. Okay. Well, there's no need to look at, you know, at the lumbar spine. And um I have to make the comment just because, um you know, it just happened this week, but I was, you know, one of my proudest moments so far on morning report is one of our new PG by Tues was presenting this case of, of this person who came, you know, this woman who came in and, and you know, that you are had called him after they had ordered a, you know, MRI of the brain cervical thoracic spine. And he sees the patient, he says, well, has this kind of a sending parasthesia and hyperreflexia, a little bit of minor hip flexor weakness. And he said, you know, I I told him no, just, you know, we don't need to look there. Uh You know, I really thought that this was a poly radiculopathy and I thought, you know, you know, that, you know, the future is bright um, you know, there, there, you know, it makes your, uh, neurologist is still there and, and, um, and so, you know, that sort of thing is, you know, makes me so proud when I hear our students thinking like that, um because they're, they're generating hypotheses, um, you know, in the room and then they're testing it with an MRI and that we're uh lumbar puncture as the case may be. That's awesome. Yes. So, so two year to your point in terms of like, you know, like you said, it almost seems like magic when like these experienced attendings with decades of experience coming and see these patient's. And um you know, there are a lot of medical schools out there that uh you know, maybe they're neuroscience courses are taught by more phds or non, non clinical staff. So they don't necessarily get that exposure to clinical neurology. And, you know, I happen to work in an area that uh there's not, you know, let's just say a dearth of neurologists as there are in many parts of the country. Um So for the trainees out there, um other than just buying a copy of your book and using that with their neuroanatomy text, uh what's, what's the best way for them to, to try and get exposure to, to that, to get better feelings for that. What kind of resources would you recommend or uh just calling local clinicians which I know can be a little space as well. I mean, it's a, I mean, it's a huge challenge. Um, I don't know if I have a great answer for you. Right. I mean, I mean, I mean, this is a problem everywhere is and correct me. If I'm wrong you might know the, the data. At least I, I think what the data is. It's about one in 50 medical students go into neurology. Yeah. So, actually I just saw a paper earlier this week and it was 2%. So you're right on the money? Okay. Okay. Okay. Um, you know, which I think, you know, that's, that's kind of my observation as well. Um And what's, what's interesting to me is, you know, I've, historically, I've been in places where there are, you know, they're, you know, neurologists are bountiful, you know, they're ever, even then the ratio is not that different than 2% you know, or one in 50. And so I guess, you know, that really begs the question. Um I mean, you, you asked a specific question which I, I, I'm not answering just yet. I haven't answered this yet. What I would say is, you know, even when there are neurologists around still that ratio, you know, maybe it changes a little bit, but at least in my anecdotal experience, um, it's, it's not too different. Um, you know, it's still close to one in 50. And so theoretically, those students are also seeing neurologist, you know, they're getting that clinical exposure, they aren't having to go out of their way. It's actually being put right in front of them. It's a court clerkship rotation. Um, and so that's still being missed. Um, and so, you know, I think, you know, and people have written about that as well, um, in terms of why and that goes back to, you know, so those, you know, original article on your, a phobia back in, you know, the, you know, 1994. Yeah, I think, um, but it's still a problem, you know, I guess it's a problem that's been discussed for decades. Um, and doesn't have a solution yet. Yeah. And it, you know, it's, I think it's becoming a more and more pressing issue, uh, just in terms of, you know, there are treatments being developed for neurologic issues and if there's no one to recognize the problem in a timely fashion and administer the appropriate treatments, then we're, now we're really missing the boat. Yeah. Um, yeah. No, no, it's absolutely true. I mean, the, the percentage of the population that has neurologic diseases is only increasing. Yeah, just as we have an aging population. Um, it's simple net. But, yeah. Well, you know, I guess I just raised more questions that we don't have answers to. Yeah. Yeah. I mean, I'm trying to think of a good answer back to your original question, which is, you know, without it, you know, without it in front of you. Um, you know, how do you improve that? Um, and I think, um, you know, that's the challenge is because when I think of, you know, how to get students interested to me it's all about stimulating curiosity. Um, and I think, you know, that's the shame about maybe neurology is that, you know, that should be, it is objectively interesting. You know, I have plenty of friends that are not neurologist. Um, they would never want to be a neurologist in practice and that's okay and, you know, I wouldn't want to do what, what they do and that's okay. You know, neither of us is wrong. But, you know, neurology is objectively fascinating and, and I think that that's one of the challenges I see sometimes is, you know, when the focus, at least for, for some students coming in is, you know, I have to memorize some of the, you know, the brain stem stroke syndromes or the neuroanatomy seems very dense. It's hard to then see the relevance of that, you know, the, you know, see that in practice and see how powerful that knowledge is. Um And so, you know, when I have students on service, even the ones who don't want to be neurologist and they see a patient and they have this, you know, opportunity to practice imaging negative neurology, which I love that term, right? Um where they go in the room and there's something that's unexpected, they come out and they say, you know, that person, you know, that that was clonus, you know, and it said, yeah, you know, and they had weakness and, you know, I thought that that was going to be a tractor. But so okay, you know, so where's the closest, you know, and they kind of get there and think, you know, you know, is this a, you know, a spinal cord injury and, and, you know, and, and to see that connection happen, even for someone who, you know, may want to do something very far removed from neurology and practice. I, I think everybody is, you know, I think everyone finds that fascinating and I get, you know, I think maybe that's, it's not really the answer but, you know, the question, you know, that's what I think of when I think of the medical school curriculum is we have to be showing students, you know, what's really cool about neurology and, you know, they may not become neurologist. Um That's okay, but it'll at least make them more willing to think about neurology because they're going to see patients with neurologic diseases, right? And, and that's, you know, that's the big challenge. Um is there's so much overlap with other specialties and people throw up their hands because they don't want to write. And, you know, you used a phrase actually one of my, my attendings used as well the black box of the brain and, you know, as soon as it's a neurologic issue, you know, that's exactly what happens. Right. It's like, oh, well, you know, that's probably complicated. I better just, you know, send a garage. But then, you know, we run into that same problem again. Right where it's a weight of, like, three plus months, depending on what part of the country you're in. And, you know, we need, you know, internists and family physicians who are well versed in neurology because they are the frontline people. So, so yeah. Uh how do you think like, let's say we have a, like a practicing physician out there like an internist or family doc? Um How could they best best utilize this information here to, to guide their practice? Yeah. Um you know, that, that is a question I think I can answer. Um you know, one thing I like to tell students and rotators when they're on service with me, you know, as an example in terms of what I want them to get out of our time spent together, which is usually to brief is, you know, give them the example of, you know, if they're in the hospital and they have a patient and they think that patient has an acute abdomen. And I asked them, would you ever call the surgeon without ever having pushed on the belly? Um or if you did call the surgeon without having pushed on the belly, what do you think their response would be on the you know, on the other end of the phone it would, that, you know, they wouldn't be acceptable not to try. And I think that, that to me is what I think about, you know, for the book and what I think about when I work with them is what I want them to do is I want them to focus less on, can they get the answer? Right. But more can they go in the room and they can they obtain the language, you know, really be able to speak the language and be able to describe what they're seeing. You know, if someone's coming in and, you know, and they're altered, you know, we all, you know, it's in Robert's, we'll get these questions. Oh, patient is altered. I don't need them to tell me what it is. You know, I need them to say, you know, you know, MS Jones was, you know, she was, you know, out playing bridge with her friends this morning and now she's lying in bed and I'm, you know, she's asleep unless I'm constantly stimulating her. Perfect, you know, you know, you're really giving me a lot of information about the acuity. And so, um I think, you know, the book, you know, is trying to get a little bit to that, which is to empower the reader to say that even with just observation and being curious and asking those questions, you actually get a ton of information that you know, that you should feel empowered to try and act on, you know, that that would be a step to try and get the diagnosis. But even getting that information makes you a better physician and makes you someone who will be more informed when you are asking for help. Yeah, I think it's, yeah, identifying what you're observing is a big piece of it. And, you know, like, like you said, we, we don't necessarily get trained in that on the, like, the behavioral side of things as much as we probably should be. And, um, you know, that's exactly right. Like, I, I always tell people on rounds, like, well, you know, you don't have to, like, you know, spell world backwards for their mental status exams. Like, are like exactly what you're saying. Like, do they fall asleep while you're talking to them? Like, you have to keep shaking their shoulder the whole time. Um, just describe what you see. And, uh, yeah, it's, it's really a struggle sometimes to get people to kind of break out of that, you know, sort of mental rut that they're in. Yes. You know, so the book, it actually started as a lecture, I gave medical students at the beginning of the clerkship. Um, and I was asked to talk about, you know, it wasn't, you know, it, it wasn't anatomy, it was, you know, kind of clinical, you know, it was something and, and that's where the, it came from. But, um, and it started with this disclaimer that I would get the students, you know, these were small sessions about eight students. And I said, look, you know, all of these are rare cases. Um, and the likelihood is that no one in the room here knows the answer or has it, you know, and most of the time you've never even heard of the disease. Um, and, you know, not too many spoil over it's with the book, you know, but there are things like, you know, artery pressure on stroke in there that, you know, maybe some student happen to have heard in passing, but there's no way that they would have that on their mind and they, and they shouldn't. Um, but I tell them because these are all rare and you're not going to get the answer. The intent is that it removes any sort of, um fear of standing up in front of the class and saying, you know, and, and, you know, getting it wrong and that none, you know, none of you will have it and there's no reward too quickly going through the stem looking for the, you know, kind of the red flag words, you know, buzz words and then trying to make that connection. Um And so, you know, the intent, you know, this was again before the book even existed, was to have this lecture where we were doing these cases and it was forcing the students to not try and guess the ultimate pathologic diagnosis based on the question stem, right, based on the case presented. Um, and so, you know, that's, that's kind of how it, how it started in practice. And, you know, and then I realized, oh, actually, you know, the students were really enjoying this, you know, they were, you know, it was something that was new that they really hadn't experienced yet and, you know, often at the being of the lecture, almost always they still try and do it, you know, you know, circulating around or talking a little small groups and I hear people saying, oh, you know, aneurysm or something, no, stop. You know, I'm not gonna ask you if you think it's an aneurysm. I don't care about that. I'm going to ask you what you think the clinical syndrome was. Um, but sure enough within five or 10 minutes, you know, they're really doing it and, and I'm proving to them that they're actually essentially making the diagnosis, you know, you know, rapidly progressive fatal meningoencephalitis, you know, they're, they're putting that together where they can just put it into Google and get the answer. Um, and we often do that to prove to them that actually they did get it right, because, you know, they, you know, their medical students, they do want to get it right. Of course, that's what we're all programmed to do from the, uh, but yeah, I, I really like uh, and the one of the beautiful things about, about your book is that, you know, there's, I think like 40 some cases in here and, you know, each one it's, it's nice and digestible and your writing style is very, very good. I very much enjoy it. Thank you. Um, but, you know, if you even just have 10, 20 minutes, you can, you can get through, you know, at least one or two of these cases. So it's, it's a great book to just have, uh sitting on your desk and be like, if you, even if you're not actively studying neurology, just, uh, you know, want a quick diversion. It's, I think a great uh text for that. No, it's not meant to be dense. It's meant to be something you can pick up, you can put down. Um, it's meant to be, you know, it's an adjunct. Um, it's, um, to, you know, some sort of more dense neuroanatomy studying or, or disease studying and, um, and, you know, and, and it's supposed to be approachable. Um, and I, you know, I think that that's really critical in neurology teaching, maybe getting a little bit back to some of the questions you asked before, which is that, you know, neurology is, it's hard and, and it's pretty humbling, you know, even as someone who, you know, you know, now I'm an attending, I'm supposed to always know the answer and, and, you know, and I don't um you know, sometimes, you know, you know, you know, people make mistakes or, you know, you missed some subtle finding or you get anchored on something. Um, and neurology is hard and I, you know, I have this distinct recollection as a, when I was a PGY too, you know, I finished intern year, you know, I'm pretty good at being an intern, you know, obviously I'm not, you know, very, you know, I've learned some medicine, you know, but I'm good at my job and then I became a phy too and I thought, man, I am just getting my butt kicked. Um And, and just remember just feeling, you know, um like, you know, how I, I didn't realize how much complexity there was um to really trying to do this well and, and I think that if we don't acknowledge that, you know, you know, now with someone, I guess who's on the other side, we don't acknowledge that this is really challenging field. And um and it, and, you know, you can be the world's best neurologist and still not always get it right that um you know, the book is supposed to be approachable and that it's supposed to say, you know, and, you know, you can see in the book especially, you know, the cases get a little bit harder as they go. Um You know, there are times where the diagnosis wasn't clear or the diagnosis diagnosis is missed and it's not because somebody was lazy. It's not because they were bad. It's just that, you know, what, um, neurology can be challenging. Sometimes it takes a little bit of time to figure something out. I know it's, I, I always feel like residents are frustrated when I say that's like, you know, over time it will likely declare itself as to, as of which of these things it is. And it's like, well, that's not very satisfying, is it? Yeah. You know, I'm, I say that as well. You know, I'm not too far out of training. I think I need a few more gray hairs. You know, you know, you know, when you have a lot of gray hairs, I think you can kind of sit back and you can, you know, you can stroke your chin or something and you can say that and people don't roll their eyes as much. Um but it's true, right. You know, and I find myself saying that as well as, you know, I really would love to have the answer. Now, we might just have to see this person come back and follow up in three months and that will really tell us which way we're going. Uh And, you know, to your earlier point. Uh You know, I, I too had an epilepsy attending in my fellowship who you would just say, you know, it's such a humbling field because you're just wrong so often. Like your initial impression is just wrong, like just this last week. Uh, another anecdote I had a, you know, a young woman come in for spells and, you know, they've been increasing in, you know, the tempo was increasing and, uh, you know, they would be last just a couple of minutes. She had a burning smell, but then she's like, I, I flooded my eyes but I don't lose consciousness. And I'm like, well, you know, maybe it's something, maybe it's not, but, you know, they're happened almost daily. So like, all right, we'll just put you on continuous eeg and we'll catch her up and I went into it fully expecting these to be, you know, non epileptic spells of some nature. And, you know, I will, I will be dang if, if they weren't epilepsy. Uh And so I, you know, I'm glad I did the work up and I didn't just, you know, buy into my own assumptions. Uh But, but yeah, it just goes to show that you're just wrong sometimes. Yeah. Yeah. And I, you know, I think that, you know, it is something that I've noticed when students asked me about, you know, how, you know, why, you know, why neurology, you know, which is, which is always a complicated question. But one thing I tell them is that, you know, it's a bit of a personality test, right? You know, if you all, you know, if you want to be very clear cut, you know, black and white, you know, get the answer right there. So, you know, have a problem then solve it or fix it. Neurology may not be for you. Okay. Maybe interventional or, you know, something more. But, you know, for the most part, if you're someone who, who really loves, you know, the puzzle, right. You know, we, I read lots of applications for neurology residency. You know, the puzzle, you know, the mystery that, you know, the logic of it. Um I think it takes a certain personality to say, you know, that's really interesting. I want to figure that out um and being okay that they may or may they may not or that it might take some time to unravel it. And there was, you know, it's, it's very uh propose that you said that there was a study just in the last couple of years that was looking at like they did like language analysis of personal statements for neurology applicants and the highest things that were like, you know, most commonly seen were like references to Sherlock Holmes and puzzle solving. And it really is like there, there is a, you know, sometimes stereotypes exist for a reason, right? And I think the stereotype of the neurologist does hold true in some respects. No, no, it does. But you know, that that's what makes a good neurologist. Um again, you know, you have to be curious, you know, when, when somebody says something, you know, you kind of have to have that, you know, that kind of prickling sensation on the back of your neck, you say? Oh, yeah. What do they mean by that? You know? You know, I want to learn more. Um, and, you know, I do that with the, you know, students, you know, they have all these Os keys, you know, these standardized things and, and I try and tell them when I'm doing it in the hospital with him, I say, you know, I don't need you to do these checklists. You know, if someone says something that you think it's interesting, I just want you to stop and explore that, you know, spend as much, you know, if, if they, if you think that there's something that's important or they use a word and you want them to explore more, you know, just focus on that. Um because the likelihood is that, you know, that's actually gonna be much more relevant than asking the, you know, the other parts of the review of systems. Yeah, I hate to review of systems. I think it's, it's an artifact of billing. But yeah, but uh yeah, and I, I do find like, you know, every once in a while it is, there's like almost 1/6 sense where you just, you're sitting down talking with somebody and then like, like you said, the hair on the back of your neck just goes up and be like, oh, because you're, you're like, kind of sloshing back and forth between all these, like, how can I link all these disparate symptoms together? And then, like, like one key phrase falls into your lap and it just, like, it just crystallizes in that. Uh, I don't know, it's a rush of, like, this epiphany where you're like, I'm hot on the trail now. Yeah. Yeah. I mean, I guess, you know, we throw out lots of anecdotes all throughout another. Yeah, I've seen this one recently in clinic and she had come to me, um, you know, I'm a, I guess part of my day job as I'm a neuro immunologist. And so I have an MS and terminology clinic and a woman with MS, but she also carried this diagnosis of epilepsy and had these spells and I saw her the first visit and I clearly didn't pick up on something, you know, I, I hadn't probed it enough and I said, you know, she was establishing care, said okay, so as long history she had been having more spells, you know, let's get that eg, you know, let's make sure that you're safe and you're on some anti seizure medicines, you know, so that you're not having these things and then she came back a few months later and it's one of these things that, you know, I sat there after the visit, I thought, you know, what, what was different, you know, how did I get such a different answer? And, and I realized in that second visit, you know, these spells, these were all things that were happening only when she was very tired and, and, you know, and I think one of the differences with the husband was there to give some more, you know, information and, and we went on this whole path where it seemed like, you know, this was actually sound like a sleep disorder. And there were all these features of narcolepsy with cataplexy and, and it seemed, you know, and it went back to this pace and localization actually, you know, probably criminally uh type of case I didn't include in the book in terms of these corrupt instead of neurologic symptoms, um would be sleep disorders. Um So explore where there's, there's not a patient with a sleep disorder in the book, although there should be. Um and, and I was thinking back and I thought, you know, I completely, you know, I completely missed it because in my mind, I had closed this syndrome when I was thinking about the syndrome of okay new onset of rather abrupt transient neurologic symptoms. I was okay stroke, you know, you know, seizure and she had this diagnosis of epilepsy. And then when I had really sat back, got a little bit more history, the husband was there to help, help out a little bit. I thought, oh, I've been completely blind to other things that can cause rather sudden loss of consciousness, um which would be jesus' sleep. Um And, and so, you know, going back to the neurology is humbling, but also, you know, with time you can figure it out. And so I kind of sat down and said, actually, everything we kind of spoke about, let's not, you know, let's not throw it out yet, but let's do some further investigation. And I think that's, that's a great point, especially for non neurologists, right? We tend to think, you know, obviously from our training, uh people with certain types of neurologic issues, whether it's epilepsy or like, you know, recrudescence of like stroke or MS related symptoms, things like that, you know, it's very stereotyped. But if there's a change in the symptomatology or the events, you know, that that kind of for us raises red flags. But for other people, like you said, you know, they could say like, oh, well, you've got the history of epilepsy, you're losing consciousness. I need to go, I don't need to go any further down that path because we already know you have epilepsy and you know, like maybe having syncope sleep disorders and the list goes on. Um But yeah, I mean, that's, that's a great point is that we always have to be constantly reevaluating our diagnoses. Yeah, and you know, going on a tangent from that. But because you mentioned it, you know, one other thing I think about is, you know, how do we define what is neurologic and what is not neurological, right? You know, even in this conversation mentioned things, you know, like, you know, you know, non epileptic seizures, you know, are those neurological, non, you know, we've talked about syncope, we've talked about sleep disorders. And I think that's one of the challenges in our medical education when a lot of the medical education occurs in the hospital um where there's an enrichment and disproportionate amount of seizure or stroke. Um And then, you know, as neurologists, you know, we're very quick to say, you know, to sign off, you know, this is, you know, this was syncope, this was not a seizure and our work here is done and we'll pass this back. Um you know, but um you know, does that follow within the realm of neurology, you know, the, you know, that's loss of blood but, you know, but there is brain dysfunction and often this is related to neurologic disorders, you know, is it autonomic failure, you know, um and these other things and I think that that also is one challenge. You know, I think, you know, I struggle with is, you know, what I'm talking to students and even to our own residents, you know, this idea of what we own is neurologist, you know, what, what we should be experts in and what we don't need to worry about and don't need to be experts in. Um And if we are kind of shunning this and putting it to the side. Then it, it, you know, I think it, it makes us not as good as neurologist. I think it's harder for the patient. Um, but it probably exposes us to more errors. Right. Because then we're just saying, oh, it's not a seizure so we can sign off. Um, which I think is dangerous. Yeah. And, you know, you're absolutely right. Like, just, you know, to your point. Right. Just this last week I saw a gentleman who came in with Syncope. Right. But, you know, he, he has Parkinson's so, uh he needed his meds tweaked just because it just because it's syncope doesn't mean that there's not a neurologic component or someone with a severe peripheral neuropathy who's having again some decompensation in their autonomic. So I think that was, that was a mantra that helped me get through a residency a little bit. Like when I would get a console, like this is nonsense and I'll be like, maybe there will be something that I can help with. Uh, and that was the only way I could make it through because otherwise I would just be hating everything. Yeah. Yeah. And yeah, it's not that I don't understand, you know, it's not that I expect our residents, you know, at, at 2 a.m. Okay. Yeah, you can, you can be bothered. It's okay. Uh, you know, that that's human. Um, but then, you know, you know, all right, then now you're in the room, you know, there's a patient, their time to, you know, time to really, you know, ask some questions. Absolutely. Yeah. Yeah. And I, I know, you know, it's, it's easy to, especially when you are on the hospital service to, to gripe and belly ache about uh a lack of perceived effort on our colleagues parts. But I think in reality it is and it kind of comes back to, to this, to emphasize the education uh aspect so that people are aware like, oh, well, I should be thinking of Xy and Z uh these are a few things screening tests I can do, especially in hospitals that are short staffed on neurologist or maybe don't even have neurologists at all. Um to kind of help you get through the very early steps of the evaluation. Yeah. And you know, I, I talk with our residence and, you know, I know that this is not something unique to me but, you know, when, when we're getting a console, you know, somebody that's asking for help and right, and I think that, you know, as a neurologist, we, you know, we should have a lot of pride in what we do. And this goes back a bit to what I said at the beginning is, you know, this is a, it's a skill, right? It's not doing a lumbar puncture, it's not doing Botox, it's not doing a procedure, but there is a real hard skill. Um And that's what I'm trying to teach in the book that we have from our training. Um and to not sell ourselves short when we go in the room. And that thought process going through the history, going through exam, identifying the clinical syndrome. Um that is true expertise and something that's honed, overtraining, something that needs to be done intentionally. And um that was, you know, maybe one other component to the impetus for the book was that I found that a lot of are, you know, the students are a lot of our residents. Um, they were doing this but they didn't realize that they weren't doing it. You know, they weren't intentionally setting out to do it. Um, and they weren't really codifying it in their mind and I thought, okay, if I could attempt to, you know, have people do this intentionally, um, and with intent and practice it, um, then, you know, maybe that will help their training, you know, much like you would never, you know, if you're a musician and, you know, um, you know, and I play cello. And so, you know, I started when I was a kid, you would never just sit down and start playing. You could, but you're not going to be very good at it and you're not really gonna progress very far. But if you really focus on the methods in the process, you know, there's a reason why people do scales and, you know, do these sort of reps Right. You know, if you're playing sports, you don't just go out and play basketball. Um, you know, the practice isn't just, you know, 10 guys on the court going back and forth, you're practicing drills, you're practicing different components of it. And in neurology, you know, do we really do that? Um, you know, our is, are, you know, curriculum for medical students is our curriculum when we have internists, um, or, you know, psychiatrists or family medicine, you know, future family medicine doctors or for our own residents, are we intentionally trying to break that part down in a different discrete components to further the training? Um And, you know, it's something I think about when I'm on service. And again, I'm not saying that the book does that for everybody. Um, but it was a thought that I had in mind when I thought, you know, is this a book that might be worthwhile that people might actually think helps them in their clinical practice? I think, I think it will. Uh, and I think even, you know, as a neurologist, again, I will say all the same, not, not terribly far out of training. Uh although I am getting some gray but uh I think that this, uh even in just, I've read about half of it so far and it's, uh I think it's good like you said, to examine our own thought process is as well, even if we're, you know, somewhat experienced a neurologist uh so that we can, because the further you get away from that initial training, part of your uh education, you know, it becomes one of the things that you, you do automatically and you know, how, how can I best communicate this to someone who doesn't speak the same language that I do clinically and uh re familiarizing yourself with those very basic steps to get someone on the right path. So they too can reap the benefits of a, uh creating this neurologic framework. Yeah, I agree. 100%. Awesome. Well, I wanna thank you. Do you have any final thoughts? Anything else you wanted to share? Mm, no. II, I think that we've, you know, we've really touched on a lot of topics, you know, maybe the, the end one, although it's a bit cheesy to end on, but, you know, it's too late. I've already committed to it. Um, is that, you know, I find neurology just fun and, and I think that, um, it can be fun if you have the tools, right? Um You know, it's not fun if everyone else knows something or has the tools and you don't. And so, you know, when I'm working with our, you know, off service rotator's from medicine or our medical students, you know, it's not fun for them if, you know, if I'm talking with the senior resident and the junior residents even, and, and we're all part of a club and they're not, um, you know, likewise when someone calls a consult and we dismiss it and we, you know, we kind of brush it off in the note that's not fun to them. You know, we're not, you know, we're not including them. And so, um, you know what I try, you know, I try and meet people where they are. I try and, and see, you know, for a medical student, what's their knowledge base and then, and then kind of bring them in from there. Um, you know, consult, if they're silly, it's a time for education, you know, for the off service rotator's at the time to give them the skills they think are going to be relevant for them to, you know, to be able to see these patient's in the future and, and, um, you know, if we can't, if we can't make neurology fun, we can't take the passion that we feel as a neurologist and then make that an enjoyable experience for others. Um, you know, we're, we're never going to increase that 2%. Um, and, um, you know, hopefully the, the book is supposed to, it's supposed to be fun. It's supposed to, you know, be mysteries. It's supposed to feel a little bit like Sherlock Holmes where, you know, there's, you know, there's something that's happened. Um, we need to figure it out and that we can get there together. Um, you know, and no, you know, no matter where the reader is starting from. Um And so, you know, maybe that, that would be what I would end on and I, I will say 11 additional uh one final compliment uh if you can stand it, uh it's your podcast. So yeah, you can do whatever you want. Well, I'll make it to uh first, you know, I know everyone's listening but the cover has this beautiful art deco inspired a picture of the brain from an artist. Uh Aaron Michael D Greater. Am I saying that correctly? And I'll include a link to that in the show notes, but it is beautiful. He has other organ systems as well. Although obviously I'm biased. And then the second thing uh the, the chapter title's are and then the, the initial vignettes, uh they give me like very strong Oliver Sacks vibes, which I very much it gives you, like you said, that kind of like a mystery is beginning. Uh You know, uh and again, it is that very Sherlock Holmes, Ian Vibe, you know, it's like uh the cases a foot. So uh II I like it's very like they're very punchy opening. So, you know, there's it a lot of neurology, you know, especially the big door stopper text, have, you know, just looking at them sitting on your desk is intimidating, right? Uh Like I know you mentioned Adams and Victor's uh in your book, which is the one I use through most of residency and you know, Bradley is, is even bigger and, you know, uh, even as a neurologist looking at those, you're just like, you just have like an internal sigh, uh, you flip open to a chapter and be like, these pages are so thin so they can fit even more in here. Uh, but, uh, but no, like I want to emphasize how, how digestible each one of these case vignettes are and, uh, how quickly you can get to like uh this was a myopathy, this was a neuropathy, this was a brain stem syndrome. And you know, it's, it's very well put together and it doesn't uh it doesn't outstay its welcome in each case. So that even people who are only, let's say passing, I don't know how they could be, but passing li interested in neurology uh could still maintain their attention uh through, through a case. So I, I just want to thank you again for one for coming on and to for, for writing such an excellent textbook. I think it, it has good applications for folks all the way from, you know, med students, even in other specialties, you know, people who are working in neuroscience, adjacent fields uh all the way up through attending physicians, uh neurologist and non neurologists alike. I think there's a role for it in everybody's library. Great. Uh Thank you for the kind words and thank you so much for having me. Thank you. And if folks wanna reach out to you. Where should they track you down if you're wanting people to do? So. Oh, gosh. Um, so, you know, I guess I'm newly on social media on Twitter. I'll have to tell you, I actually, I have to pull up my Twitter profile to make sure I'm giving you the right name. It's, it's E Meltzer MD. Um, so at emails or MD, um, um, is probably a way to reach out and um you know, I'm always love to talk neurology. Um And so you can find me there and I also have a link to the book on my Twitter page. Excellent. I'll include a link to that as well in the show notes. And uh thank you again so much for coming on. I really appreciate the chance to talk with you. Yeah. Thank you. Thank you, everyone for listening. If you enjoyed this podcast, please rate review and share it on Apple Spotify or wherever you get your podcasts and please subscribe for future episodes. You can reach me on Twitter at Doctor Ken Trees. That's Drkentris or by email at the Neuro transmitters podcast at gmail dot com with any questions or show suggestions. We'll see you all next time.