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A Focus On: The Art and Science of Clinical Neurology
Superposition of the human nervous system and a subway system. From: Chapter 1. Where’s the Lesion? Douglas Gelb, MD, PhD. In: Introduction to Clinical Neurology. Publisher: Oxford University Press. DOI: 10.1093/med/9780199734849.001.0001 © Oxford University Press 2010
Neurology, the medical field that deals with diseases of the nervous system, is partly art and partly science. Neuroscience contains the fields that are the basic science underlying neurology (neuroanatomy, neuropathology, neurogenetics, neuropharmacology), but the practice of neurology requires training, experience and judgment that are applied to the patient who is ill with a disease of the nervous system. For the vast majority of problems faced by practicing neurologists there is no one-to-one relationship between science and medical practice.
Practicing Neurology is an iterative process whereby the accumulated experience of the neurologist, informed by relevant basic and clinical science, is brought to bear on the complex interaction between the nervous system and the rest of the body. Neurologists (and their medical cousins the psychiatrists) are the only specialists who talk to the affected organ. The absurdity of the question: “How long have you had this memory problem?” underlines the difference between the standard medical approach and the neurological method.
The neurological method involves taking an open ended history, allowing the patient to do the talking, sometimes aided with the versions told by observers, such as family members, work associates, police, ambulance personnel and others. The neurologist then formulates a theory of the localization and pathogenesis of the disorder. The neurological examination has the specialized role of either supporting or refuting the theory. If the latter, then a new theory is formulated and again tested to create the best fit. Laboratory tests, including images, are considered ancillary studies, which serve to further cohere the theory of localization and cause. Management and treatment are formulated once the method has pointed in the proper direction. Failure to adhere to the neurological method runs the risk of uncovering unrelated and often misleading findings. Modern science, including exquisite imaging and every broadening use of genetic testing, can uncover the “incidentaloma”, which is not only expensive but potentially quite dangerous to patients, who may as a result undergo uncomfortable and even life-threatening procedures aimed at addressing a laboratory or imaging finding that have no clinical importance.
The clinical pathological conference is a technique aimed at teaching this method to the next generation of neurologists. The method involves a detailed presentation of a case, which is then dissected by an expert using the neurological method. The reader (student) should be able to appreciate the thinking process of the expert who melds experience and science to come to the correct answer.
Oxford has published the entire career experience of two expert neurologists who have demonstrated the clinical pathological conference technique, as originally published in the New England Journal of Medicine’s Cabot Cases, more than anyone. Studying these cases, which span an enormous swath of clinical neurology and its interfaces with general medicine, will help the reader to adopt this method that they can then apply to their own expanding clinical experience over a professional lifetime.
Martin A. Samuels, M.D, Department of Neurology, Brigham & Women's Hospital, Boston, MA, USA
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