No one would argue with the view that neurology has changed immeasurably over the past fifty years. But perhaps those most qualified to attest to those changes are neurologists who were groundbreakers in our specialty and can boast fifty years or more of membership in the AAN. When I contacted them on behalf of Neurology Today and asked them to reflect on their long careers, one thing was unanimous: No one regretted their choice of profession and everyone would do it all over again.
“Today we can do a lot more for patients than give them diagnoses based on the names of 19th-century neurologists,” said Jerome B. Posner, MD, who is a full-time member of the staff at Memorial Sloan-Kettering Cancer Center. Many others reflected on the technological and therapeutic advances of the past five decades. The advent of CT and MRI was often cited by longtime neurologists, including Gordon J. Gilbert, MD, who has been in solo practice for 43 years, working for the past 30 to 40 years with the same office manager, typist, and technologist! He expressed relief that they have eliminated the need to do painful procedures like pneumoencephalography.
“Things we could not have imagined previously are now understood,” said Nelson G. Richards, MD, former AAN president, who has retired from private practice and the McGuire VA Hospital in Richmond, adding, “Advances in neurophysiology, neurochemistry, neuroimaging, and dynamic observations have opened up many new areas and changed some of our previous ideas.”
THE DEVALUATION OF COGNITIVE ABILITIES
“Changes I like are the advances in basic sciences and technology, which alter clinical practice,” said John F. Kurtzke, MD, Professor Emeritus at Georgetown who retired as chief of the neurology service at the Veterans Administration Medical Center in Washington, DC, in 1995. On the flip side, he said, he did not like the advances in basic sciences and technology that alter clinical practice. “The current generation of neurologists seems much more attuned to technology and less to the history and physical examination and personal interest in patients,” he said.
This observation was reflected by most respondents and echoed by Herbert Rosenbaum, MD, who still teaches medical students after nearly 60 years of practice at Washington University in St. Louis, and laments the devaluation of cognitive abilities. Charles M. Poser, MD, who retired from Harvard Medical School in 2005, admitted that the parts of neurology most attractive to him were learned from his two mentors: H. Houston Merritt, MD, who taught him to make a diagnosis on the basis of a good history, and Ludo van Bogaert, MD, who helped him understand the underlying pathology. “I dislike the misplaced overemphasis on the MRI in the diagnosis of multiple sclerosis (MS) — my specialty — and the therapeutic frenzy, even though we do not understand the pathogenesis of the disease,” he explained. Likewise, David Prince, MD, who works full-time in epilepsy research on the mechanisms of epileptogenesis, has observed a transition to excessive reliance on lab results with insufficient time devoted to the neurological history and exam.
The reduced emphasis on cognitive skills was often accompanied by regret over the shortened length of patient encounters, both in the office and in the hospital. “I dislike the pressure to reduce the time patients are allowed to stay in the hospital and the almost instantaneous plans for discharge made by hospital staff upon patient admission,” said Richard Satran, MD, who now teaches neurology at the University of Rochester School of Medicine. The current arrangement makes it difficult for medical students and house officers to learn about patients and their families, he said, as well as to obtain more comprehensive histories and follow changes during the course of illness. “I believe that these factors limit the opportunity for those in training to become better observers and better advocates for their patients,” he concluded.
“I really disliked, in recent years, the pressure to earn more and work faster,” said Charles H. Markham, MD, Emeritus Professor of Neurology at UCLA, who left practice in 2005, but continues to publish papers.
Not surprisingly, excessive paperwork and bureaucracy were blamed for the shrinking time spent with patients but perhaps more poignantly appreciated by those who remembered practicing without these encumbrances. Dr. Posner admitted that he gave up attending responsibilities because the interference from insurance companies had become overwhelming. John H. Menkes, MD, a pediatric neurologist at the University of California-Los Angeles, referred to a refusal for an EEG at UCLA for a child seen in his practice on the very day he responded. “This is an example of how insurance companies waste my time,” he said.
Several respondents also commented on the changes in hospitals. “They used to be cohesive fraternities among caring physicians, but have become big businesses with administrators almost outnumbering professional staff,” commented Gerard M. Lehrer, MD, who still enjoys caring for MS patients in the Monterey Peninsula, despite barely breaking even. And John R. Hughes, MD, professor of neurology at the University of Illinois Medical Center, expressed disappointment that some medical centers' struggles to avoid operating in the red places them in the position of doing unnecessary studies.
Views on this subject were also influenced by personal experience. “Insurance companies make for an increasingly inhumane form of medical practice,” observed Roger Duvoisin, MD, who retired as chair of neurology at the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School and cared for his wife after she suffered a major stroke. He added: “I am fascinated by the fumbling and inept progress American medicine is making towards universal health care.” Emeritus Professor of Pediatrics and Neurology Richard J. Allen, MD, advocated for more national programs such as Newborn Screening, which he directed at the University of Michigan for 35 years until his retirement.
FOCUS ON HUMANISM
Many respondents reflected on the importance of acting with kindness and humility — both to patients and colleagues. “I've learned to do less talking and more listening,” said Joseph M. Stein, MD, who officially retired from practice in Topeka, KS, in 2000, but whose partners have encouraged not to quit completely. “I also remain comfortable telling a patient that I don't know the answer to a particular question but will make every effort to find one,” he reflected.
“I always thought of my patients as equals and tried to consider how I would feel in their shoes,” said 89-year-old Clarence Glenn, MD, who is retired from sleep medicine at Decatur Memorial Hospital. Dr. Hughes said his most valuable lessons have included trying to strive to be as fine a person as possible and treating everyone with kindness.
Headache specialist Seymour Solomon, MD, admitted that his interest has been sustained by observing progress, and referred to the satisfaction of helping patients, not “clients.” George W. Paulson, MD, Emeritus Professor and former neurology chairman at Ohio State University, who now serves at a free clinic, also stressed forgiveness and truth-telling in interaction with others.
Commenting on changes in health care today, Dr. Richards urged, “If you don't like what's going on, get involved to improve the situation.” He, like most others, expressed optimism for the future.
“The future should be spectacular,” predicted Richard F. Mayer, MD, Professor Emeritus of Neurology at the University of Maryland School of Medicine, adding, “It's a wonderful field for imaginative young doctors.”
And Dr. Kurtzke summed up the reason this entire group had no regrets, “This is still the most fascinating branch in medicine!” •
Fifty-Plus Years in the AAN