FRONTIERS IN NEUROSCIENCE
TELLING A PATIENT'S STORY
BRUCE L. MILLER, MD
Many neurologists will tell you that they have been fascinated by science virtually since they emerged from the womb. Bruce L. Miller, MD, Professor of Neurology and Psychiatry and Director of the Memory and Aging Center at University of California-San Francisco (UCSF), is not one of them.
In fact, Dr. Miller, who will speak on “Portraits of Artists: Emergence of Visual Creativity in Dementia” during the Frontiers in Neuroscience Plenary Session at the Academy's Annual Meeting, graduated from the University of Wisconsin as an English major without ever taking a single basic science course – “unless you count ‘physics for poets,’” he said.
Until his senior year of college, Dr. Miller expected to pursue a career in writing or some other creative profession. Then he took a psychology course that happened to have a strong biological orientation. “I loved the intellectual rigor, loved the way it probed the way the brain worked. This was a big transformation for me – science was such an exciting world, and I knew nothing about it,” he recalled.
Caught up in the social conscience of the 1960s, Dr. Miller left the university “with the sense that I wanted to give something back to the world. I decided that I was excited about medicine, so I went to Butler University for two years to get a degree in chemistry and fell in love with science. I spent every living moment reading and studying organic chemistry. It was hard for me, because it was something I did not have any background in, but I loved it.”
COGNITIVE ASPECTS OF NEUROLOGY
From his earliest moments in medical school – the end goal of all that struggle with organic chemistry – Dr. Miller found himself fascinated by neurology. “I was just really excited by the idea that you could understand how the brain worked by talking with a patient,” he said. “Very early on, I was interested in the cognitive aspects of neurology as opposed to the neuromuscular.”
Thanks to a close relationship with his grandparents, with whom he'd lived while pursuing his chemistry degree, he enjoyed spending time with older people, and so, by the time he'd completed medical school, he “was pretty clear about neurology and pretty clearly interested in dementia and geriatrics.”
FRANK BENSON: A MENTOR
After his residency at Vancouver General Hospital, the University of Western Ontario, and Harbor-University of California-Los Angeles (UCLA) Medical Center, Dr. Miller took a fellowship at UCLA so that he could work with the man he identified as the biggest influence on his career: Frank Benson, MD.
“I'd seen him speak, and I'd read his book on aphasia, alexia, and agraphia,” Dr. Miller recalled. “He had this wonderful passion for the bedside and the importance of clinical observation, and was unapologetic about it. He thought that was where neurology began and where most important discoveries came. This was at a time when everyone emphasized group studies, bio-data, and statistics, and he was very much swimming against the stream.”
Dr. Benson was also one of the only people at the time who believed one could differentiate frontotemporal dementia from Alzheimer. “We'd see patients with Pick disease, as we called it then, and he would explain to me why these deficits were different than those of Alzheimer – the language, the behavioral deficits. He was uncannily accurate,” Dr. Miller said. “I left my fellowship feeling very comfortable at the bedside, having learned to probe histories very carefully and not take things for granted.”
Fate must have a sense of symmetry. The path into neurology that first opened up back in that senior psychology course has led Dr. Miller right back to his early passions, writing and creativity, as they manifested themselves in what he calls the “bionarratives” of his patients with frontotemporal dementia.
“Frank Benson had really encouraged me to collect the histories of these patients, and I would take a very careful, biologically-oriented history of their lives, trying to figure out when the illness started,” he said.
One of these patients was a man with an unusual language problem, who had been labeled schizophrenic by some. “He was very eccentric; he wore only purple shirts and yellow pants, and had decided during the course of his disease that he wanted to become an artist,” Dr. Miller recalled. “In talking with his son, I asked him if the art had deteriorated as the disease had progressed. He said, ‘Oh no. It has gotten better.’”
Assuming that any neurologic disorder could only impair, not enhance, cognitive functions, Dr. Miller was skeptical. But as an afterthought, he asked the son to send a series of pictures his father had done over the past ten years. “I was just ecstatic. He was doing some of the most beautiful pictures I'd ever seen, and they got more and more interesting as the illness progressed. I showed them to a lot of people, and I have to confess I was the only one excited,” Dr. Miller said. “They thought it was some sort of aberrant event.”
But it wasn't. “Once you realize that something happens, you start asking about it, and I started to realize that this wasn't rare in the setting of a certain type of frontotemporal dementia, to see this emergence of creativity,” he said.
He might have been particularly attuned to this kind of creativity, he said, because of his family background. Although Dr. Miller cites many mentors, from Jeff Cummings at UCLA to Gordon Robinson, John Noseworthy, and George Rice in Canada, he feels he was particularly influenced by his parents.
“My mom is an artist, and so I think my interest in art started early. My parents were taking me to museums from a very early age – although I couldn't do art, I really appreciated it,” he said. “When I suddenly realized in studying frontotemporal dementia that some of these individuals became artistic, it really excited me because I had already had some background thinking about art.
“The creative aspect of frontotemporal dementia, when it appears, can differ from patient to patient. In some it's visual, and in others it's musical. Paintings by frontotemporal dementia patients are usually strikingly realistic, and feature dominant colors like purple, yellow, and blue.
“We published a paper on 12 patients about three years ago, and we've certainly doubled that number since I've come to UCLA,” Dr. Miller said. “We're now starting to collect a whole library of art from our patients, and we're about to put some of it on the Web site (www.memory.ucsf.edu).”
The implications for neurology are powerful, as Dr. Miller plans to explain during his plenary presentation. “It makes us rethink the whole idea of degenerative dementia. It's not a unitary process. Associated with some neurodegenerations may actually be improvements in the brain,” he said. “It makes you think more globally – about strengths as well as deficits. If we're going to help people with very long-flow progressive diseases, we have to focus on their strengths.”