Diagnosis - TV series

Diagnosis is a Netflix TV series based on the New York Times 'Diagnosis' column written by Dr Lisa Sanders.  Lisa Sanders is an attending physician (a consultant in the UK) who previously contributed to House MD as a medical advisor.  House MD is one of my favourite medical TV shows.

In Diagnosis she looks at 8 diagnostic challenges.  The majority of these cases are neurological in origin.  To reach diagnosis in these cases she published a column online and invited people from around the world to make suggestions.  In several cases a diagnosis is reached.

This is almost an exercise in folk medicine, with random strangers making diagnostic suggestions.  Unsurprisingly Lyme disease is mentioned a lot and unsurprisingly positive Lyme tests suddenly appear.  In some cases I was not satisfied with the ultimate diagnosis and in at least one case I think the patient was unsatisfied.  A lot of mistrust of doctors is vocalised which is common.  Some doctors are good and some doctors are bad.  All doctors make mistakes and all doctors get things wrong.  Some diagnoses are hard to understand and will be refused by the person with the symptoms.

As a medical TV show, I enjoyed this, partly because it was mainly neurological problems and partly because it is what I see in clinic on a regular basis.

Worth watching.

Migraine Aura

A visual migraine aura can be an intense experience.  Last night I was using my laptop and watching channel 4 news when my vision began to change on the left side.  Things started to blur and then an irregular oval shape appeared in the left side of my vision.  The rim of this shape was made up of small flashing triangles that were silver and multi-coloured.  This was clearly a migraine aura but much more intense than normal.

It had been a hot day and a thunder storm was forecast.  I tend to get headaches when atmospheric pressure changes and this was a big change.  I realised that half my vision was blurred behind the scintillating scotoma as I looked at myself in the mirror.  I tried to check my physiological blind spot but I couldn't find it.  I took some aspirin and some paracetamol and I put on my sunglasses which helped.

The aura peaked for about 10 to 15 minutes then gradually faded.  I only developed a mild headache, probably because of my early use of aspirin.  I was tired and I went to my bed early.  In my bed, the lightening storm intermittently illuminated the room.  With the overlay of the residual migraine everything felt a bit otherworldly, a bit like an episode of Twin Peaks.  Eventually I fell asleep and I felt a lot better when I woke up this morning.

Most migraines are boring, painful and annoying but this one was fascinating.  I can see how someone experiencing that, not knowing what it was, would be freaked out.  I enjoyed it although I did feel a bit 'disconnected'.  I'm glad I was in my own house and not travelling or working.

Recently, geneticists have suggested that the tendency to migraine may be associated with an ability to sense when the weather is becoming stronger.  That certainly could explain the trigger of some of my headaches.

Lying in bed afterwards I felt like my hearing was heightened and that I could hear all of the individual drops of rain falling.

Stiffed by James Morrow

James Morrow is a retired consultant neurologist from Northern Ireland.  He did outstanding work in the field of epilepsy, particularly in his work looking at the effects of anti-epileptic drugs on pregnant women and their children.  He had to take early retirement when he developed autoimmune encephalitis and he wrote about his experience of this in Practical Neurology, a British neurology journal, a few years ago.

He has kept busy during his retirement and he has written a book, Stiffed, about the pharmaceutical industry and the various challenges it faces.  The book is a comedy crime novel in the vein of Chris Brookmyre and has a few unexpected twists and turns.

There is a palpable sense of reality to the book as Dr Morrow borrows details from his extensive medical career and work with the pharmaceutical industry.  I don't want to spoil things but there were a couple of sightly unexpected twists in the tale.

The text of the kindle edition could do with some additional proof reading but it's a good read.  I'd read another book by him.  Best novel by an eminent neurologist that I've read for some time.

It's All in Your Head: Stories from the Frontline of Psychosomatic Illness by Suzanne O'Sullivan

Functional Neurological Disorders (FND) are hard to understand, both for people affected by FND and doctors involved in their care.  Functional Neurological Disorders are essentially real neurological symptoms which exist when damage to the nervous system cannot be detected with tests or on clinical examination.  The symptoms are real and disabling but the function of the nervous system is intact.  Many of these symptoms may be due to stress or psychological symptoms, some can be due to other non-neurological diseases or an exaggerated response to a neurological disease process and at times no cause is found.

Often, a person affected by FND can make a good recovery, especially if they engage with the diagnosis.  Others can be stuck with the symptoms forever.  The symptoms are extremely upsetting for those affected by them.

Suzanne O'Sullivan is a neurologist with an interest in functional neurological disorders and epilepsy who works in specialist neurological disorders in London.  In her book she tackles dissociative seizures, psychosomatic illness and functional neurological disorders.  Many doctors struggle to deal with patients affected by these illnesses, thinking that the patients are faking symptoms, attention seeking or trying to fool doctors.  This is not the case.  People with FND are distressed and often lead difficult lives.  Dr O'Sullivan puts a human face on these stories and tackles the issues surrounding this complicated diagnosis.  She highlights some of the mistakes she has made and the communication breakdowns she has encountered.  FND is a difficult diagnosis for both doctor and patient.

This book is a good one for neurologists to read and a good book for anyone affected by FND.  A good patient resource is the Neurosymptoms website, developed by neurologists from Edinburgh which can be used to help understand strange symptoms.  This book also helps make sense of odd symptoms and is worth some of your time.

Podcasts

Over the past few years I've started listening to a lot of Podcasts.  I always liked listening to the radio although I didn't always find the broadcast shows to be very exciting.  Podcasts are homemade radio shows that you can download and listen to at a time that suits you.  They also often cover more offbeat or esoteric subjects that appeal to me.

Mostly I listen to real life mystery podcasts, American political podcasts (mainly ones about Trump), Twin Peaks related podcasts and comic book podcasts.  And the Private Eye podcasts.

One of the first mystery style I started to listen to was Thinking Sideways - in this podcast three presenters take turns to present a mystery every week and discuss various theories on what went on.  The first episode that I listened to was on the 'Glasgow effect'.

Another slightly more fantastical podcast that I enjoy is Astonishing Legends - this podcast goes into strange tales in a great degree of detail.  They exude an X-Files type vibe and they are often rather credulous but the production values are good and I enjoy the shows.

From a comic book point of view Fatman on Batman produced by Clerks director Kevin Smith as part of his Smodcast empire is a good starting point (if you like Batman).  The early episodes in the archive are great, often focusing on individual comic book writers or artists and Batman related stuff. More recently the podcast has developed into a general forum for discussion of sic-fi, superheroes and anything Smith wants to talk about.

The Stuff You Should Know network has several good podcasts including Stuff They Don't Want You To Know and Stuff to Blow Your Mind (both of which have a sort of counterculture vibe) as well as the more mainstream, flagship Stuff You Should Know series.  All of these are fairly interesting.

In terms of Trump bashing Trumpcast is fairly funny and a good place to start.  The Pod Save America team have more White House connections and often have serious guests on to interview although they are often pretty funny too.

No Such Thing As A Fish  was one of the first podcasts I listened to, a spin off from the BBC QI series, where strange facts are discussed in an amusing manner every week.  It's good for a smile every now and again.

There are many more podcasts to check out - a few more are below
Page 94 - The Private Eye Podcast
The 2000AD Progcast - some great 2000AD chat
The Politico Nerdcast
A Twin Peaks Podcast

Enjoy

When medical science fails

As a doctor one of the most frustrating things you can experience is failure, the realisation that medical science is not good enough to fix a person.  It's worse if that person is a friend (or the spouse of a friend) and they have a health problem that is part of your specialist interest.  It is also important to note that as a doctor you should really not be involved in the medical care of your friends.

I wish medical science was better.  I wish that the drugs we have now were available 20 years ago.  I wish we were better. I wish we could stop young people becoming disabled.  I wish everyone could live full, pain free lives with no fucking problems at all.

My wishes are unrealistic.

As a doctor I want to make things good for my patients.  I know this is not always possible.  I can accept that. It's just fucking difficult to accept if it's someone you know, with a disease you work with, but sadly the boat has been missed and the great drugs came along too fucking late. It's a shitty fucking deal.  Sometimes you wish you could turn back the clock but life is not going to let that happen.

You also want to give all of your patients all of your effort all of the time but that is not possible either. As a doctor you are still human and your resources are limited.  It is impossible to fire on full cylinders all the time.

Anyway, I'm on holiday.  Rant over.

Teaching

I regularly reflect on what a lucky bastard I am.  I spent the last week teaching a full year group of medical students about my speciality interest.  I had a great time.  Teaching is one of the most enjoyable parts of being a doctor.

Part of what you want to do is stop the students falling asleep.  A lot of medicine is boring.  It's difficult to just absorb a stream of facts.  It's also difficult to filter the massive amount of information that we deal with.  Hundreds of pages of medical data are published every day and the vast majority of it is bullshit.  You want the students to walk away with knowledge of the important stuff that will save a life and help patients get better.  You want the important stuff to stick.

By teaching, you learn.  I've learned some neuroanatomy myself this week and I've come to realise that my understanding of at least one condition was wrong.  I don't know if this is because I was taught badly myself 16 or 17 years ago or if I just misunderstood a concept.  The important thing is that I have corrected my knowledge now.

We were trying to make things fun for the students so we set up a text number on a mobile phone to let them ask us questions as well as a twitter account.  We got a lot of useful texts as well as a few abusive ones.  I used the twitter account to promote YouTube videos of examination skills, patient experiences and other useful websites.  If the students are interested they will check it out.

I'm a bit of an extrovert so I enjoy public speaking.  My problem is, that as a Glasweigan, I tend to swear or say inappropriate things.  The students did seem to like this.  I didn't say anything that was too out of order, especially when I compare myself to a surgical colleague who started to talk about shagging goats.

We got some decent feedback and hopefully it was a success.  With luck the students will pass their exams and some of them may even develop a greater interest in neurology as time goes on.  I have to get back to regular doctoring this week but I'm already looking forward to my next bit of teaching.

Jason Becker: Not Dead Yat

I must admit that I'd never heard of Jason Becker but I must have bought some guitar magazines with his face in them at some point in the early nineties.  Becker played a style of guitar that I am not really a fan of but he was a talented young guitarist.  He had signed up with David Lee Roth when disaster struck.  At the age of 20 Jason Becker was diagnosed with motor neurone disease.  Somehow he is still alive.

I'm a neurologist.  I've met a lot of people with motor neurone disease.  It's a terrible disease, one of the worst diseases I know of.  Very few people live for a long period of time.  Through luck, excellent family support and good resources Jason Becker is still alive and still making music.

Through a mixture of family photographs, super 8 cinefilms, concert footage and interviews we hear Jason's life story.  He should have been Stevie Vai or Van Halen but his body betrayed him and now he communicates with his eyes. Based on the film he has shown amazing resilience and focus.  Most people couldn't do that.  The only other person that I can think of who has survived so long with a motor neurone disease is Steven Hawking.

This film is worth seeing.  It interests me as a doctor and as a music fan. I'm not a fan of 'shred' guitar but it's great to see one man keeping on despite the odds.

Achievements

So it has been a big week for me in a way.  I had the viva for my MD thesis on Monday crowning nearly five years of research work.  My examiners liked my thesis (much to my surprise) and it will be accepted by the University.  An achievement.

Does that make me an academic? I have 3 degrees in science, medicine and research.  I do clinical work and I have clinical qualifications.  I work hard and I am probably a bit addicted to it.  Work is almost an end in itself.  Money is a happy side effect.  I have published a few useful scientific papers.  I hope they are useful as other authors have cited them but it is difficult to be sure.  I have made tentative moves to do more academic work.

How do you know when you have achieved enough? When can you sit back and relax? What drives you on?  Sometimes I feel like I have blinked and 15 years have vanished.  At times my life has been a whirlwind.

I like helping people when I can and I like to have an interesting life.  I get bored easily and I like a bit of variety in my life.  Research and teaching give me a bit of variety.  Clinical work is enjoyable too but burnout is always possible and important to avoid.  

I honestly don't know why I work so hard.  I do it because it's easy and it gives me something to do.  Work means that I don't need to think too much about anything else and I can feel like I am doing something worthwhile.  I guess I'm lucky to have a job that lets me do that.  I have a job that sometimes lets me feel like I'm achieving something.

Thesis submitted

So, after 4 years and 7 months I've finally submitted my MD thesis.  It was a massive amout of work but I've finished it.  The feeling of relief associated with this is immense.  I now have my evenings and weekends back and I no longer have a constant feeling of guilt.  It's not totally over because I still have a viva examination but this will take a few months to organise.

So,  I'm free.

For a bit.  Since August I've spent an average of 8 hours working on this thing.  Eight hours of solid unpaid work every weekend.  A big chunk of my life.  At times I wasn't sure that I  would get there but I did.  It cost about £180 to get 4 copies of the 300 page document printed.  They weighed a tonne.  But it was a good weight.

That's enough egotism for tonight.

Sometimes there are good things about being a doctor.

Every so often you do manage to do something worthwhile as a doctor.  Today we managed to get a young woman home after more than 80 days on the ward.  The woman had an unusual diagnosis  (anti-NMDA receptor encephalitis) and I managed to guess what was going on.  I did the right test quickly and we confirmed the diagnosis early.  We managed to deal with all the problems that can occur in this condition and we managed to deliver the correct treatments (or at least what are hopefully the correct treatments).

I cannot say that we got everything right all the time but we did our best and the patient seems to be better.  Her partner and her family were very happy.  I got a bit embarrassed and slightly teary when they were saying goodbye.  As a doctor you don't really expect people to thank you.  I'm just there to do a job to the best of my ability and I get paid well for it.  People are often unhappy with their doctors and I'm always a bit surprised when they are nice to us.

So, despite being run off my feet and working like a blue-arsed fly it was a good day.  We got a good result.  We don't always get them.

Parkinson's disease - patients perspective film

Here's a clip from a film about Parkinson's disease made by a girl I knew when I was younger.

Parkinson's disease is a common neurological illness that we need to learn more about. The treatments currently available for this condition are not perfect and more research is needed.

Good television shows about creative people with degenerative neurological disorders

February is cold and I have no money so I've been watching a lot of TV. Given my interest in neurology and comic books I have enjoyed a couple of interesting documentaries.

Last night I watched 'Here's Johnny', a 2008 film about John Hickleton, a comic book artist who has Multiple Sclerosis (MS). In case you don't know, MS is an autoimmune problem where parts of the the nervous system are attacked by the immune system. It's relatively common in the UK and has a range of clinical presentations. It can be mild in some people and very severe in other people. In the past it was untreatable although there are now some more promising therapeutic options.

John Hickleton used to draw Nemesis the Warlock and Judge Dredd (among others) for 2000AD when I was a kid. His art is pretty mental but good. Some of his images, especially those from Nemesis, really stuck in my mind. I missed the first 5 minutes of the film but I think Hickleton was diagnosed with MS in 2001. Much of his disease affects his spinal cord and he has had great difficulties in walking. The documentary covers his life from 2001 to 2007.

Hickleton initially took the diagnosis very badly and threw himself into drink and drugs. He admits that he was very angry and depressed at the time. He starts to experiment with various 'alternative' medications and there are some hilarious moments in the film where he takes a horse laxative (I might be wrong here). Eventually he accepts his diagnosis and he appears to be more comfortable with his life.

Hickleton comes across as energetic and likable. The visual design of the film uses a lot of his comic art and looks great. I strongly advise you to watch this film.

Over the last two weeks I've been watching a documentary about Terry Pratchett who has been diagnosed with posterior cortical atrophy, a variant of Alzheimer's disease, another neurodegenerative disorder. Alzheimer's is less treatable than MS and is a progressive form of dementia. The variant that Pratchett has initially attacks the visual system.

Prachett, who is a highly successful and entertaining writer, has much more money than Hickleton. He has donated lots of money to medical research and has done a great deal to publicise the plight of people with dementia. The documentary follows him as he tours the world looking for a cure. He meets a lot of people who have unusual ideas about how to treat the disease and he seems to assess them in a fairly intelligent manner. Again, I enjoyed this film and I hope a lot of people see it.

For more info

http://www.alzheimers.org.uk/headroom?gclid=COywkdry5ZgCFQ9SQgodTCvUdw
http://www.terrypratchettbooks.com/
http://www.mssociety.org.uk/
http://www.mssociety.org.uk/news_events/news/press_releases/johnny.html

I couldn't find a link for a John Hickleton page but if anyone finds something please let me know.

I have escaped.....

Today was my first day in research and it was good. I didn't need to carry a page and I didn't need to run about too much.

I showed up, found my office and had a chat with my boss for a couple of hours. I then went to a departmental meeting and it was nice to find out that a lot of people remembered me from when I had been a student there 5 years earlier.

In the afternoon I had time to do some reading and get my thoughts in order. I also had some time to shadow one of my more experienced co-workers to find out what I should do on an average day.

It's all rather encouraging. I wish I'd got here a while ago.

I now have my dream job so today was a good day

Despite the sheer hell and emotional turmoil of the past week or so today was a brilliant day. I had an interview for my perfect job and I was offered it a couple of hours later. This is the sort of job that I wanted to do when I applied to medical school. I'm gonna do research, teaching and interesting clinical work in a good unit. I feel like I'm walking on air.

On top of that I've finished paying the deposit on my yuppie flat. It should be built by the end of the year.

Best of all I get to stay in Glasgow for another couple of years.

funky

Musicophilia - Tales of Music and the Brain by Oliver Sacks

This book deals with two of my obsessions - music and neurology. I first got into Oliver Sacks in the third year of my Neuroscience BSc at Glasgow Uni. Until I read his work I'd never really thought about being a doctor but I found that his writing put a human face on the various conditions that I learned about in my lectures. Eventually I decided that I wanted to be a neurologist like Oliver Sacks and applied to medical school which got me to where I am today.

In this book Sacks looks at how music interacts with the brain. He describes musical auras which precede epileptic seizures and seizures which are triggered by music. He writes about the neurological basis of advertising jingles and musical hallucinations. He also talks about how music can help people with conditions like Parkinson's Disease or amnesia as well as the specific neurological problems that can affect musicians (which has left me thinking that I might have a bit of a dystonia affecting my left hand when I play guitar too much.)

He also describes musical hallucinations in deaf people and synaesthesia. I actually wish that I had synaesthesia, a neurological condition in which sensory input is cross-wired and musical notes can be associated with colours or tastes. It is for the most part harmless and it sounds like it might be interesting.

He writes about a rare congenital condition called Williams Syndrome that results in unusual musical abilities and about musical savants. I have learned a fair bit from this book although much of what he writes about has already been covered in his previous works.

I enjoyed this book although I would advise a new reader to start with The man who mistook his wife for a hat (which supplied the title of a Travis album) or An anthropologist on Mars. I would also tell a new reader about the film Awakenings although I would reassure the reader that Sacks books are not as sugary as the film inspired by his work.

For more try www.oliversacks.com