How I became a neurologist?

Even today I find myself waking up from a dreadful nightmare filled with neurological pathways crisscrossing the spinal cord, the brain stem and then the brain and I stuck entwined between the crisscrossing fibers. That is how scared I am of neurological diagnosis and treatment. And in this story, I am going to narrate the events that made me a neurologist. I do not have a DM in neurology. I don’t even have an MD in General Medicine. In the rural area where I practice medicine, somehow word spread that I am a “narambu doctor” which is Tamizh for “nerve doctor” or neurologist. How did the word spread like that? What does this mean to me as a primary care provider, to primary care practice that is followed today and to the overall practice of medicine? Read along for some of my reflections.

Gopal (name changed for confidentiality) was a 29-year-old man working as a construction supervisor in a large construction site. He suddenly developed weakness of his hands. First, it started as difficulty in carrying heavy weights. He kept dropping objects that were even heavier than 250 gms. Then slowly it progressed to inability to wear his shirt, comb his hair, eat his food by himself or even move his own hand. He had become completely dependent on his mother to bathe, clean and clothe him. This was becoming very much uncomfortable to Gopal and so he had come to the clinic with his mother and elder brother. All these problems started about 2 years ago. Before this started Gopal had been diagnosed with tuberculosis of his lungs. He had been given a complete 6-month course of treatment with anti-tuberculosis drugs and he was declared cured after taking the medicines. This weakness had started just after he had completed the treatment for tuberculosis.

The first encounter that Gopal had with a doctor for his weakness was with a tuberculosis specialist. This person examined Gopal thoroughly and said there was no sign of recurrence of tuberculosis that had just recently been cured. He advised Gopal that what he was having was a form of extreme weakness following treatment with tuberculosis. Gopal was given vitamins and mineral tablets and asked to follow up after a month. The vitamins and minerals did not help Gopal regain the strength in his hands.

His second encounter was with a general medicine practitioner (MD) near his house. After hearing all this history, the doctor ordered for some blood tests including tests for blood sugars, cholesterol, liver function tests, and kidney function blood tests. The results of these tests showed that some of the enzymes from Gopal’s liver were slightly elevated. Everything else was in order. The doctor attributed the raised liver enzyme levels to the anti-tuberculosis treatment (it is a well-known side effect) and told Gopal that the weakness was because of a liver problem. The doctor started him on some “liver medication”, which was an Ayurvedic herbal preparation. Even after taking this medicine for 2 months, Gopal found no improvement.

An intelligent relative, who saw Gopal in a wedding ceremony, asked him to go and visit the neurologist, nerve doctor, at the Government Hospital in Chengalpet. The relative strongly felt that the problem that Gopal had was linked to nerves and so he had to see a nerve doctor. Gopal, whose hand weakness was by now rapidly deteriorating, went to the neurology outpatient department of Chengalpet Government Hospital. Gopal reached Chengalpet GH around 10 AM in the morning of a Wednesday. It was the neurology outpatient clinic day and the outpatient clinic was already jam-packed with patients as Gopal entered and got his token. He waited for more than 3 hours and at 1.20 PM it was Gopal’s turn to see the neurologist. The neurologist was heading out of the clinic as he had a clinical meeting after lunch, and he was irritated to see Gopal. He yelled, “Why don’t you people come to OP early? Do you know what time I come to work? I come at 7 AM and you people walk in casually at 1.20 PM?” Gopal was equally irritated, but he could not shout back. He had no power here. This was the doctor’s territory. So, Gopal could not say that he did not enter the OP at 1.20 PM. In fact, he had come at 10 AM and had been sitting outside the sweltering, overcrowded OP waiting area for his turn. The doctor yelled, “Why have you come?” As Gopal started mumbling his complaint, the doctor snatched the notebook that was perched on Gopal’s thighs. He saw the first few pages. And started writing something on Gopal’s OP chit. He called a very young doctor who was standing nearby, “Hey, you intern. Come here! This guy is an old case of TB. The pulmonology guys send all their cooked-up cases to us just to deflect attention. Do an examination, write “post-tuberculosis drug-induced neuritis” and start the patient on vitamin B complex and refer him to pulmonology. After that, run to Anand Bhavan and get me my mini meals. Quick. I am going to duty room” and he walked away. That day Gopal got an amateur physical examination, and some vitamin tablets and went back home without an answer for the weakness of his hands. Gopal felt trapped inside his weakening hands. He couldn’t do anything independently. His hands had given up on him. He could not do anything about it, because he did not know whom to contact, whom to ask and what to do to even find out what is wrong. Getting things fixed now seemed like a far-fetched dream.

It was in this state that Gopal landed in my clinic. He came because a patient who had diabetes and was currently under my treatment was his neighbor and she had told Gopal that he should come and meet me. She said, “He is a sugar and BP doctor. But he will listen to you, do a checkup and talk to you about your problem. Just go and see him once”.

I have seen a wide variety of patients, but most have one of the following three attitudes – (1) confused, irritated and agitated about the disease, (2) apathetic, resigned and hopeless about a cure, (3) afraid, eager, optimistic about a cure. Gopal had a lost look on his face. There was no optimism or anticipation of a cure, but there was a subtle hint of a search for an answer for his problem. “Why am I having this condition?”, his eyes seemed to ask me. After hearing out his full story, most of which I have narrated above, I took him to the examination cabin to do a thorough examination. Gopal had typical muscle wasting in his shoulders, upper chest, arms, forearms, and hands. The muscles in his arms and upper chest were twitching and flickering – referred to as fasciculation – indicating a wasting of the muscles due to damage to the nerves. There was no wasting in his lower limbs. The power in his upper limbs was almost absent. He was not even able to grasp my fingers. His lower limb power was normal. Then I performed the deep tendon reflexes. Deep tendon reflexes are very useful clinical signs in neurology. When we tap any muscle at its tendon where it meets the bone which it moves, the muscle contracts involuntarily and then relaxes. When the deep tendon reflexes are absent or weak, it indicates damage to the muscle or nerve just adjacent to the muscle, lower motor neuron disease. But when the deep tendon reflexes are exaggerated, it indicates damage to the nerve at a higher level closer to the brain, known as upper motor neuron damage. Gopal’s deep tendon reflexes were absent in the upper limbs and exaggerated in the lower limbs. This type of typical neurological findings is not common and indicates a specific condition like damage at the spinal cord level. I am not going into details of the neurological diagnosis and level of lesion etc. As I told you, those areas of medicine are still a nightmare to me. But it was evident that what Gopal had was not just a post-tuberculosis weakness, not a “drug-induced neuritis” or general weakness or any such diagnosis. I immediately spoke to Gopal, his mother and elder brother, explained the situation that there is more to it than just ‘post TB weakness’ and referred him to the Government General Hospital in Chennai. There Gopal is admitted in the neurology ward now and is undergoing evaluation for his neurological condition. Gopal’s brother calls me regularly now to update me on the progress of his brother’s treatment. In typical rural areas, news like this spread very fast. Following this small and rather insignificant event at the clinic, we noticed that many patients with complex neurological conditions had started coming to the clinic.

Last week we saw a lady with ataxic gait, abnormal limb movements and head nodding, probably a case of spinocerebellar ataxia and today a guy with Broca’s aphasia. Not only was it unusual to get such complex patients to our primary care clinic but these patients came to us from very far away, more than 30 km away, and they had all been previously seen and treated in big tertiary care centers. We were wondering what is happening to our clinic? We understood the situation where previously undiagnosed patients with neurological conditions were getting picked up by us. But previously diagnosed and treated patients, who know that they had neurological conditions, knew that they needed to see a neurologist or “narambu doctor” were coming to us. On asking the wife of the man with Broca’s aphasia, why she traveled such a long distance to come and see me, she said, “Sir, they said that a very good ‘narambu doctor’ – neurologist is seeing patients here. They said that the doctor is treating very well. So, we came.” After completing the examination, and discussing the treatment plan with the couple, I explained that I am not a neurologist, but a ‘general doctor’. But the patient and her wife did not seem to care. They smiled and said, “ok sir” and gave me a big “vanakkam” with their palms joined in reverence and left.

My colleagues and I were discussing these events as we were returning from the clinic back home. The detailed examination that I did for Gopal, to pick up his neurological condition, was something that any 4th-year MBBS student can do. In fact, I stopped short of just identifying a problem, did not even go on to make a detailed diagnosis. And that gesture made me a “narambu doctor”. To me, this could indicate a couple of things:

1.      The compartmentalization of medicine has led to a complete metamorphosis of the idea of a ‘doctor’ from a person who deals with health problems of people, to ‘specialists’ who deal with specific compartments of the body. Therefore the pulmonologist did not see the neurological condition and the MD doctor saw only the liver enzyme disorder.

2.      The specialization and super-specialization in medicine have led to deep compartmentalization of diseases and treatments, that patients themselves do not expect a ‘general doctor’ to do a neurological examination. Any doctor doing a detailed neurological examination and finding neurological problems, in their minds, is a ‘narambu doctor’ or neurologist, thus making me a neurologist, despite not having a DM in neurology.

Again, in tune with what I have been writing before, at the cost of sounding like a broken record repeating the same thing again and again, I come back to the same point, the quintessence of medicine being the clinical encounter. Contrary to what the title may lead you to believe, this story is not about a ‘generalist’ becoming a ‘specialist’. It is about how every generalist is many specialists rolled into one. A careful and conscientious ‘general practitioner’ or primary care provider has the potential to reach out and touch the lives of many more people. I am not trying to draw a feud between specialists and generalists here. My argument is that every specialist should first be a generalist in approach if they must reach out in meaningful ways to the lives of their patients.