Hitting a Nerve

I’m not hiding anything.

Occasionally I deal with patients and families who seem to think I have some miracle cure for a condition that I’m not telling them about.

I promise, I don’t work that way. Besides the obvious ethical issues, why would I? What could I possibly gain from doing that?

The trouble is that people are blanketed by news headlines, some reputable and some not, about a research study suggesting a new direction in treatment, or that a new drug in development has promise. Often these stories are forwarded to them by well-meaning relatives and friends, or just show up in their social media feed.

While some of these findings may actually lead somewhere, the vast majority don’t. In my career I’ve seen statins touted as potential treatments for MS and Alzheimer’s disease, and vilified as causes of dementia and peripheral neuropathy, all disproved or (to date) still up in the air.

But nonmedical people don’t understand that. It made the news, so it must mean something. I have no problem trying to explain this to them, but it’s never easy.

It’s even harder to explain to the ones who’ve already purchased a costly over-the-counter placebo for such a condition that they wasted their money.

We live in a world of amazing technological achievements, but that doesn’t mean all diseases have been cured and problems fixed. Far from it.

New discoveries are made, but a lot of times it’s a very slow journey to find the solution. One discovery may not lead to THE answer, but hopefully will get you closer to it.

That generally doesn’t happen overnight. The mathematical problem of Goldbach’s Conjecture has been around since 1742 and still hasn’t been definitively answered.

Medicine isn’t math, either. The people and families dealing with these conditions want answers. I don’t blame them. So do I. Believe me, there would be nothing that would bring me more joy as a doctor than to be able to give someone with a serious diagnosis the comfort that comes with saying it’s also curable.

I never have, and never would, withhold such a thing from a patient. Ever. I just wish some of them would believe me when I say that.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I’m not hiding anything.

Occasionally I deal with patients and families who seem to think I have some miracle cure for a condition that I’m not telling them about.

I promise, I don’t work that way. Besides the obvious ethical issues, why would I? What could I possibly gain from doing that?

The trouble is that people are blanketed by news headlines, some reputable and some not, about a research study suggesting a new direction in treatment, or that a new drug in development has promise. Often these stories are forwarded to them by well-meaning relatives and friends, or just show up in their social media feed.

While some of these findings may actually lead somewhere, the vast majority don’t. In my career I’ve seen statins touted as potential treatments for MS and Alzheimer’s disease, and vilified as causes of dementia and peripheral neuropathy, all disproved or (to date) still up in the air.

But nonmedical people don’t understand that. It made the news, so it must mean something. I have no problem trying to explain this to them, but it’s never easy.

It’s even harder to explain to the ones who’ve already purchased a costly over-the-counter placebo for such a condition that they wasted their money.

We live in a world of amazing technological achievements, but that doesn’t mean all diseases have been cured and problems fixed. Far from it.

New discoveries are made, but a lot of times it’s a very slow journey to find the solution. One discovery may not lead to THE answer, but hopefully will get you closer to it.

That generally doesn’t happen overnight. The mathematical problem of Goldbach’s Conjecture has been around since 1742 and still hasn’t been definitively answered.

Medicine isn’t math, either. The people and families dealing with these conditions want answers. I don’t blame them. So do I. Believe me, there would be nothing that would bring me more joy as a doctor than to be able to give someone with a serious diagnosis the comfort that comes with saying it’s also curable.

I never have, and never would, withhold such a thing from a patient. Ever. I just wish some of them would believe me when I say that.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I’m not hiding anything.

Occasionally I deal with patients and families who seem to think I have some miracle cure for a condition that I’m not telling them about.

I promise, I don’t work that way. Besides the obvious ethical issues, why would I? What could I possibly gain from doing that?

The trouble is that people are blanketed by news headlines, some reputable and some not, about a research study suggesting a new direction in treatment, or that a new drug in development has promise. Often these stories are forwarded to them by well-meaning relatives and friends, or just show up in their social media feed.

While some of these findings may actually lead somewhere, the vast majority don’t. In my career I’ve seen statins touted as potential treatments for MS and Alzheimer’s disease, and vilified as causes of dementia and peripheral neuropathy, all disproved or (to date) still up in the air.

But nonmedical people don’t understand that. It made the news, so it must mean something. I have no problem trying to explain this to them, but it’s never easy.

It’s even harder to explain to the ones who’ve already purchased a costly over-the-counter placebo for such a condition that they wasted their money.

We live in a world of amazing technological achievements, but that doesn’t mean all diseases have been cured and problems fixed. Far from it.

New discoveries are made, but a lot of times it’s a very slow journey to find the solution. One discovery may not lead to THE answer, but hopefully will get you closer to it.

That generally doesn’t happen overnight. The mathematical problem of Goldbach’s Conjecture has been around since 1742 and still hasn’t been definitively answered.

Medicine isn’t math, either. The people and families dealing with these conditions want answers. I don’t blame them. So do I. Believe me, there would be nothing that would bring me more joy as a doctor than to be able to give someone with a serious diagnosis the comfort that comes with saying it’s also curable.

I never have, and never would, withhold such a thing from a patient. Ever. I just wish some of them would believe me when I say that.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Growing up, my dad would often go to his law office on weekends to get work done.

As a kid I didn’t really understand this. Dad had an office at home, and could close the door if he needed to. Usually he did this, but sometimes he left to go to his REAL office.

And now ... I sometimes do the same thing.

I don’t see patients on Fridays these days. In the postpandemic world my schedule still hasn’t returned to normal (maybe it never will and this is the new normal), and with research and case reviews and other stuff it seemed logical to just work from home and do them that day. My staff works from home, so if I’m not seeing patients, why can’t I?

After a few Fridays of this, I began going to my empty office, too, and understood where my dad was coming from.

My little solo office, as non-fancy as it is (the carpeting and interior are all from 1993), is quiet. From my back office I can’t hear the corridor hustle and bustle of people going to their appointments or arguing on a cell phone. Just the hum of the air conditioner and the occasional few seconds of a car alarm outside. If I put on iTunes no one complains about my musical tastes.

There isn’t much to do there BUT work, which is the idea. The building’s wifi is too slow to stream or watch Youtube. I’m not tempted to work on a puzzle with my daughter, take a book off a shelf, play with my dogs, or go down the hall for a nap. All the little things we do to procrastinate aren’t there, like convincing myself that I need to clean the pool or balance the checkbook ASAP.

I don’t have the distractions of my dogs barking at passing cars, or kids going up and down the hall, or the phone ringing with people asking who I’m voting for.

My little office is a private oasis, of sorts. Quiet and undisturbed.

Not quite Superman’s Fortress of Solitude, but close enough for me.

And, with all due respect to the Man of Steel, the Fortress of Solitude doesn’t have a Keurig.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Growing up, my dad would often go to his law office on weekends to get work done.

As a kid I didn’t really understand this. Dad had an office at home, and could close the door if he needed to. Usually he did this, but sometimes he left to go to his REAL office.

And now ... I sometimes do the same thing.

I don’t see patients on Fridays these days. In the postpandemic world my schedule still hasn’t returned to normal (maybe it never will and this is the new normal), and with research and case reviews and other stuff it seemed logical to just work from home and do them that day. My staff works from home, so if I’m not seeing patients, why can’t I?

After a few Fridays of this, I began going to my empty office, too, and understood where my dad was coming from.

My little solo office, as non-fancy as it is (the carpeting and interior are all from 1993), is quiet. From my back office I can’t hear the corridor hustle and bustle of people going to their appointments or arguing on a cell phone. Just the hum of the air conditioner and the occasional few seconds of a car alarm outside. If I put on iTunes no one complains about my musical tastes.

There isn’t much to do there BUT work, which is the idea. The building’s wifi is too slow to stream or watch Youtube. I’m not tempted to work on a puzzle with my daughter, take a book off a shelf, play with my dogs, or go down the hall for a nap. All the little things we do to procrastinate aren’t there, like convincing myself that I need to clean the pool or balance the checkbook ASAP.

I don’t have the distractions of my dogs barking at passing cars, or kids going up and down the hall, or the phone ringing with people asking who I’m voting for.

My little office is a private oasis, of sorts. Quiet and undisturbed.

Not quite Superman’s Fortress of Solitude, but close enough for me.

And, with all due respect to the Man of Steel, the Fortress of Solitude doesn’t have a Keurig.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Growing up, my dad would often go to his law office on weekends to get work done.

As a kid I didn’t really understand this. Dad had an office at home, and could close the door if he needed to. Usually he did this, but sometimes he left to go to his REAL office.

And now ... I sometimes do the same thing.

I don’t see patients on Fridays these days. In the postpandemic world my schedule still hasn’t returned to normal (maybe it never will and this is the new normal), and with research and case reviews and other stuff it seemed logical to just work from home and do them that day. My staff works from home, so if I’m not seeing patients, why can’t I?

After a few Fridays of this, I began going to my empty office, too, and understood where my dad was coming from.

My little solo office, as non-fancy as it is (the carpeting and interior are all from 1993), is quiet. From my back office I can’t hear the corridor hustle and bustle of people going to their appointments or arguing on a cell phone. Just the hum of the air conditioner and the occasional few seconds of a car alarm outside. If I put on iTunes no one complains about my musical tastes.

There isn’t much to do there BUT work, which is the idea. The building’s wifi is too slow to stream or watch Youtube. I’m not tempted to work on a puzzle with my daughter, take a book off a shelf, play with my dogs, or go down the hall for a nap. All the little things we do to procrastinate aren’t there, like convincing myself that I need to clean the pool or balance the checkbook ASAP.

I don’t have the distractions of my dogs barking at passing cars, or kids going up and down the hall, or the phone ringing with people asking who I’m voting for.

My little office is a private oasis, of sorts. Quiet and undisturbed.

Not quite Superman’s Fortress of Solitude, but close enough for me.

And, with all due respect to the Man of Steel, the Fortress of Solitude doesn’t have a Keurig.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

This past weekend, because of a series of unfortunate events, I had to move a lot of furniture. This included the bookshelves in my home office. I began by taking books off the shelves to make the bookcase easier to move.

After blowing away a few pounds of dust, I found myself staring at tomes that were once the center of my life: Robbin’s “Pathological Basis of Disease,” Cecil’s “Essentials of Medicine,” Stryer’s “Biochemistry, Grant’s Method of Anatomy,” Stedman’s “Medical Dictionary,” and a few others. All of them more than 30 years old.

I piled the books up on a table as I moved the bookcase, thinking about them. I hadn’t opened any of them in at least 20 years, probably more.

When it was time to put them back, I stared at the pile. They’re big and heavy, qualities that we assume are good things in textbooks. Especially in medical school.

Books have heft. Their knowledge and supposed wisdom are measured by weight and size as you slowly turn the pages under a desk lamp. Not like today, where all the libraries of the world are accessible from a single lightweight iPad.

I remember carrying those books around, stuffed in a backpack draped over my left shoulder. In retrospect it’s amazing I didn’t develop a long thoracic nerve palsy during those years.

They were expensive. I mean, in 1989 dollars, they were all between $50 and $100. I long ago shredded my credit card statements from that era, but my spending for books was pretty high. Fortunately my dad stood behind me for a big chunk of this, and told me to get whatever I needed. Believe me, I know how lucky I am.

I looked at the books. We’d been through a lot together. Long nights at my apartment across the street from Creighton, reading and rereading them. The pages still marked with the yellow highlighter pen that never left my side back then. A younger version of myself traced these pages, committing things to memory that I now have no recollection of. (If you can still draw the Krebs cycle from memory you’re way ahead of me.)

Realistically, though, there was no reason to hold onto them anymore. I’m about two-thirds of the way through my career. If I haven’t opened my old medical textbooks in 20-25 years, the odds are that I’m not going to now.

Plus, they’re out of date. Basic anatomy knowledge hasn’t changed much, but most everything else has. I started med school in 1989, and if I’d been looking things up in 1959 textbooks then, I probably wouldn’t have gotten very far. When I need to look things up these days I go to UpToDate, or Epocrates, or other online sources or apps.

I carried the majority of the books out to the recycling can. (It took a few trips.)

Facing some now-empty space on my bookshelf, I put my next challenge there: A pile of 33-RPM records that I still can’t bring myself to get rid of.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

This past weekend, because of a series of unfortunate events, I had to move a lot of furniture. This included the bookshelves in my home office. I began by taking books off the shelves to make the bookcase easier to move.

After blowing away a few pounds of dust, I found myself staring at tomes that were once the center of my life: Robbin’s “Pathological Basis of Disease,” Cecil’s “Essentials of Medicine,” Stryer’s “Biochemistry, Grant’s Method of Anatomy,” Stedman’s “Medical Dictionary,” and a few others. All of them more than 30 years old.

I piled the books up on a table as I moved the bookcase, thinking about them. I hadn’t opened any of them in at least 20 years, probably more.

When it was time to put them back, I stared at the pile. They’re big and heavy, qualities that we assume are good things in textbooks. Especially in medical school.

Books have heft. Their knowledge and supposed wisdom are measured by weight and size as you slowly turn the pages under a desk lamp. Not like today, where all the libraries of the world are accessible from a single lightweight iPad.

I remember carrying those books around, stuffed in a backpack draped over my left shoulder. In retrospect it’s amazing I didn’t develop a long thoracic nerve palsy during those years.

They were expensive. I mean, in 1989 dollars, they were all between $50 and $100. I long ago shredded my credit card statements from that era, but my spending for books was pretty high. Fortunately my dad stood behind me for a big chunk of this, and told me to get whatever I needed. Believe me, I know how lucky I am.

I looked at the books. We’d been through a lot together. Long nights at my apartment across the street from Creighton, reading and rereading them. The pages still marked with the yellow highlighter pen that never left my side back then. A younger version of myself traced these pages, committing things to memory that I now have no recollection of. (If you can still draw the Krebs cycle from memory you’re way ahead of me.)

Realistically, though, there was no reason to hold onto them anymore. I’m about two-thirds of the way through my career. If I haven’t opened my old medical textbooks in 20-25 years, the odds are that I’m not going to now.

Plus, they’re out of date. Basic anatomy knowledge hasn’t changed much, but most everything else has. I started med school in 1989, and if I’d been looking things up in 1959 textbooks then, I probably wouldn’t have gotten very far. When I need to look things up these days I go to UpToDate, or Epocrates, or other online sources or apps.

I carried the majority of the books out to the recycling can. (It took a few trips.)

Facing some now-empty space on my bookshelf, I put my next challenge there: A pile of 33-RPM records that I still can’t bring myself to get rid of.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

This past weekend, because of a series of unfortunate events, I had to move a lot of furniture. This included the bookshelves in my home office. I began by taking books off the shelves to make the bookcase easier to move.

After blowing away a few pounds of dust, I found myself staring at tomes that were once the center of my life: Robbin’s “Pathological Basis of Disease,” Cecil’s “Essentials of Medicine,” Stryer’s “Biochemistry, Grant’s Method of Anatomy,” Stedman’s “Medical Dictionary,” and a few others. All of them more than 30 years old.

I piled the books up on a table as I moved the bookcase, thinking about them. I hadn’t opened any of them in at least 20 years, probably more.

When it was time to put them back, I stared at the pile. They’re big and heavy, qualities that we assume are good things in textbooks. Especially in medical school.

Books have heft. Their knowledge and supposed wisdom are measured by weight and size as you slowly turn the pages under a desk lamp. Not like today, where all the libraries of the world are accessible from a single lightweight iPad.

I remember carrying those books around, stuffed in a backpack draped over my left shoulder. In retrospect it’s amazing I didn’t develop a long thoracic nerve palsy during those years.

They were expensive. I mean, in 1989 dollars, they were all between $50 and $100. I long ago shredded my credit card statements from that era, but my spending for books was pretty high. Fortunately my dad stood behind me for a big chunk of this, and told me to get whatever I needed. Believe me, I know how lucky I am.

I looked at the books. We’d been through a lot together. Long nights at my apartment across the street from Creighton, reading and rereading them. The pages still marked with the yellow highlighter pen that never left my side back then. A younger version of myself traced these pages, committing things to memory that I now have no recollection of. (If you can still draw the Krebs cycle from memory you’re way ahead of me.)

Realistically, though, there was no reason to hold onto them anymore. I’m about two-thirds of the way through my career. If I haven’t opened my old medical textbooks in 20-25 years, the odds are that I’m not going to now.

Plus, they’re out of date. Basic anatomy knowledge hasn’t changed much, but most everything else has. I started med school in 1989, and if I’d been looking things up in 1959 textbooks then, I probably wouldn’t have gotten very far. When I need to look things up these days I go to UpToDate, or Epocrates, or other online sources or apps.

I carried the majority of the books out to the recycling can. (It took a few trips.)

Facing some now-empty space on my bookshelf, I put my next challenge there: A pile of 33-RPM records that I still can’t bring myself to get rid of.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Mrs. Stevens has migraines. Fortunately, they’re well controlled on nortriptyline, and she’s never had side effects from it. She’s taken it for more than 20 years now.

In that time she and I have had a strange, slow-motion, waltz.

In spite of the medicine helping her, she stops it on her own roughly twice a year, never calling my office in advance. Sometimes it’s to see if the headaches come back (they always do). Other times it’s because of something she read online, or a friend told her, or she overheard in the grocery checkout line.

Whatever the reason, her migraines always come back within a week, and then she calls my office for an urgent appointment.

I’ve never really understood this, as I know her history and am happy to just tell her to restart the medication and call it in. But, for whatever reason, the return of her migraines is something that she wants to discuss with me in person. Since it’s usually a pretty brief visit, my secretary puts her on the schedule and I get paid to tell her what could have been handled by phone. I’m not complaining. I have to make a living, too.

But still, it makes me wonder. She can’t be the only patient out there who does this. Multiply that by the number of doctors, the cost of visits, the time she takes off from work to come in ... it adds up.

The consequences of noncompliance in migraineurs certainly aren’t as bad – or as expensive – as those for seizure patients, but they aren’t minor either.

So why does this happen?

Believe me, for the past 20 years I’ve spent these occasional visits reminding Mrs. Stevens about the importance of sticking with her medication and calling my office if she has questions. She agrees to, but when she’s thinking about stopping nortriptyline ... she still does it and only tells me after the fact.

I can’t change human nature, or at least not hers. And when multiplied by many like her, it creates entirely unnecessary costs on our health care system. I wish there were a way to stop it.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Mrs. Stevens has migraines. Fortunately, they’re well controlled on nortriptyline, and she’s never had side effects from it. She’s taken it for more than 20 years now.

In that time she and I have had a strange, slow-motion, waltz.

In spite of the medicine helping her, she stops it on her own roughly twice a year, never calling my office in advance. Sometimes it’s to see if the headaches come back (they always do). Other times it’s because of something she read online, or a friend told her, or she overheard in the grocery checkout line.

Whatever the reason, her migraines always come back within a week, and then she calls my office for an urgent appointment.

I’ve never really understood this, as I know her history and am happy to just tell her to restart the medication and call it in. But, for whatever reason, the return of her migraines is something that she wants to discuss with me in person. Since it’s usually a pretty brief visit, my secretary puts her on the schedule and I get paid to tell her what could have been handled by phone. I’m not complaining. I have to make a living, too.

But still, it makes me wonder. She can’t be the only patient out there who does this. Multiply that by the number of doctors, the cost of visits, the time she takes off from work to come in ... it adds up.

The consequences of noncompliance in migraineurs certainly aren’t as bad – or as expensive – as those for seizure patients, but they aren’t minor either.

So why does this happen?

Believe me, for the past 20 years I’ve spent these occasional visits reminding Mrs. Stevens about the importance of sticking with her medication and calling my office if she has questions. She agrees to, but when she’s thinking about stopping nortriptyline ... she still does it and only tells me after the fact.

I can’t change human nature, or at least not hers. And when multiplied by many like her, it creates entirely unnecessary costs on our health care system. I wish there were a way to stop it.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Mrs. Stevens has migraines. Fortunately, they’re well controlled on nortriptyline, and she’s never had side effects from it. She’s taken it for more than 20 years now.

In that time she and I have had a strange, slow-motion, waltz.

In spite of the medicine helping her, she stops it on her own roughly twice a year, never calling my office in advance. Sometimes it’s to see if the headaches come back (they always do). Other times it’s because of something she read online, or a friend told her, or she overheard in the grocery checkout line.

Whatever the reason, her migraines always come back within a week, and then she calls my office for an urgent appointment.

I’ve never really understood this, as I know her history and am happy to just tell her to restart the medication and call it in. But, for whatever reason, the return of her migraines is something that she wants to discuss with me in person. Since it’s usually a pretty brief visit, my secretary puts her on the schedule and I get paid to tell her what could have been handled by phone. I’m not complaining. I have to make a living, too.

But still, it makes me wonder. She can’t be the only patient out there who does this. Multiply that by the number of doctors, the cost of visits, the time she takes off from work to come in ... it adds up.

The consequences of noncompliance in migraineurs certainly aren’t as bad – or as expensive – as those for seizure patients, but they aren’t minor either.

So why does this happen?

Believe me, for the past 20 years I’ve spent these occasional visits reminding Mrs. Stevens about the importance of sticking with her medication and calling my office if she has questions. She agrees to, but when she’s thinking about stopping nortriptyline ... she still does it and only tells me after the fact.

I can’t change human nature, or at least not hers. And when multiplied by many like her, it creates entirely unnecessary costs on our health care system. I wish there were a way to stop it.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Everything in medicine, and pretty much the universe, is based on averages. Average reduction of seizures, average blood levels, average response to treatment, average insurance reimbursement, average time spent with a new consult.

Statistics are helpful in working through large amounts of data, but on a smaller scale, like my practice, statistics aren’t quite as helpful.

I see, on average, maybe 10 patients per day, consisting of new ones, follow-ups, and electromyography and nerve conduction velocity (EMG/NCV) studies. That is, by far, a smaller number of patients than my colleagues in primary care see, and probably other neurology practices as well. But it works for me.

But that’s on averages and not always. Sometimes we all hit slumps. Who knows why? Everyone is on vacation, or the holidays are coming, or they’ve been abducted by aliens. Whatever the reason, I get the occasional week where I’m pretty bored. Maybe one or two patients in a day. I start to feel like the lonely Maytag repairman behind my desk. I check to see if any drug samples have expired. I wonder if people are actually reading my online reviews and going elsewhere.

Years ago weeks like that terrified me. I was worried my little practice might fail (granted, it still could). But as years – and cycles that make up the averages – go by, they don’t bother me as much.

After 23 years I’ve learned that it’s just part of the normal fluctuations that make up an average. One morning I’ll roll the phones and the lines will explode (figuratively, I hope) with calls. At times like these my secretary seems to grow another pair of arms as she frantically schedules callers, puts others on hold, copies insurance cards, and gives the evil eye to drug reps who step in and ask her if she’s busy.

Then my schedule gets packed. My secretary crams patients in my emergency slots of 7:00, 8:00, and 12:00. MRI results come in that require me to see people sooner rather than later. My “average” of 10 patients per day suddenly doesn’t exist. I go home with a pile of dictations to do and work away into the night to catch up.

With experience we learn to take this in stride. Now, when I hit a slow patch, I remind myself that it’s not the average, and to enjoy it while I can. Read a book, take a long lunch, go home early and nap.

Worrying about where the patients are isn’t productive, or good for your mental health. They know where I am, and will find me when they need me.

Learning to ride out the highs and lows that make up an average patient load is just another part of the job. Enjoy the slow times while you can.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Everything in medicine, and pretty much the universe, is based on averages. Average reduction of seizures, average blood levels, average response to treatment, average insurance reimbursement, average time spent with a new consult.

Statistics are helpful in working through large amounts of data, but on a smaller scale, like my practice, statistics aren’t quite as helpful.

I see, on average, maybe 10 patients per day, consisting of new ones, follow-ups, and electromyography and nerve conduction velocity (EMG/NCV) studies. That is, by far, a smaller number of patients than my colleagues in primary care see, and probably other neurology practices as well. But it works for me.

But that’s on averages and not always. Sometimes we all hit slumps. Who knows why? Everyone is on vacation, or the holidays are coming, or they’ve been abducted by aliens. Whatever the reason, I get the occasional week where I’m pretty bored. Maybe one or two patients in a day. I start to feel like the lonely Maytag repairman behind my desk. I check to see if any drug samples have expired. I wonder if people are actually reading my online reviews and going elsewhere.

Years ago weeks like that terrified me. I was worried my little practice might fail (granted, it still could). But as years – and cycles that make up the averages – go by, they don’t bother me as much.

After 23 years I’ve learned that it’s just part of the normal fluctuations that make up an average. One morning I’ll roll the phones and the lines will explode (figuratively, I hope) with calls. At times like these my secretary seems to grow another pair of arms as she frantically schedules callers, puts others on hold, copies insurance cards, and gives the evil eye to drug reps who step in and ask her if she’s busy.

Then my schedule gets packed. My secretary crams patients in my emergency slots of 7:00, 8:00, and 12:00. MRI results come in that require me to see people sooner rather than later. My “average” of 10 patients per day suddenly doesn’t exist. I go home with a pile of dictations to do and work away into the night to catch up.

With experience we learn to take this in stride. Now, when I hit a slow patch, I remind myself that it’s not the average, and to enjoy it while I can. Read a book, take a long lunch, go home early and nap.

Worrying about where the patients are isn’t productive, or good for your mental health. They know where I am, and will find me when they need me.

Learning to ride out the highs and lows that make up an average patient load is just another part of the job. Enjoy the slow times while you can.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Everything in medicine, and pretty much the universe, is based on averages. Average reduction of seizures, average blood levels, average response to treatment, average insurance reimbursement, average time spent with a new consult.

Statistics are helpful in working through large amounts of data, but on a smaller scale, like my practice, statistics aren’t quite as helpful.

I see, on average, maybe 10 patients per day, consisting of new ones, follow-ups, and electromyography and nerve conduction velocity (EMG/NCV) studies. That is, by far, a smaller number of patients than my colleagues in primary care see, and probably other neurology practices as well. But it works for me.

But that’s on averages and not always. Sometimes we all hit slumps. Who knows why? Everyone is on vacation, or the holidays are coming, or they’ve been abducted by aliens. Whatever the reason, I get the occasional week where I’m pretty bored. Maybe one or two patients in a day. I start to feel like the lonely Maytag repairman behind my desk. I check to see if any drug samples have expired. I wonder if people are actually reading my online reviews and going elsewhere.

Years ago weeks like that terrified me. I was worried my little practice might fail (granted, it still could). But as years – and cycles that make up the averages – go by, they don’t bother me as much.

After 23 years I’ve learned that it’s just part of the normal fluctuations that make up an average. One morning I’ll roll the phones and the lines will explode (figuratively, I hope) with calls. At times like these my secretary seems to grow another pair of arms as she frantically schedules callers, puts others on hold, copies insurance cards, and gives the evil eye to drug reps who step in and ask her if she’s busy.

Then my schedule gets packed. My secretary crams patients in my emergency slots of 7:00, 8:00, and 12:00. MRI results come in that require me to see people sooner rather than later. My “average” of 10 patients per day suddenly doesn’t exist. I go home with a pile of dictations to do and work away into the night to catch up.

With experience we learn to take this in stride. Now, when I hit a slow patch, I remind myself that it’s not the average, and to enjoy it while I can. Read a book, take a long lunch, go home early and nap.

Worrying about where the patients are isn’t productive, or good for your mental health. They know where I am, and will find me when they need me.

Learning to ride out the highs and lows that make up an average patient load is just another part of the job. Enjoy the slow times while you can.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

“Go outside and play!”

How often have you said that to your kids (or grandkids)? For that matter, how often did you hear it when you were a kid?

A lot, if memory serves me correctly. Some of it was just my mom wanting me out of the house, some of it an innate realization on her part that too much time spent planted in front of the TV was bad for you. (When I was a kid, Brady Bunch reruns kicked off my summer day at 8:00 a.m.).

The idea that too much time in front of a screen can be bad is nothing new. Regrettably, some of this ancient wisdom has been lost in the eons since I was a kid.

A recently published article found that people who stopped using social media for 1 week had “significant improvements in well-being, depression, and anxiety.”

Does this surprise you?

Humans, like all primates, are a social species. We’ve benefited from the combined power of our minds to leave caves, harness nature, and build civilizations. But this has a cost, and perhaps the social media screen has been a tipping point for mental health.

I’m not knocking the basic idea. Share a joke with a friend, see pictures of the new baby, hear out about a new job. That’s fine. The trouble is that it’s gone beyond that. A lot of it is perfectly innocuous ... but a lot isn’t.

As it’s evolved, social media has also become the home of anger. Political and otherwise. It’s so much easier to post memes making fun of other people and their viewpoints than to speak to them in person. Trolls and bots lurk everywhere to get you riled up – things you wouldn’t be encountering if you were talking to your neighbor at the fence or a friend on the phone.

Recent trends on TikTok included students bragging about things they’d stolen from their high schools and people boasting of having “ripped off” Six Flags amusement parks with an annual membership loophole (the latter resulted in park management canceling the plan). How do such things benefit anyone (beyond those posting them getting clicks)?

I’m pretty sure they do nothing to make you feel good, or happy, or positive in any way. And that’s not even counting the political nastiness, cheap shots, and conspiracy theories that drown out rational thought.

Unfortunately, social media in today’s forms is addictive. Seeing one good thing from a friend gives you a dopamine boost, and this drives you to overlook all the bad things the screen does. Like the meth addict who lives for the high, and ignores all the negative aspects – loss of money, family, a home, teeth – that it brings.

So it’s not a surprise that walking away from it for a week made people happier and gave them time to do things that were more important than staring at a screen. Though I do wonder how many of the subjects ended up going back to it, forgetting about the benefits they’d just experienced.

When Frank Zappa released “I’m the Slime” in 1973, it was about television. But today the song is far closer to describing what social media has become than he could have ever imagined. (He died in 1993, never knowing how accurate he’d become).

We encourage our patients to exercise. The benefits of doing so are beyond question. But maybe it’s time to point out not only the good things that come from exercise, but also those that come from turning off the screen in order to do so.

As my mother said: “Go outside and play!”

It’s good for the body and sanity, and both are important.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

“Go outside and play!”

How often have you said that to your kids (or grandkids)? For that matter, how often did you hear it when you were a kid?

A lot, if memory serves me correctly. Some of it was just my mom wanting me out of the house, some of it an innate realization on her part that too much time spent planted in front of the TV was bad for you. (When I was a kid, Brady Bunch reruns kicked off my summer day at 8:00 a.m.).

The idea that too much time in front of a screen can be bad is nothing new. Regrettably, some of this ancient wisdom has been lost in the eons since I was a kid.

A recently published article found that people who stopped using social media for 1 week had “significant improvements in well-being, depression, and anxiety.”

Does this surprise you?

Humans, like all primates, are a social species. We’ve benefited from the combined power of our minds to leave caves, harness nature, and build civilizations. But this has a cost, and perhaps the social media screen has been a tipping point for mental health.

I’m not knocking the basic idea. Share a joke with a friend, see pictures of the new baby, hear out about a new job. That’s fine. The trouble is that it’s gone beyond that. A lot of it is perfectly innocuous ... but a lot isn’t.

As it’s evolved, social media has also become the home of anger. Political and otherwise. It’s so much easier to post memes making fun of other people and their viewpoints than to speak to them in person. Trolls and bots lurk everywhere to get you riled up – things you wouldn’t be encountering if you were talking to your neighbor at the fence or a friend on the phone.

Recent trends on TikTok included students bragging about things they’d stolen from their high schools and people boasting of having “ripped off” Six Flags amusement parks with an annual membership loophole (the latter resulted in park management canceling the plan). How do such things benefit anyone (beyond those posting them getting clicks)?

I’m pretty sure they do nothing to make you feel good, or happy, or positive in any way. And that’s not even counting the political nastiness, cheap shots, and conspiracy theories that drown out rational thought.

Unfortunately, social media in today’s forms is addictive. Seeing one good thing from a friend gives you a dopamine boost, and this drives you to overlook all the bad things the screen does. Like the meth addict who lives for the high, and ignores all the negative aspects – loss of money, family, a home, teeth – that it brings.

So it’s not a surprise that walking away from it for a week made people happier and gave them time to do things that were more important than staring at a screen. Though I do wonder how many of the subjects ended up going back to it, forgetting about the benefits they’d just experienced.

When Frank Zappa released “I’m the Slime” in 1973, it was about television. But today the song is far closer to describing what social media has become than he could have ever imagined. (He died in 1993, never knowing how accurate he’d become).

We encourage our patients to exercise. The benefits of doing so are beyond question. But maybe it’s time to point out not only the good things that come from exercise, but also those that come from turning off the screen in order to do so.

As my mother said: “Go outside and play!”

It’s good for the body and sanity, and both are important.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

“Go outside and play!”

How often have you said that to your kids (or grandkids)? For that matter, how often did you hear it when you were a kid?

A lot, if memory serves me correctly. Some of it was just my mom wanting me out of the house, some of it an innate realization on her part that too much time spent planted in front of the TV was bad for you. (When I was a kid, Brady Bunch reruns kicked off my summer day at 8:00 a.m.).

The idea that too much time in front of a screen can be bad is nothing new. Regrettably, some of this ancient wisdom has been lost in the eons since I was a kid.

A recently published article found that people who stopped using social media for 1 week had “significant improvements in well-being, depression, and anxiety.”

Does this surprise you?

Humans, like all primates, are a social species. We’ve benefited from the combined power of our minds to leave caves, harness nature, and build civilizations. But this has a cost, and perhaps the social media screen has been a tipping point for mental health.

I’m not knocking the basic idea. Share a joke with a friend, see pictures of the new baby, hear out about a new job. That’s fine. The trouble is that it’s gone beyond that. A lot of it is perfectly innocuous ... but a lot isn’t.

As it’s evolved, social media has also become the home of anger. Political and otherwise. It’s so much easier to post memes making fun of other people and their viewpoints than to speak to them in person. Trolls and bots lurk everywhere to get you riled up – things you wouldn’t be encountering if you were talking to your neighbor at the fence or a friend on the phone.

Recent trends on TikTok included students bragging about things they’d stolen from their high schools and people boasting of having “ripped off” Six Flags amusement parks with an annual membership loophole (the latter resulted in park management canceling the plan). How do such things benefit anyone (beyond those posting them getting clicks)?

I’m pretty sure they do nothing to make you feel good, or happy, or positive in any way. And that’s not even counting the political nastiness, cheap shots, and conspiracy theories that drown out rational thought.

Unfortunately, social media in today’s forms is addictive. Seeing one good thing from a friend gives you a dopamine boost, and this drives you to overlook all the bad things the screen does. Like the meth addict who lives for the high, and ignores all the negative aspects – loss of money, family, a home, teeth – that it brings.

So it’s not a surprise that walking away from it for a week made people happier and gave them time to do things that were more important than staring at a screen. Though I do wonder how many of the subjects ended up going back to it, forgetting about the benefits they’d just experienced.

When Frank Zappa released “I’m the Slime” in 1973, it was about television. But today the song is far closer to describing what social media has become than he could have ever imagined. (He died in 1993, never knowing how accurate he’d become).

We encourage our patients to exercise. The benefits of doing so are beyond question. But maybe it’s time to point out not only the good things that come from exercise, but also those that come from turning off the screen in order to do so.

As my mother said: “Go outside and play!”

It’s good for the body and sanity, and both are important.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

A few weeks ago I talked about my evening practice of doing jigsaw puzzles to relax, as a pleasant alternative to surfing the Internet.

Last week my daughter moved home from college for the summer. It’s been several years since she and I last did puzzles together, and I’d forgotten how much she likes them.

So now each night we sit there, either side by side or across the table from each other, each quietly working on some little portion of the same jigsaw. Very little is said, but it’s still the same bonding time I’ve always cherished.

But I notice things I’d never thought of.

I always start a puzzle like I thought most people do: Pick out the flat edge pieces to build the outside frame, then work inward from there.

But she doesn’t. Once the box is opened and pieces dumped out, she starts sorting them by patterns and colors, and begins there. The edges don’t get her attention at all as she begins. She assembles like-pieces and gradually expands from there.

Why?

I mean, I’m a neurologist. Brains are my business. So why are our thought patterns on the same task so different?

I have no clue.

This is part of the mystery of the brain. Why different ones, although anatomically similar, can function so differently in how they approach and solve the same problem.

I can’t blame this on who she learned from. We’ve been doing puzzles together since she was little. Think about it – do you even remember someone teaching you to do jigsaw puzzles at some point? Neither do I. I assume a family member or schoolteacher showed me a basic one at some point, and how the pieces fit together, but that’s a guess.

So I sit there working on my section and watch her doing hers, and the neurologist turns the whole thing over. Does she have more neurons and/or glia in whatever the “puzzle solving” portion of her brain (I assume part of visual memory and spatial relationships) is? Or do I? Like so much of neurology this should have a structural answer – I think.

It reminds me of how little we still know. And it bugs me.

Has anyone done PET scans while people work on jigsaw puzzles? I checked PubMed and couldn’t find anything. I doubt it due to the logistics of having someone do one inside a scanner. Searching Google with the same question only gets me ads for customized jigsaws of pets.

So I made the leap to doing a jigsaw puzzle on an iPad while in a PET machine. But even then, how do I know I’d be testing the same functions? The touchscreen is similar, but not the same, as doing a real jigsaw. (In my opinion real puzzles are preferable to iPad ones, except when traveling).

At the end of the day it’s a mystery I don’t know the answer to, probably never will, and realistically shouldn’t think too much about.

Because this summer the real meaning of the puzzle isn’t the jigsaw itself. It’s the young woman sitting next to me working on it.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

A few weeks ago I talked about my evening practice of doing jigsaw puzzles to relax, as a pleasant alternative to surfing the Internet.

Last week my daughter moved home from college for the summer. It’s been several years since she and I last did puzzles together, and I’d forgotten how much she likes them.

So now each night we sit there, either side by side or across the table from each other, each quietly working on some little portion of the same jigsaw. Very little is said, but it’s still the same bonding time I’ve always cherished.

But I notice things I’d never thought of.

I always start a puzzle like I thought most people do: Pick out the flat edge pieces to build the outside frame, then work inward from there.

But she doesn’t. Once the box is opened and pieces dumped out, she starts sorting them by patterns and colors, and begins there. The edges don’t get her attention at all as she begins. She assembles like-pieces and gradually expands from there.

Why?

I mean, I’m a neurologist. Brains are my business. So why are our thought patterns on the same task so different?

I have no clue.

This is part of the mystery of the brain. Why different ones, although anatomically similar, can function so differently in how they approach and solve the same problem.

I can’t blame this on who she learned from. We’ve been doing puzzles together since she was little. Think about it – do you even remember someone teaching you to do jigsaw puzzles at some point? Neither do I. I assume a family member or schoolteacher showed me a basic one at some point, and how the pieces fit together, but that’s a guess.

So I sit there working on my section and watch her doing hers, and the neurologist turns the whole thing over. Does she have more neurons and/or glia in whatever the “puzzle solving” portion of her brain (I assume part of visual memory and spatial relationships) is? Or do I? Like so much of neurology this should have a structural answer – I think.

It reminds me of how little we still know. And it bugs me.

Has anyone done PET scans while people work on jigsaw puzzles? I checked PubMed and couldn’t find anything. I doubt it due to the logistics of having someone do one inside a scanner. Searching Google with the same question only gets me ads for customized jigsaws of pets.

So I made the leap to doing a jigsaw puzzle on an iPad while in a PET machine. But even then, how do I know I’d be testing the same functions? The touchscreen is similar, but not the same, as doing a real jigsaw. (In my opinion real puzzles are preferable to iPad ones, except when traveling).

At the end of the day it’s a mystery I don’t know the answer to, probably never will, and realistically shouldn’t think too much about.

Because this summer the real meaning of the puzzle isn’t the jigsaw itself. It’s the young woman sitting next to me working on it.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

A few weeks ago I talked about my evening practice of doing jigsaw puzzles to relax, as a pleasant alternative to surfing the Internet.

Last week my daughter moved home from college for the summer. It’s been several years since she and I last did puzzles together, and I’d forgotten how much she likes them.

So now each night we sit there, either side by side or across the table from each other, each quietly working on some little portion of the same jigsaw. Very little is said, but it’s still the same bonding time I’ve always cherished.

But I notice things I’d never thought of.

I always start a puzzle like I thought most people do: Pick out the flat edge pieces to build the outside frame, then work inward from there.

But she doesn’t. Once the box is opened and pieces dumped out, she starts sorting them by patterns and colors, and begins there. The edges don’t get her attention at all as she begins. She assembles like-pieces and gradually expands from there.

Why?

I mean, I’m a neurologist. Brains are my business. So why are our thought patterns on the same task so different?

I have no clue.

This is part of the mystery of the brain. Why different ones, although anatomically similar, can function so differently in how they approach and solve the same problem.

I can’t blame this on who she learned from. We’ve been doing puzzles together since she was little. Think about it – do you even remember someone teaching you to do jigsaw puzzles at some point? Neither do I. I assume a family member or schoolteacher showed me a basic one at some point, and how the pieces fit together, but that’s a guess.

So I sit there working on my section and watch her doing hers, and the neurologist turns the whole thing over. Does she have more neurons and/or glia in whatever the “puzzle solving” portion of her brain (I assume part of visual memory and spatial relationships) is? Or do I? Like so much of neurology this should have a structural answer – I think.

It reminds me of how little we still know. And it bugs me.

Has anyone done PET scans while people work on jigsaw puzzles? I checked PubMed and couldn’t find anything. I doubt it due to the logistics of having someone do one inside a scanner. Searching Google with the same question only gets me ads for customized jigsaws of pets.

So I made the leap to doing a jigsaw puzzle on an iPad while in a PET machine. But even then, how do I know I’d be testing the same functions? The touchscreen is similar, but not the same, as doing a real jigsaw. (In my opinion real puzzles are preferable to iPad ones, except when traveling).

At the end of the day it’s a mystery I don’t know the answer to, probably never will, and realistically shouldn’t think too much about.

Because this summer the real meaning of the puzzle isn’t the jigsaw itself. It’s the young woman sitting next to me working on it.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

“It was my wife’s walker, and I’ve never used one before. Sorry that I keep bumping into things.”

He was in his early 70s, recently widowed. He hadn’t needed a walker until yesterday, and his son had gotten it out of the garage where they’d just stowed it away. I showed him how to change the height setting on it so he didn’t have to lean so far over.

His daughter was a longstanding patient of mine, and now she and her brother were worried about their dad. He’d been so healthy for years, taking care of their mother as she declined with cancer. Now, 2 months since her death, he’d started going downhill. He’d been, understandably, depressed and had lost some weight. A few weeks ago he’d had some nonspecific upper respiratory crud, and now they were worried he wasn’t eating. He’d gotten progressively weaker in the last few days, leading to their getting out the walker.

I knew my patient for several years. She wasn’t given to panicking, and was worried about her dad. By this time, I was too. Twenty-eight years of neurology training and practice puts you on the edge for some things. The “Spidey Sense,” as I’ve always called it, was tingling.

It took a very quick neurologic exam to find what I needed. He was indeed weak, had decreased distal sensation, and was completely areflexic. It was time to take the most-dreaded outpatient neurology gamble: The direct office-to-ER admission.

I told his daughter to take him to the nearby ER and scribbled a note that said “Probable Guillain-Barré. Needs urgent workup.” They were somewhat taken aback, as they had dinner plans that night, but his daughter knew me well enough to know that I don’t pull fire alarms for fun.

As soon as they’d left I called the ER doctor and told her what was coming. My hospital days ended 2 years ago, but I wanted to do everything I could to make sure the right ball was rolling.

Then my part was over. I had other patients waiting, tests to review, phone calls to make.

This is where the anxiety began. Nobody wants to be the person who cries wolf, or admits “dumps.” I’ve been on both sides of admissions, and bashing outpatient docs for unnecessary hospital referrals is a perennial pastime of inpatient care.

I was sure of my actions, but as the hours crept by some doubt came in. What if he got to the hospital and suddenly wasn’t weak? Or it was all from a medication error he’d made at home?

No one wants to claim they saw a flare when there wasn’t one, or get the reputation of being past their game. I was worried about the patient, but also began to worry I’d screwed up and missed something else.

I finished the day and went home. After closing out my usual end-of-the-day stuff I logged into the hospital system to see what was going on.

Normal cervical spine MRI. Spinal fluid had zero cells and elevated protein.

I breathed a sigh of relief and relaxed back into my chair. I’d made the right call. The hospital neurologist had ordered IVIG. The patient would hopefully recover. No one would think I’d screwed up a potentially serious case. And, somewhere in the back of my mind, the Sherlock Holmes inside every neurologist tipped his deerstalker cap at me and gave a slight nod.

There’s the relief of having done the right thing for the patient, having made the correct diagnosis, and, at the end of the day, being reassured that (some days at least) I still know what I’m doing.

It’s those feelings that brought me here and still keep me going.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

“It was my wife’s walker, and I’ve never used one before. Sorry that I keep bumping into things.”

He was in his early 70s, recently widowed. He hadn’t needed a walker until yesterday, and his son had gotten it out of the garage where they’d just stowed it away. I showed him how to change the height setting on it so he didn’t have to lean so far over.

His daughter was a longstanding patient of mine, and now she and her brother were worried about their dad. He’d been so healthy for years, taking care of their mother as she declined with cancer. Now, 2 months since her death, he’d started going downhill. He’d been, understandably, depressed and had lost some weight. A few weeks ago he’d had some nonspecific upper respiratory crud, and now they were worried he wasn’t eating. He’d gotten progressively weaker in the last few days, leading to their getting out the walker.

I knew my patient for several years. She wasn’t given to panicking, and was worried about her dad. By this time, I was too. Twenty-eight years of neurology training and practice puts you on the edge for some things. The “Spidey Sense,” as I’ve always called it, was tingling.

It took a very quick neurologic exam to find what I needed. He was indeed weak, had decreased distal sensation, and was completely areflexic. It was time to take the most-dreaded outpatient neurology gamble: The direct office-to-ER admission.

I told his daughter to take him to the nearby ER and scribbled a note that said “Probable Guillain-Barré. Needs urgent workup.” They were somewhat taken aback, as they had dinner plans that night, but his daughter knew me well enough to know that I don’t pull fire alarms for fun.

As soon as they’d left I called the ER doctor and told her what was coming. My hospital days ended 2 years ago, but I wanted to do everything I could to make sure the right ball was rolling.

Then my part was over. I had other patients waiting, tests to review, phone calls to make.

This is where the anxiety began. Nobody wants to be the person who cries wolf, or admits “dumps.” I’ve been on both sides of admissions, and bashing outpatient docs for unnecessary hospital referrals is a perennial pastime of inpatient care.

I was sure of my actions, but as the hours crept by some doubt came in. What if he got to the hospital and suddenly wasn’t weak? Or it was all from a medication error he’d made at home?

No one wants to claim they saw a flare when there wasn’t one, or get the reputation of being past their game. I was worried about the patient, but also began to worry I’d screwed up and missed something else.

I finished the day and went home. After closing out my usual end-of-the-day stuff I logged into the hospital system to see what was going on.

Normal cervical spine MRI. Spinal fluid had zero cells and elevated protein.

I breathed a sigh of relief and relaxed back into my chair. I’d made the right call. The hospital neurologist had ordered IVIG. The patient would hopefully recover. No one would think I’d screwed up a potentially serious case. And, somewhere in the back of my mind, the Sherlock Holmes inside every neurologist tipped his deerstalker cap at me and gave a slight nod.

There’s the relief of having done the right thing for the patient, having made the correct diagnosis, and, at the end of the day, being reassured that (some days at least) I still know what I’m doing.

It’s those feelings that brought me here and still keep me going.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

“It was my wife’s walker, and I’ve never used one before. Sorry that I keep bumping into things.”

He was in his early 70s, recently widowed. He hadn’t needed a walker until yesterday, and his son had gotten it out of the garage where they’d just stowed it away. I showed him how to change the height setting on it so he didn’t have to lean so far over.

His daughter was a longstanding patient of mine, and now she and her brother were worried about their dad. He’d been so healthy for years, taking care of their mother as she declined with cancer. Now, 2 months since her death, he’d started going downhill. He’d been, understandably, depressed and had lost some weight. A few weeks ago he’d had some nonspecific upper respiratory crud, and now they were worried he wasn’t eating. He’d gotten progressively weaker in the last few days, leading to their getting out the walker.

I knew my patient for several years. She wasn’t given to panicking, and was worried about her dad. By this time, I was too. Twenty-eight years of neurology training and practice puts you on the edge for some things. The “Spidey Sense,” as I’ve always called it, was tingling.

It took a very quick neurologic exam to find what I needed. He was indeed weak, had decreased distal sensation, and was completely areflexic. It was time to take the most-dreaded outpatient neurology gamble: The direct office-to-ER admission.

I told his daughter to take him to the nearby ER and scribbled a note that said “Probable Guillain-Barré. Needs urgent workup.” They were somewhat taken aback, as they had dinner plans that night, but his daughter knew me well enough to know that I don’t pull fire alarms for fun.

As soon as they’d left I called the ER doctor and told her what was coming. My hospital days ended 2 years ago, but I wanted to do everything I could to make sure the right ball was rolling.

Then my part was over. I had other patients waiting, tests to review, phone calls to make.

This is where the anxiety began. Nobody wants to be the person who cries wolf, or admits “dumps.” I’ve been on both sides of admissions, and bashing outpatient docs for unnecessary hospital referrals is a perennial pastime of inpatient care.

I was sure of my actions, but as the hours crept by some doubt came in. What if he got to the hospital and suddenly wasn’t weak? Or it was all from a medication error he’d made at home?

No one wants to claim they saw a flare when there wasn’t one, or get the reputation of being past their game. I was worried about the patient, but also began to worry I’d screwed up and missed something else.

I finished the day and went home. After closing out my usual end-of-the-day stuff I logged into the hospital system to see what was going on.

Normal cervical spine MRI. Spinal fluid had zero cells and elevated protein.

I breathed a sigh of relief and relaxed back into my chair. I’d made the right call. The hospital neurologist had ordered IVIG. The patient would hopefully recover. No one would think I’d screwed up a potentially serious case. And, somewhere in the back of my mind, the Sherlock Holmes inside every neurologist tipped his deerstalker cap at me and gave a slight nod.

There’s the relief of having done the right thing for the patient, having made the correct diagnosis, and, at the end of the day, being reassured that (some days at least) I still know what I’m doing.

It’s those feelings that brought me here and still keep me going.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Doctors love puzzles, they say. Especially neurologists.

The detective work on a case is part of the job’s appeal. Taking clues from the history, exam, and tests to formulate a diagnosis, then a treatment plan.

But I’m not talking about that.

As I’ve written before, I’ve tried hard to divorce myself from the news. In times where the world seems to have gone mad, I just don’t want to know what’s going on. I focus on my family, my job, and the weather forecast.

But, inevitably, I need something to do. At some point I run out of notes to type, tests to review, emails to answer, and bills to pay. I used to read the news, but now I don’t do that anymore. I even avoid my favorite satire sites, like Onion and Beaverton, because they just reflect the real news (I still read the Weekly World News, which has no relationship to reality, or pretty much anything, whatsoever).

So now, when I’m done with the day’s work, I shut down the computer (which isn’t easy after 25 years of habitual surfing) and sit down with a jigsaw puzzle. I haven’t done that since I was a resident.

It usually takes me 2-3 weeks to do one (500-1,000 pieces) in the 30 minutes or so I spend on it each evening. There’s solace in the quiet, methodical process of carefully looking for matching pieces, trying a few, the brief glee at getting a fit, and then moving to the next piece.

I know I can do this on my iPad, but it’s different with real pieces. Lifting up a piece and examining it for matching shapes and colors, sorting through the tray, wondering if I made a mistake somewhere. The cardboard doesn’t light up to let me know I got it right.

Inevitably, the mind wanders as I work on them. Sometimes back to a puzzle at the office, sometimes to my doing the same puzzle (I’ve had them for a while) at my parents’ house in my teens, sometimes to my kids away at college, or a book I once read.

But that’s the point. It’s almost a form of meditation. Focusing on each piece as my mind moves in other directions. It’s actually more relaxing than I thought, and a welcome escape from the day.

And, like other seemingly unrelated tasks (such as Leo Szilard waiting for a traffic light to change, albeit on a lesser scale), sometimes it brings me an answer I’ve been searching for. A light bulb will go on for a patient case I’ve been turning over for a few days. When that happens I grab my phone and email the thought to myself at work.

It puts my mind in neutral at the end of the day. When I finally go to bed I’m less focused on things that can keep me awake at night.

Though occasionally I do dream of puzzles.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Doctors love puzzles, they say. Especially neurologists.

The detective work on a case is part of the job’s appeal. Taking clues from the history, exam, and tests to formulate a diagnosis, then a treatment plan.

But I’m not talking about that.

As I’ve written before, I’ve tried hard to divorce myself from the news. In times where the world seems to have gone mad, I just don’t want to know what’s going on. I focus on my family, my job, and the weather forecast.

But, inevitably, I need something to do. At some point I run out of notes to type, tests to review, emails to answer, and bills to pay. I used to read the news, but now I don’t do that anymore. I even avoid my favorite satire sites, like Onion and Beaverton, because they just reflect the real news (I still read the Weekly World News, which has no relationship to reality, or pretty much anything, whatsoever).

So now, when I’m done with the day’s work, I shut down the computer (which isn’t easy after 25 years of habitual surfing) and sit down with a jigsaw puzzle. I haven’t done that since I was a resident.

It usually takes me 2-3 weeks to do one (500-1,000 pieces) in the 30 minutes or so I spend on it each evening. There’s solace in the quiet, methodical process of carefully looking for matching pieces, trying a few, the brief glee at getting a fit, and then moving to the next piece.

I know I can do this on my iPad, but it’s different with real pieces. Lifting up a piece and examining it for matching shapes and colors, sorting through the tray, wondering if I made a mistake somewhere. The cardboard doesn’t light up to let me know I got it right.

Inevitably, the mind wanders as I work on them. Sometimes back to a puzzle at the office, sometimes to my doing the same puzzle (I’ve had them for a while) at my parents’ house in my teens, sometimes to my kids away at college, or a book I once read.

But that’s the point. It’s almost a form of meditation. Focusing on each piece as my mind moves in other directions. It’s actually more relaxing than I thought, and a welcome escape from the day.

And, like other seemingly unrelated tasks (such as Leo Szilard waiting for a traffic light to change, albeit on a lesser scale), sometimes it brings me an answer I’ve been searching for. A light bulb will go on for a patient case I’ve been turning over for a few days. When that happens I grab my phone and email the thought to myself at work.

It puts my mind in neutral at the end of the day. When I finally go to bed I’m less focused on things that can keep me awake at night.

Though occasionally I do dream of puzzles.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Doctors love puzzles, they say. Especially neurologists.

The detective work on a case is part of the job’s appeal. Taking clues from the history, exam, and tests to formulate a diagnosis, then a treatment plan.

But I’m not talking about that.

As I’ve written before, I’ve tried hard to divorce myself from the news. In times where the world seems to have gone mad, I just don’t want to know what’s going on. I focus on my family, my job, and the weather forecast.

But, inevitably, I need something to do. At some point I run out of notes to type, tests to review, emails to answer, and bills to pay. I used to read the news, but now I don’t do that anymore. I even avoid my favorite satire sites, like Onion and Beaverton, because they just reflect the real news (I still read the Weekly World News, which has no relationship to reality, or pretty much anything, whatsoever).

So now, when I’m done with the day’s work, I shut down the computer (which isn’t easy after 25 years of habitual surfing) and sit down with a jigsaw puzzle. I haven’t done that since I was a resident.

It usually takes me 2-3 weeks to do one (500-1,000 pieces) in the 30 minutes or so I spend on it each evening. There’s solace in the quiet, methodical process of carefully looking for matching pieces, trying a few, the brief glee at getting a fit, and then moving to the next piece.

I know I can do this on my iPad, but it’s different with real pieces. Lifting up a piece and examining it for matching shapes and colors, sorting through the tray, wondering if I made a mistake somewhere. The cardboard doesn’t light up to let me know I got it right.

Inevitably, the mind wanders as I work on them. Sometimes back to a puzzle at the office, sometimes to my doing the same puzzle (I’ve had them for a while) at my parents’ house in my teens, sometimes to my kids away at college, or a book I once read.

But that’s the point. It’s almost a form of meditation. Focusing on each piece as my mind moves in other directions. It’s actually more relaxing than I thought, and a welcome escape from the day.

And, like other seemingly unrelated tasks (such as Leo Szilard waiting for a traffic light to change, albeit on a lesser scale), sometimes it brings me an answer I’ve been searching for. A light bulb will go on for a patient case I’ve been turning over for a few days. When that happens I grab my phone and email the thought to myself at work.

It puts my mind in neutral at the end of the day. When I finally go to bed I’m less focused on things that can keep me awake at night.

Though occasionally I do dream of puzzles.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Mrs. Smith came in for neck pain.

This isn’t a new issue, her last flare was 4 or 5 years ago. I’d done an MRI back then, which just showed reassuringly typical arthritic changes, and she did great with a few sessions of physical therapy.

She’d woke one morning a few months ago with a stiff and aching neck, similar to how this started last time. A couple weeks of rest and NSAIDs hadn’t helped. There were no radiating symptoms and her exam was the same as it’s been since I met her back in 2010.

I wrote her an order for physical therapy and found the address and phone number of the place she’d gone to for it a few years ago. She looked at my order, then set it on my desk and said “Doctor, I’d really like an MRI.”

I went back to her chart and reread my note for her last flare of neck pain. Identical symptoms, identical exam. I pulled up the previous MRI report and went over it. Then I explained to her that there really was no indication for an MRI at this point. I suggested we go ahead with physical therapy, and if that didn’t help I would then re-check the study.

She wasn’t going to budge. A friend of hers had recently needed urgent surgery for a cervical myelopathy and was in rehab. Mrs. Smith’s husband’s health was getting worse, and if her neck had something seriously wrong she wouldn’t be able to take care of him if it went unchecked.

So I backed down and ordered a cervical spine MRI, which was pretty much unchanged from the previous MRI. After it came back she was willing to do therapy.

I’m sure some out there will accuse me, the doctor, of letting the patient call the shots. To some degree you’re correct. But it’s not like the request was insanely unreasonable. Obviously, there were other factors going on, too. She was scared and needed reassurance that there wasn’t anything therapy wouldn’t help and that she would be able to keep caring for her ailing husband during his cancer treatments.

There are doctors out there with a more paternalistic view of patient care than mine. They’re probably thinking I should have taken a hardball approach of “you don’t need an MRI. You can do therapy, or you can find another doctor.” But that’s not me. I can’t do that to a nice older lady, especially one who’s been coming to me for various ailments over the last 12 years.

Not only that, but such an approach seemed doomed to fail in this case. It might have gotten her to go to therapy, but I suspect she wouldn’t have gotten better. Her fears about a serious neck issue would increase over time, until she (or the therapist) finally called, said she wasn’t getting better, and could I order an MRI now?

In that way, maybe the MRI helped guarantee that she’d have a good response to therapy.

Medicine is never easy. We learn a lot of rules and guidelines in the name of providing good, economically viable, patient care, but still have to recognize that there isn’t a one-size-fits-all approach.

I can’t say that what I did was the right thing. But it was right for Mrs. Smith.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Mrs. Smith came in for neck pain.

This isn’t a new issue, her last flare was 4 or 5 years ago. I’d done an MRI back then, which just showed reassuringly typical arthritic changes, and she did great with a few sessions of physical therapy.

She’d woke one morning a few months ago with a stiff and aching neck, similar to how this started last time. A couple weeks of rest and NSAIDs hadn’t helped. There were no radiating symptoms and her exam was the same as it’s been since I met her back in 2010.

I wrote her an order for physical therapy and found the address and phone number of the place she’d gone to for it a few years ago. She looked at my order, then set it on my desk and said “Doctor, I’d really like an MRI.”

I went back to her chart and reread my note for her last flare of neck pain. Identical symptoms, identical exam. I pulled up the previous MRI report and went over it. Then I explained to her that there really was no indication for an MRI at this point. I suggested we go ahead with physical therapy, and if that didn’t help I would then re-check the study.

She wasn’t going to budge. A friend of hers had recently needed urgent surgery for a cervical myelopathy and was in rehab. Mrs. Smith’s husband’s health was getting worse, and if her neck had something seriously wrong she wouldn’t be able to take care of him if it went unchecked.

So I backed down and ordered a cervical spine MRI, which was pretty much unchanged from the previous MRI. After it came back she was willing to do therapy.

I’m sure some out there will accuse me, the doctor, of letting the patient call the shots. To some degree you’re correct. But it’s not like the request was insanely unreasonable. Obviously, there were other factors going on, too. She was scared and needed reassurance that there wasn’t anything therapy wouldn’t help and that she would be able to keep caring for her ailing husband during his cancer treatments.

There are doctors out there with a more paternalistic view of patient care than mine. They’re probably thinking I should have taken a hardball approach of “you don’t need an MRI. You can do therapy, or you can find another doctor.” But that’s not me. I can’t do that to a nice older lady, especially one who’s been coming to me for various ailments over the last 12 years.

Not only that, but such an approach seemed doomed to fail in this case. It might have gotten her to go to therapy, but I suspect she wouldn’t have gotten better. Her fears about a serious neck issue would increase over time, until she (or the therapist) finally called, said she wasn’t getting better, and could I order an MRI now?

In that way, maybe the MRI helped guarantee that she’d have a good response to therapy.

Medicine is never easy. We learn a lot of rules and guidelines in the name of providing good, economically viable, patient care, but still have to recognize that there isn’t a one-size-fits-all approach.

I can’t say that what I did was the right thing. But it was right for Mrs. Smith.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Mrs. Smith came in for neck pain.

This isn’t a new issue, her last flare was 4 or 5 years ago. I’d done an MRI back then, which just showed reassuringly typical arthritic changes, and she did great with a few sessions of physical therapy.

She’d woke one morning a few months ago with a stiff and aching neck, similar to how this started last time. A couple weeks of rest and NSAIDs hadn’t helped. There were no radiating symptoms and her exam was the same as it’s been since I met her back in 2010.

I wrote her an order for physical therapy and found the address and phone number of the place she’d gone to for it a few years ago. She looked at my order, then set it on my desk and said “Doctor, I’d really like an MRI.”

I went back to her chart and reread my note for her last flare of neck pain. Identical symptoms, identical exam. I pulled up the previous MRI report and went over it. Then I explained to her that there really was no indication for an MRI at this point. I suggested we go ahead with physical therapy, and if that didn’t help I would then re-check the study.

She wasn’t going to budge. A friend of hers had recently needed urgent surgery for a cervical myelopathy and was in rehab. Mrs. Smith’s husband’s health was getting worse, and if her neck had something seriously wrong she wouldn’t be able to take care of him if it went unchecked.

So I backed down and ordered a cervical spine MRI, which was pretty much unchanged from the previous MRI. After it came back she was willing to do therapy.

I’m sure some out there will accuse me, the doctor, of letting the patient call the shots. To some degree you’re correct. But it’s not like the request was insanely unreasonable. Obviously, there were other factors going on, too. She was scared and needed reassurance that there wasn’t anything therapy wouldn’t help and that she would be able to keep caring for her ailing husband during his cancer treatments.

There are doctors out there with a more paternalistic view of patient care than mine. They’re probably thinking I should have taken a hardball approach of “you don’t need an MRI. You can do therapy, or you can find another doctor.” But that’s not me. I can’t do that to a nice older lady, especially one who’s been coming to me for various ailments over the last 12 years.

Not only that, but such an approach seemed doomed to fail in this case. It might have gotten her to go to therapy, but I suspect she wouldn’t have gotten better. Her fears about a serious neck issue would increase over time, until she (or the therapist) finally called, said she wasn’t getting better, and could I order an MRI now?

In that way, maybe the MRI helped guarantee that she’d have a good response to therapy.

Medicine is never easy. We learn a lot of rules and guidelines in the name of providing good, economically viable, patient care, but still have to recognize that there isn’t a one-size-fits-all approach.

I can’t say that what I did was the right thing. But it was right for Mrs. Smith.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.