The practice of neurology today looks very different than it did even twenty years ago. New applications of MRI technology give us a clearer window into how the brain functions, new drugs have improved the quality of life of patients with previously untreatable conditions like Alzheimer’s disease and multiple sclerosis, and a range of breakthroughs in the biological sciences have increased our understanding of the genetic and environmental determinants of these diseases.
From the perspective of Dr. Vanja Douglas, a practicing neurologist and assistant clinical professor of neurology at UCSF, the field “has gone from a specialty known for its ability to make elegant diagnoses but unable to offer any treatments to one with a huge armamentarium of medications for a variety of conditions.” Still, many of the most severe and disabling diseases today are neurological and the difficulty of treating these conditions emerges in our analysis today.
Last week, we used word clouds to visualize the differences between men and women in medical care. Today, we’ll look at a word cloud of the most distinctive terms in neurological diagnoses. Based on an analysis of 700,000 de-identified medical diagnoses by Practice Fusion’s Research Division, the one word that distinguishes diagnoses made by neurologists compared to other types of doctors is “intractable,” or difficult to treat. This term appears exclusively in diagnoses related to 2 conditions: epilepsy and migraine.
As any neurologist knows well, a diagnosis of intractable epilepsy often comes when a patient has experienced several seizures despite being on medication that has previously been successful in controlling them. With the condition uncontrolled, an activity as benign as taking a bath, swimming alone, or standing near the edge of the street can quickly become life-threatening.
Patients with intractable migraine must contend with severe and debilitating headaches, sometimes lasting multiple days. Another condition that contains words appearing prominently in the word cloud (mostly because doctors are noting that the patient has not had it), Status Migrainosus, is the term for a migraine that lasts more than 72 hours.
Not all cases of migraine and epilepsy are intractable. In this sample of data, about 27% of diagnoses for epilepsy are intractable, while a little more than half of diagnoses of migraine are considered so. As Dr. Douglas noted, we have certainly come a long way in controlling these conditions.
Historically, the medical field had a very different approach. Thomas Willis, an influential British physician working in the 17th century, describes how another physician, William Harvey, tried to convince a patient to undergo trepanation, a surgical procedure that involves drilling a hole through the patient’s skull. Needless to say, both Willis and the patient express a healthy dose of skepticism. He writes in The London Practice of Physick:
“Our famous Harvey endeavour’d to perswade a Lady of great quality to this, who was troubled with a terrible and inveterate Headach, promising her a Cure therebye; but neither she nor any other has been content to admit of the administration. Truly it does not appear to me what certainty we may expect from the Scull being opened where it pains.”
The field hasn’t completely moved away from opening up the skulls of its patients, but now it’s much better justified. For instance, for Parkinson’s disease, neurosurgeons can implant a device that directly stimulates the brain and helps relieve symptoms. “It’s amazing to watch someone go from seriously afflicted to normal when the right part of the brain is stimulated,” says Dr. M. Nathan Nair, a neurosurgeon and assistant professor at Georgetown University. He sums up the experience as “immediately rewarding”, in contrast to many cases of brain surgery for epileptics, “since the results aren’t anywhere near as dramatic” and recovery is fragile.
To the doctors in the audience, how has practice in your field changed since you were in medical school? What are the conditions for which treatment is “immediately rewarding” and what are the conditions that you wish you had more tools for? Share your comments below.