u/Purple-Marzipan-7524

It was my understanding that the trials examining ESUS demonstrated no benefit of DOAC over antiplatelet. Yet there are a few attendings I work with who will still anticoagulate if the stroke pattern appears to be very clearly embolic and/or if there are underlying conditions that may increase thrombotic risk like underlying malignancy. Some will even do very extensive work up for thrombosis such as genetic hypercoag work up in a 70 year old or 4 extremity Doppler even in the absence of DVT signs/symptoms.

I’m genuinely just curious because I get some opposing messages and when the attending switches then the new attending on service may cancel the work up the prior attending said to order. So just confused and hoping for some clarity.

I know some of this may just be different practice preferences so if that’s what it is then I’m happy to accept that. I just wanted to make sure there wasn’t some important piece of information I was overlooking.

My apologies if this seems like a choppy post. I don’t have a specific question so much as I’m just trying to start a discussion.

I’m a PGY-3 going into general outpatient neurology where I no doubt will be seeing and managing patients with seizures and managing antiepileptic medications.

Given the recent highly publicized trial (please forgive me as my intention is NOT to start a political commentary in this sub) it made me wonder how much physicians can potentially be liable for their patient’s actions.

This has me worried, especially since it appears that the initial medication we put everyone on is Keppra. In my residency the attendings appear to be pretty reasonable about considering alternate options besides starting with keppra in patients with a history of significant mood disorders. I plan to carry this in my practice as well.

I’ve had patients families describe patients as “monsters” on certain AEDs. I’ve had patients tell me they have had raging suicidal thoughts on certain AEDs. And of course we all know that one of them has a black box warning of homicidal ideation.

And only a fraction of my resident clinic patients have a psychiatrist they are established with. And I also plan on working in an underserved community where not many patients will have access to good mental health care.

The overall discussion I want to start is how can we help our patients and also protect ourselves legally when it comes to the psychiatric side effects of AEDs? Especially when patients with epilepsy are more likely to have behavioral and psychiatric co-morbidities?

I’m a DO

/shitpost

I’ve been looking at the fellowship curricula for the different neuromuscular and CNP fellowships I’ve been seeing. But here’s the problem.

I’m not interested in EEG, research, single fiber EMG, ICU NCS/EMG, or facial/cranial nerve NCS/EMG. I want to mainly practice bread and butter NCS/EMG and mainly focus on myopathies and nerve entrapments +/- RNS for NMJ disorders. And even then I’m not sure how much learning RNS will help given that I’m probably never going to see a patient with LEMS and I won’t be losing too many referrals by referring seronegative MG to a neuromuscular specialist anyways.

And here’s another big problem. I genuinely want to do general neurology so I’m worried about skill and atrophy knowledge of movement/neuroimmunology/headache/dementia/neuro-ophth and (depending on whether I go CNP or NM) epilepsy knowledge while i spend a year in fellowship.

So I’m in this position where residency isn’t enough but at the same time a neuromuscular fellowship will be overkill and CNP training with have me spend only 6 months on EMG.

TLDR:
I grew up in a very poor area and it’s always been my goal to go back there and practice general neurology with bread and butter EMG/NCS. So I’m worried that a fellowship with teach me a lot of sub speciality knowledge I won’t use and will also cause me to lose general neurology knowledge.

I’m a neurology resident. My program offers EMG rotations but not enough to be specifically EMG certified.

However I’ve found a few faculty members who are willing to train me on EMGs a bit more during down time where I can work with them when my other rotations don’t have much going on because the attendings in those rotations are either on vacation or doing their own research/teaching/inpatient service. I also have an extended family member who is a PMR physician that is cool with me working with him on my vacation time strictly as an observer just to teach me to read and do EMGs.

My only question is whether doing EMGs without an official EMG certification will limit job opportunities.

Took MSF. Only stalled twice in the beginning and passed the class without any points lost on the evaluation. Bought myself an MT03.

Been having issues with stalling when I’m on the road. Just on the road. Not in my driveway or parking lot. Usually happens when I’m turning on intersections where I’m yielding to other drivers. I think part of it is definitely psychological. I’m so tense because I lose my chance to go if someone starts coming down the road that I’m in a rush to turn and I let my clutch slip too fast and I stall.

Senioritis is wild. Some of these graduating seniors are really riding the fact that they’re mostly untouchable 2 weeks out from finishing.

I usually get fantastic, eager, medical students. Even the ones that are gunners have something to offer and half way through the rotation they learn how to make my job a bit easier because they’re good at incorporating feedback.

Then there’s those students who… just don’t know how to explain it. But one thing they all have in common is that that they’re just so god damn unteachable. The other day we had a new patient with seizures and I prepped my student for the presentation for a good 30 minutes. I taught him about EEGs, showed him the spot on the MRI the seizures are coming from that correlated with the EEG. Explained to him why we’re using certain seizure meds and why we aren’t using certain other seizure meds. Went with him to show him the physical exam.

And when it came time to do the presentation he just….. flopped. Didn’t mention basic parts of the history. Didn’t even mention the MRI or EEG that we spent 10 minutes going over. It got to the point that when he finished I basically just gave the presentation all over again. And it wasn’t even a first time thing. It’s every damn day. And I’ve talked to him about it and he says sorry and just does it over again. I’ve tried practicing presentations beforehand and that doesn’t help either.

It feels like I’m teaching SpongeBob SquarePants how to drive. I try to not give him more than one patient in a day but he sees the other med student (who’s a head above him) carrying 3-4 patients so he aggressively tries to get me to give him more.

For example, a 30 year old with epilepsy has been seeing an epileptologist for several years. The patient begins to develop migraines, should their epileptologist mange their migraines?

Or suppose a 65 year old with Parkinson’s is well established with a movement specialist. The patient ends up getting a TIA. Should they follow up with their movement specialist for stroke prevention care?

At my residency program I’ve seen it go both ways. Some attendings are comfortable managing all of these things on their own. Other attendings try to look to pass on everything not related to their sub speciality onto someone else (usually resident clinic).

As a neurology resident, our field is complicated and a big part of my job is to educate patients and educate medical students. But when I’m getting consulted by another service…. a part of my job becomes educating NPs and PAs. I’ll send them a message listing out our recommendations. And then I’m hit with “why do you want….” and “why not….” and “can you educate me on….”. But when it’s a resident who’s consulting me, somehow they just follows our recommendations without asking too many questions.

I understand that consultants have to explain their rationale and explain what they’re thinking. Not a problem with that at all. But these NPs are arguing with me about giving a dose of dexamethasone to a patient failing a migraine cocktail just because he’s a diabetic, even though he’s well controlled with an A1C of 6.5. Or arguing with me about why a patient that likely has meningitis needs an LP instead of just “giving them vanc and zosyn for a week” (don’t even get me started on that one).

Again my problem isn’t about them asking questions. My problem is that I’m not here to make up for their lack of medial education and, moreover, they seem to be more interested in arguing rather than learning.

Patient is a right handed bodybuilder and can provide full resistance with both upper extremities (5/5 bil). But to me (well built male in his 20s) it’s obvious that the L is stronger than the R when I apply enough force, which is concerning since the patient is R handed. But to my attending (100ish pound woman in her 60s) he seems to be equal strength on both sides when she personally tests his muscle strength.

Anyways, turned out he did have a lacunae stroke in his L internal capsule after all.