Tuesday, March 24, 2009

Starting Neuro Rotation

This is my first week on neurology. So far, it's been really intense! Not that I expected it to be a cakewalk, but the Block III* administrator went out of her way several times to warn us about not missing conferences, and to emphasize that we have to go straight from the conferences to our clinical responsibilities. We have conferences twice a day (morning and noon), and I'm on outpatient this week, so there's really not any downtime for me to read about my patients or catch up with my logs. I feel frustrated, because by the time I get home at night, I've already seen too many patients to even remember them all.

I went to talk to my physician advisor about this problem, because it was making me feel a little stressed. Now, my PA is not the type of person who would ever condone slacking, but she did suggest that I could probably take a little time here and there to chill out and read. We agreed that I certainly should not ever miss any of the required clinical time or the teaching conferences specifically created for the students, but that maybe missing the resident-oriented conferences once in a while might be ok. I thought that was a fair compromise, and it is helping me relax and enjoy the rotation a little more.

The actual clinic part has been pretty interesting so far. There are several different kinds of specialized neuro clinics, and I think it's kind of random which ones we get assigned to work in. Some of the other students are doing Parkinson's or MS clinics, which I didn't get. But I have a couple of days of headache clinic, and it's really interesting. There is a program at CCF called IMATCH, which is for patients who have chronic headaches. It's common to see patients with medication rebound headaches. These are chronic headaches that are due to taking too much pain medication. If the patient tries to stop taking the medications, the headaches come back with a vengeance, so they keep taking more and more of them. That just feeds the vicious cycle.

IMATCH patients spend three weeks coming to the headache clinic. In the first week, they start by getting a multidisciplinary evaluation by neurologists and psychologists. This is to help determine what kind of help they will need to overcome their headaches, or at least to learn to manage the pain to a tolerable level. For the rest of the first week, the patients lie in a dark room, where they get IV infusions of pain medicine. This is tapered down over time to help break their dependence on pain meds. Patients also get physical therapy and counseling to help them cope better with the discomfort and manage headaches more effectively.

For the record, I have a lot of sympathy for people who have migraines. I get migraines myself, but sometimes I have to go out and do things anyway even though I have a migraine. If I take medicine to abort the headache to a more dull pain, I can usually do my work even with that background level of pain. It's not the most comfortable, but it's doable. So I asked my preceptor how bad a person's migraines have to get before they become so crippling that the patient can't function normally anymore. She told me that the difference between me and the patients who get seen at the clinic is that I have pain, but they have a pain syndrome. The pain controls their lives, and they feel too helpless to live their lives normally. She also explained that it was important to make the patient's expectations more realistic. Even when I take pain medications, I understand that the headache may not go away completely, and I don't expect to be completely pain-free. Apparently some patients have difficulty coping with any pain at all.

I have one more day in the headache clinic this week. Even though the headache clinic is really interesting, I'm kind of disappointed that I won't get to do all of the other clinics too. But I'm glad that I had some time to see how the IMATCH program works. Plus, the preceptors who work in the headache clinic are really good and like to teach. I can already tell that neurologists are impressively smart and knowledgeable about medicine.

*Note that Block III in the new curriculum is an eight week block for neurology and psychiatry. I am part of the last group of students going through the old curriculum, which didn't have a Block III, but we are taking these two rotations with the first group of students going through the new curriculum. Don't worry about it if you're confused, because all of us are, too. :-P


medicine girl said...

Thanks for sharing your Neuro rotation experience! I'm always interested in therapies & approaches that go beyond medication to address pain syndromes. Do you think the IMATCH program effectively accomplishes its goals (for some patients, at least)? I also wonder what types of physical therapy are used in the program.

CCLCM Student said...

Yes, I think IMPACT does help people. Probably not everyone, but at least some people do better with it than they would have without it.

I spent a week in the anesthesiology-run chronic pain clinic during my anesthesia rotation. Also, while I was on psych, I spent a day in their chronic pain rehab program, which is more similar to IMPACT in the sense of being multidisciplinary. I'll put up all of those posts at a later time, because the comparison is interesting.

Not that I'm an expert by any means, but I think the multidisciplinary treatments are much more likely to be successful than the physical-only treatments. Multidisciplinary treatments teach patients to help themselves rather than being passive beings acted upon by physicians. Giving patients the ability to overcome learned helplessness due to pain can only improve their lives in the long run.