#allan ropper

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Everybody in my internal medicine residency program was appalled when I announced my intention to go into neurology. “What a waste of time! There’s nothing that you can treat.” Then I went to a talk given by my future mentor, who happened to be visiting the hospital. Raymond Adams, one of the greatest clinical neurologists of the twentieth century, gave an overview of where neurology stood in medicine, and, more importantly, where it was headed. I can remember his advice to this day: “Think about it: There are more diseases of the muscle, just the muscle, which is a tiny sliver of neurology, than there are all diseases of the lungs. There are more diseases of the spinal cord than there are all diseases of the heart. There are more diseases of the white matter, not the whole brain, but just the white matter, than there are of all the rheumatologic and joint diseases. Neurology has more diseases and more complexity and more need for exquisite clinical analysis than any other branch of medicine. Take one little piece of neurology: there is more to it than in the totality of any other medical speciality. And yet lung disease and heart disease dominate our collective fears. Dermatology is the only field that has more diseases than neurology. There are a billion skin diseases, but only ten of them occur with any regularity. Whereas in neurology people may say, “Oh, it’s just a stroke,” well, strokes are a big proportion of neurological cases, but there’s so much else to it: What kind of stroke? Where did it occur? What caused it? To master all that is a lifetime effort. So if you really want to be challenged instead of being bored in seven years, when you know all there is to know in your speciality, you may wish to consider neurology.” The brain-mind connection attracts many people to neurology initially, but that’s foo facile a motivation. When I hear a student say, “I want to understand the mind,” I suggest they try psychoanalysis. Neurology is much bigger. Neurology isn’t a system that was invented to understand the mind, like psychodynamics. It’s the goddamned brain in all its messy glory. As another wise neurologist told me early on, “You want to be a nephrologist or urologist? C’mon! The kidney? It makes urine! Who gives a shit? Now the brain - the brain makes poetry.”

Allan Ropper & B. D. Burrell, Reaching Down the Rabbit Hole: Extraordinary Journeys into the Human Brain

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Ten minutes into the lecture I was startled by the weight of a heavy hand on my shoulder. It belonged to a guy with very long hair, who climbed right over me, sinuously propelling himself like a cat into the next row, then over that row, and onward to the front. As he made his way forward, literally walking on all fours over one shoulder after another, our attention was drawn to a second, third, and fourth wave of the invasion. Several women crawled over the backs of our seats, followed by more long-haired men. The weirdest thing I had ever experienced. Alarm gave way to annoyance, then astonishment. They swept over the entire entering class, crossing from the dark into the light, more than a dozen of them, and assembled loosely at the front of the auditorium, where they started belting out the anthem, Hair. It was the broadway cast. [Elliot] Hochstein came up with the idea. The show’s producer was his patient. They did the entire musical number, a mind-blower, and after they left, Hochstein said to us, “What do you think?” A guy named Tory, a very talkative kid who always sat in the front row in order to ask inane questions (and who, of course, went on to become a Beverly Hills gynaecologist), said, “Geez, that was an incredible experience.” And Hochstein replied, “Exactly! The trick to medicine is to have it be an active experience, not to be a passive observer. Get in there fully with your senses, and then you’ll be a great clinician. Look, listen, feel! Don’t just stand there. Leave a big mental opening, because if you go into an encounter knowing what you’re going to find, you will find it, and yet you’ll miss the important stuff. And the important findings when you are examining a patient are multimodal. It’s not just: you hit the knee with a reflex hammer and the leg goes up this high, maybe too much, maybe too little. No! It’s the whole ensemble. It’s all the senses engaged together.” He was onto something, because the actors had a very physical presence. He was talking animatedly about the medical examination, yet he was also talking about the performance we had just seen. When they went from the dark to the light it was thrillingly, intensely physical. The feeling of somebody else’s body touching and even grabbing your shoulder was meant to make us feel uncomfortable and to acquaint us with the idea of touching others, our future patients. Hochstein was saying, “You need to feel them. You need to go with that. A young woman patient comes in and you’re going to feel her liver, okay? You cannot think of it as an inanimate object. You’re not feeling a block of wood. You know that kinaesthetic sense of someone touching you, like those actors, moving you around, climbing all over you? That’s what the patient feels. You’ve got to be in tune with them when you’re doing that.”

Allan Ropper & B. D. Burrell, Reaching Down the Rabbit Hole: Extraordinary Journeys into the Human Brain

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Deductive reasoning, as opposed to inductive reasoning, is what detectives and diagnosticians should be doing. Deduction works from general facts toward specific conclusions. If the “facts” really are facts, the conclusions have to be true. But induction - a quicker and much more practical method of reasoning that everyone uses every day - can lead to errors. That’s because an inductive process infers a conclusion, but doesn’t prove it. If the nerve conduction tests are normal, for example, the patient cannot have Guillain-Barré. But the inverse of that statement - that an abnormal test … must be Guillan-Barré - does not logically follow. My initial error was excessive dependence on induction due to time pressures, as well as hubris. In practice, neither Sherlock Holmes nor I have the luxury of time to indulge in the true deductive method, and when the clock is ticking we have to rely on intuition. But sometimes intuition can let you down.

Allan Ropper & B. D. Burrell, Reaching Down the Rabbit Hole: Extraordinary Journeys into the Human Brain

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What I want is for them to step away from the monitor and into the room, sit by the bed, talk to the patient, and examine the man instead of his pixels. “Here’s a small side bet,” I add. “I don’t think the enhanced MRI is going to help us. Look, you’ve got the whole package here - the scans and the tests - and you’re still not sure what’s going on. That’s why neurology is the queen of the medical specialities.” “Not the king?” “No, it’s the queen because the queen is elegant, and it is the last place in medicine where your personal synthetic intellectual effort is value added, and despite all these gee-whiz gizmos, there really are no tests. You’re going to have to sort this one out at the bedside.” Hannah has heard this speech before, and has a pretty good idea what it means. It means that if a patient comes in and can’t speak clearly or zones out mentally or can’t feel emotion, there are no standard tests. The symptom has to be reframed in terms of brain function. The only way to accomplish that reframing is through the elegant choreography of the neurological exam, not with scans, but through the painstaking examination of the patient. Every gesture, every movement, every inflection of speech, every reflex, all of these point to the precise location of the problem in the nervous system, and to its cause. The physician’s art is to synthesise the symptoms and signs of a larger framework of the patient and the structure of the nervous system. The tests are merely confirmatory, all the way from carpal tunnel syndrome to brain death.

Allan Ropper & B. D. Burrell, Reaching Down the Rabbit Hole: Extraordinary Journeys into the Human Brain

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Imagine two scenarios. In one, the viewer, perhaps yourself, sees a dog being hit by a car, being thrown thirty feet to the side of the road, where it lies motionless, probably dead. In the other, you watch a fly on a countertop, where it is swatted and effectively crushed. Most definitely dead. Why do we agonise over the dog but not the fly? The philosopher says, “Because the dog is conscious and the fly is not.” How do we know? Because the dog has eyes that look at you. The secret to consciousness is in the eyes. If the creature has humanoid eyes and it looks at you, then it is conscious. And if it doesn’t, it isn’t. The compound eyes of the fly do not convey any feeling to us of consciousness. Same with the worm. Philosophers and neurologists have come to the same conclusions with regard to consciousness, and that is that the secret to consciousness is in the eyes. If you understand the eyes, you will understand a lot about consciousness. In fact if you know a lot about the eyes - in great detail - then you’re practically a neurologist. This is not chance.

Allan Ropper & B. D. Burrell, Reaching Down the Rabbit Hole: Extraordinary Journeys into the Human Brain

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Part of my job is to impress upon the residents and the medical students that they are part of a tradition, and that the history of their profession is not merely of anecdotal interest. Unlike the study of, say, mathematics or physics, where it matters little to the high-level practitioner how Newton “discovered” the calculus or his theory of gravity, the practice of medicine benefits from revisiting the discoveries of the past. For a physician, seeing further means looking over the shoulders of giants. The history of medical discovery is instructive, and no one person embodies that process more than William Osler, a Canadian physician born in 1849, who is considered by many to be the father of modern medicine. It was Osler who created the first medical residency program at John Hopkins, and established the foundations of medical training that are still largely in use today. As a result of his example, showing up at an autopsy is Oslerian, using the postmortem as a method of improving your own skills is Oslerian, teaching from that experience is Oslerian. It may have been Osler who set the standards for deep medical training, but for me, the giant who brought clinical neuropathology to its most refined stage, not just looking at slides under a microscope and deciding whether a tumour is good or bad, but understanding how disease affects the nervous system, was Raymond Adams, who trained me at Mass General. Adams fully understood that he was working in the Oslerian tradition in that he was using pathology as the basic science of neurology, and neuropathology was to be his main vehicle for teaching. He was right, and is still right. To be truly advanced neurologist, one could argue, you have to know about the sophisticated genetics of neurological disease and the cell biology of neurological disease and the immunology of neurological disease. That is the case for the full-fledged professional. But there is a sweet spot for the clinician, and you don’t have to go quite that far to hit it. That sweet spot is still this kind of autopsy: the Osler-inspired neuropathology that Raymond Adams perfected. A lot of people might argue with that, but it’s true.

Allan Ropper & B. D. Burrell, Reaching Down the Rabbit Hole: Extraordinary Journeys into the Human Brain

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William Osler built his reputation on correlating what he had seen during the patient’s life with what he saw at the autopsy. He tried to go down in his frock coat in midsummer into these hot basement rooms with his acolytes, and stand there while the organs were removed, and he would handle them, inspect them, and discuss what he had seen in his examination of the live patient, and how it related to what they now saw; what they had missed and, equally important, what they had gotten right. He would try to create a feedback loop that completed each patient’s story. That feedback loop has now been curtailed by imaging, the new pathobiology that, by default, has replaced the autopsy with CT scans, MRIs, and ultrasounds. Before imaging and after Osler, it was considered the ultimate badge of a quality clinician to learn directly from the autopsy, which was the only way to look at the anatomical structures at that time. It meant you were willing to confront your mistakes. That was the classical approach.

Allan Ropper & B. D. Burrell, Reaching Down the Rabbit Hole: Extraordinary Journeys into the Human Brain

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We all succumb to something eventually, but few of us get to decide when to cede control of our lives.

Allan Ropper & B. D. Burrell, Reaching Down the Rabbit Hole: Extraordinary Journeys into the Human Brain