Brain, Vol. 125, No. 7, 1665,
July 2002
© 2002 Guarantors of Brain
Book Review |
THE EFFECTIVE CLINICAL NEUROLOGIST, 2ND EDITION
Department of Clinical Neuroscience, Royal Free Hospital, London, UK
THE EFFECTIVE CLINICAL NEUROLOGIST, 2ND EDITION
By Louis Caplan and Joshua Hollander
2001. Oxford: Butterworth Heinemann
Price £32.50. pp. 305. ISBN 0750672269.
This book is a manual for training doctors who want to learn how to become good neurologists. It is written by two very senior, and highly experienced, North American neurologists who know about teaching neurology trainees. The authors, as do I, clearly feel very strongly that the art of clinical neurology should remain an art, and the book consistently reminds us about how to listen to what the patient says and, having taken the history, to look very carefully during the examination for the confirmatory signs that we would expect to find. They are concerned that North American training programmes produce neurologists who are not skilled in history-taking and examination techniques, and who instead rely on the results of imaging investigations to make the diagnosis. The book is divided into three sections and each chapter is prefaced by a group of charming quotations from philosophers, authors and physicians. Conan Doyle features frequently, and it is clear that the authors liken the hunt for a neurological diagnosis to the detective work of Sherlock Holmes.
The first section is a superb account of the philosophy of clinical medicine, and clinical neurology in particular, and sets out using clear examples of why the clinical assessment is by far and away the most important aspect of the neurological consultation. They site three basic rules of diagnosis essential for the neurologist. First ‘the neurologist should always ask what is the disease mechanism and where is it located? These two queries should be pursued concurrently’. Secondly, ‘the neurologist generates and tests hypotheses, gradually refining them at each phase of the clinical encounter. During and after the history, during and after the general and neurological examination, and after each planned test, or series of laboratory investigations, the skilled neurologist models and refines the anatomical disease diagnoses much like a sculptor gradually chips away at the marble, slowly allowing a face to emerge’. Thirdly, ‘the neurologist thinks in terms of probabilities, not absolutes’. How likely is a particular diagnosis—80%, 50%? What are other possible diagnoses, and what is their probability of being correct? For these 11 pages alone the book is well worth buying.
The second and largest section involves advice given to training neurologists on how to deal with the patient encounter. There are general strategies, including putting the patient at his or her ease. They give tips on communication and how to develop a doctor–patient relationship. Following this there is a chapter on the art of history taking, how to acquire the information, what aspects of the history are particularly important and the evaluation of neurological symptoms, and they stress the importance of the system review, the family history, the social aspects of the patient and the past medical history. They also emphasize how important it is to question others around the patient.
There follows a discussion of the essence of the general and neurological examination, and this is by no means a standardized reference, indeed they give tips that they have developed themselves over many years on how to modulate the standard examination techniques, some of which I would not necessarily agree with. Neuro-ophthalmologists would be particularly concerned to find that whilst vestibular testing takes up three pages, and the trigeminal nerve takes up one, the examination of the third, fourth and sixth nerves takes up only 14 lines and colour vision is not mentioned as a test of visual acuity.
They then discuss how best to organize patient notes, reminding us how often it is the case that a patient may return several years later with a different set of neurological symptoms, and how much more satisfactory it is to be able to look up the examination findings of that particular part of the nervous system, which had previously been normal.
They then go on to discuss the methods which have been used in organizing and interpreting investigations, and finally and crucially how to explain the diagnosis and its treatment to the patient.
Chapter 9 involves a series of case histories of patients treated by the authors which show how the forgoing methods of history-taking, examination, investigation and treatment were used in these cases. Most readers on this side of the Atlantic would have rye smiles when they read that it seems possible to spend several hours with one patient, that the Consultant clerks the patient in himself and then has time to ring up several physicians and family members immediately afterwards, but this is surely the way it needs to be done if it is done properly.
The final section involves descriptions of how out-patient care, in-patient care and in-patient consultations should be undertaken, and finally how medical students and residents should be trained during this process. There is also a chapter on medicolegal aspects of neurological care, and there is a nice summary at the end that finishes with ‘The Ten Commandments of Doctoring’.
This is a wonderful book which would be of great interest to young doctors about to embark on neurological training who are serious-minded enough, and far-seeing enough to realize how important it is to be taught how to approach and deal with a patient.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||