Reaching Down the Rabbit Hole

Authors: Allan H. Ropper and Brian David Burrell

Synopsis

This book is about the day-to-day practice of one of the leading neurologists in the world. It explores his challenging work in one of the most prestigious of hospitals, the Brigham and Women’s Hospital– ‘a place where the strangest and challenging cases are sent to be sorted out, cases whose complexity would tax the resources of smaller hospitals’ (page 7). The author says the book is ‘about the process and progress of my craft‘, something he describes as ‘the systematic, logical, deductive method that was in the past applicable to all branches of medicine, but now resides mainly in neurology’ (page 7 and 12). He regards neurology as the elegant queen of all the specialties, and this is because it is ‘the last place in medicine where your personal synthetic intellectual effort is value added’ (page 11).

 

The book’s title, taken from the classical work Alice’s Adventures in Wonderland, reflects the author’s attitude to clinical neurology. He says ‘every one of our patients has, in effect, fallen into a hole, and it’s our job is to get them out again’; he makes a clearer allusion to Lewis Carroll when he whimsically quipped that ‘on any given day I will be confronted by at least six improbable things before lunch’ (page 19 and 20). And, indeed, the patients he sees are as bizarre as the the mad hatter and the Cheshire cat; take for example his patient, the computer programmer, who ‘has  the body of a Buddha, the eyes of a koala, and an air of resignation‘ (page 3); or the man who has ‘the endearing habit…of never saying anything directly that could be couched in clever circumlocution‘; or another whose mind ‘flitted like a watering can across the surface of his life experiences‘ (pages 3, 38, and 60).

 

 

For doctors, this book is a tome of wisdom for excellent patient care. And the book delivered these pearls couched in several original and practical aphorisms. Take the lesson the author gave a medical student when he said ‘if at the right moment you can combine experience, logic, and leaps of imagination, you’ll get your patients where they need to go’ (page 31). The author, like all excellent clinicians, emphasises the importance of listening to patients, saying ‘what they hope, what they expect, what they deserve, is that we take the time to listen, because the act of listening is therapeutic in itself’ (page 9). He referred to what he said was the most important and most difficult competency that any resident doctor should acquire, ‘the executive skills required to make happen the things that need to happen for their patients…you’ve got to be able to make the calls and pull the right strings‘ (page 216). In several places the author acknowledged his mentor, the exemplary Raymond Adams, who he described as ‘one of the greatest clinical neurologists of the twentieth century’, citing ‘how actively he would listen to each patient’s account of a problem’ (pages 136-139).

 

The number and diversity of the disorders in the book is simply bewildering, and each is described in elegant prose. An example is how the author characterises the common symptom, confusion, as ‘the most confusing syndrome in medicine’, and how ‘the sight of someone who can’t find his own mind can be overwhelming’ (page 52). Importantly for neurologists, the book explores many rarer disorders and provides important clues to making their diagnoses. An example is Ophelia syndrome, a disorder caused by ovarian teratoma, where the clue is the tendency for the patients to salivate ‘like a dog’ (pages 24-25). Another example is capillary fibroelastoma, a benign tumour of the mitral valve, which is a rare but important cause of recurrent stroke (pages 28-29). His descriptive style also brilliantly captures the essence of the disorders he discusses, for example when he depicts the slowing down of woman with Parkinson’s disease as ‘the spinning motor in her head has slowed down, and the clutch won’t engage’ (page 186). The author’s humour, acerbic at times, runs through all his narratives, such as when he subtitles his chapter on functional neurological disorders as ‘…a politically incorrect guide to malingering, shaming, and hysteria‘ (page 84).

As distinctive as his humour is the author’s compassion for his patients, an invaluable lesson for all doctors. He is especially touched by patients with progressive and incurable diseases, conditions where ‘there is no remission, there is no cure‘. He accurately paints the impact of such intractable diseases on his patients, such as when he said ‘there is perseverance, there is resilience, but there is also annoyance and frustration‘ (page 188). His empathy and tenderness were most evident in the two chapters he dedicated to the dreadful disease, amyotrophic lateral sclerosis (ALS). He sensitively explored the day-to-day impact of ALS, discussing diverse subjects including the controversial topic of assisted suicide. But even when discussing a disorder as morbid and as mortal as ALS, he infused his narrative with humour. An example is his self-deprecating reference to the observation that ALS seems to predominantly affect nice people…thereby ‘immunizing a substantial number of physicians’ (page 144).

 

 

A key theme throughout the book is the uncertainty and risk that typifies clinical practice. He describes medicine as ‘a high-stakes game in which you are definitely going to make some people worse‘, and he reflects on what it is like ‘to be always on the brink of your next big mistake‘ (page 255). He was very blunt when he said ‘you can’t be in this business if you can’t live with the risk and the deep disappointment of bad outcomes’ (page 256). The book also downplayed the role of technology when it comes to making diagnoses, urging doctors 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‘ (page 11).

 

Opinion

This is a book by a physician who is not only working at the coal face of neurology, but who is instrumental in defining its cutting edge. It is a hands-on description of excellent clinical practice, highlighting the importance of putting the patient at the centre, and acknowledging that we make errors, and work in challenging circumstances. The two chapter on ALS are probably excessive especially in a specialty of neurology where there are many more disorders to fill a book such as this. It was also slightly disappointing to discover at the end that the book was actually penned by a professional writer who shadowed the author for some time. These criticisms aside, the book is an excellent adventure in clinical practice, filled with fascinating stories and key lessons.

Overall assessment

This book is about neurology, but the lessons apply to all medical specialties. It teaches all physicians to recognise the importance of the basics of clinical assessment, and to recognise the limitations of technology in making diagnoses. It is very enlightening and I recommend it to all doctors.

Book Details

Publisher, Place, Year: St Martin’s, New York, 2014
ISBN: 978-1-250-03498-4
Number of Chapters: 13
Number of Pages: 263
Price: £1.50
Star rating: 5