Author: AJ Lees
Within the pages of this relatively concise book is an invigorating collection of the accumulated clinical wisdom and experience of an intriguing neurologist. Addressing more conventional, and perhaps more orthodox, neurological themes than he did in Mentored by a Madman, his other autobiographical work, the author focuses here on the elementary but largely overlooked foundations, not just of neurology, but of medicine as a whole. With a focused narrative, a simple prose, and an exquisite selection of words and phrases, the author masterfully conveys the preeminence of the now strained clinical arts of listening and observing, and of the fine skills of elucidating pathological signs and deploying economy in diagnostic testing. Whilst the author’s objective was to impart the lessons he learned during his years of dutiful ‘apprenticeship‘, his reminisces of ‘a handful of minor medical triumphs and a cemetery full of mistakes‘ also constituted sage counsel. From his love of eponyms to his abjuration of abbreviations, from his praise of mindful practice to his scathing opinion of psychiatry, the author expresses views that tug at the intellect as much as they do the heart. Whilst the book is a public advocacy for a specialty which ‘very few have much idea of’, its overriding goal appears to be the transmission of the virtues of ‘soulful neurology‘ – the harmonious thread linking every theme of the book (page vii-xiii).
The author’s love and affection for his chosen specialty flows out of every page of the book, and this reflects his view that neurology is ‘literally the brains of the medical profession’ because its ‘logical and ruthlessly rational approach‘ places it ahead of other medical specialties. In justifying this enthralment with neurology, the author particularly highlighted its cerebral appeal – as manifested in its ‘intellectual challenge‘ and the ‘inherent logic of its method’ – and its exquisite practice – as mirrored in such activities as ‘listening attentively to the distress calls of patients’ so as to ‘determine the source of their complaint‘. The ‘theatricality‘ of neurology – a distinguishing feature of the specialty – also captivated him since he observed it at close quarters as a student of Ronald Henson. It is a tribute to his enduring fixation with neurology that, ‘after almost half a century‘, whenever he sees a patient in his clinic, he still feels ‘like an explorer shining a pocket torch into a cave‘ hoping to ‘find a precious stone‘. It is also a testimony to his grounding in the specialty that his ‘enthusiasm for eliciting physical signs’ remains ‘as strong as it ever was’, and that his awe of the ‘pathognomonic‘, the ‘cardinal‘, and the ‘commemorative‘ remain undiminished (pages viii, 11, 23- 25, xi and xiii).
For most doctors, the most enlightening theme of the book must surely be its portrayal of the author’s attitude to his patients. This narrative is dominated by the almost childlike curiosity with which he approaches each patient, and this is perhaps best illustrated by how he listens to them – a superficially simple routine which he however asserts is ‘more proactive and challenging‘ than observation because it requires ‘patience, sensitivity and versatility‘, and it can ‘only be mastered by constant practice‘. On the one hand, he conceives of listening as ‘the single most effective method of making a neurological diagnosis’, and on the other, he emphasised its less appreciated therapeutic value, explaining that ‘being heard is a transformative ritual that facilitates healing‘. Listening, however, is just one dimension of the author’s concept of soulful neurology, an idea he adopted from another teacher, William Goody, who taught him that ‘neurology is deadly serious but it must be full of soul‘. Soulful neurology, he explained, conceptualises a practice that ’embraces anecdote, cordial laughter, and tacit knowledge but never lapses into sentimentality‘. He explained that it is also a philosophy which ‘insists that mistakes in medicine are inevitable, but when they are admitted and taken to heart become future friends’, and the mindset that guides him ‘to talk unhurriedly to patients as if they were my close relatives and to try to be kind and nuanced when forced to give bad news‘ (pages 13, 73-79 and 89).
The themes that dominate the autobiographical narrative of the book are the lessons the author imbibed during his life-long journey of learning. This is evident, for example, in his childhood study of natural history which established his keen observation and documentation skills, and his medical school experience which taught him that medicine was ‘a calling requiring self-sacrifice and courage’, but also a science ‘full of hasty generalisations and imperfect observations’. And from his memorable training experience at the Hospital de la Salpetriere in Paris he learned ‘to perceive things my mind did not yet know’, and to value ‘insatiable curiosity and innovative ways of thinking about neurology’. It was also in Paris that the author reflected on the great neurologist, Jean-Martin Charcot, extracting from his life the importance of how to recognise ‘what was in plain sight‘, ‘visualise afresh‘, and perceive ‘what was absent’. And from Gordon Holmes, a neurologist dedicated to the ‘search for the truth‘, he was inspired to ‘strive for greater precision in my own clinical method’ (pages 1-11, 18, 26, 43, 50-58).
The all-round impression of neurology which the author constructed is multifaceted, and it portrays the complexities, challenges, and deficiencies of the specialty. For example, the book conveyed unembellished images of neurological symptoms as ‘strange, subtle, and often unpredictable‘; neurological disorders as ‘unique‘ and ‘devastating‘; and neurological practice as ‘emotionally exacting‘. The book however conceives of these as stimulating challenges, and it describes how they are mitigated by such handy neurological pearls as smart handles, canaries, red flags, and rules of thumb. The book is also replete with practical instructions on perfecting clinical practice, such as the cautionary notes to refrain from ‘instant diagnosis‘ and to act as one’s own ‘devil’s advocate‘, and the advice that neurologists who want to make their patients better should ‘bring themselves – as well as their toolkit – to the consultation’. The author was however dubious about the overall benefit of technology to clinical practice. For example, he regretted that it has made ‘looking and listening…no longer the vaunted skills they once were when the armamentarium to treat neurological disorders was threadbare‘, and he agonised over the fact that ‘the more machinery I have at my disposal the greater the demands have become on my clinical judgement‘. He therefore cautioned that technology should remain ‘the servant of clinical reason and not its fulcrum‘ (page 13-14, 61-67, 70-71 and 144-150).
An interesting perspective the book explores is around the relationship between medicine and the fictional detective Sherlock Holmes, and this again harks back to observation and detection – themes central to the autobiography. Declaring that ‘the unreal universe of Sherlock Holmes’ was ‘my primer in neurology’, the author pointed out that Holmes’ creator, Arthur Conan Doyle, who trained as a doctor, fashioned his hero after Joseph Bell – the Edinburgh surgeon noted for paying attention to ‘the infinitely miniscule‘, and for his ability ‘to make distinctions where others saw only monotonous uniformity‘. Even more relevant to neurology is the author’s reason for having ‘found it easy to engage with the character of Sherlock Holmes’, referring to how the fictional detective reminded him of William Gowers – ‘arguably the greatest neurologist that ever lived’. The author went as far as to speculate that Doyle fashioned the detective’s ‘intellectual depth‘ on the writings of Gowers who, for example, stated that ‘it was better to accept ignorance‘ than ‘to frame a collection of baffling symptoms into a diagnostic label that would stick and then be hard to remove‘ (pages 107-120, 127-136 and 118).
It is unlikely that any review will do justice to the breadth and depth of this book which is a fascinating blend of memoir and reflection splashed with a dash of retrospection and nostalgia. In setting out his simple but effective approach to neurology, the author not only reminds the reader of the foundations of joyful practice, but of how far medical practice is being driven away from this ideal by external factors. The author celebrates the opportunities he had to learn at the feet of the great, and the leeway of having two hours to examine one patient, both luxuries in today’s time-challenged and technology-driven medicine. The author’s views on private practice, neurological leadership, and training go far in making this autobiography a benchmark for reform.
Embodied in this treasure trove of clinical pearls is the secret to sustaining a life-long passion for medicine. In the author’s insights are enough lessons to keep burnout and administrative distractions at bay – curiosity and concern for the patient being the antidotes. The book provides contextual history relevant to clinical practice, and dispenses hard earned tips for a specialty that remains the most complex in medicine. The lessons in this book go to the fundamental values of not just neurological practice, but the very foundations of medical and social interactions. At the end of the book, which I highly recommend to all doctors, the reader will surely be left wanting more of its clinically revitalising narrative.
Publisher, Place, Year: Notting Hill Editions, London, 2022
Number of chapters: 10
Number of pages: 154
Star rating: 5