Why did you choose this specialty?
In college, I majored in philosophy and biology. The study of the brain and all the ways we experience our world seemed a perfect way to continue my interest in both fields. I haven’t been disappointed.
What are the most common issues that you come across in your practice?
Neurology is the study of the powerful and complex systems we use to experience the world (vision, hearing, touch), make sense of the world (thinking, memory, creativity) and how we interact with the world (speech, writing, movement). The neurological conditions I most often see include multiple sclerosis, stroke, memory disorders, peripheral neuropathy, Parkinson’s disease and migraine.
How do you work with patients with these problems?
The care of persons with each of these conditions requires open-hearted listening and a patient explanation, in language that makes sense to them, of how their nervous system is working (or not working) and what we can do to help. That basic understanding about what is going on helps us make shared decisions about what treatment fits best with each person’s values and goals.
What are your areas of special interest?
What really piques my interest is finding the path to the correct diagnosis and treatment that is both efficient and affordable. I like to tell my patients, “Let’s see what simple, natural ways we can try first to get you relief without asking you to go through dangerous tests, take medications with side effects or have costs that are going to eat into your family finances.” I make sure that, whenever possible, the first three things on my after-visit recommendations are not pills. In migraine, for example, one of the most effective treatments is to actually stop certain types of pills rather than add more. My dream would be for patients to someday be able to see a “cost to cure” score for every doctor they might choose from so they can select doctors who excel at helping people get better with the least number of tests or expensive medications.
Is there a recent development in your field that you’re especially excited about?
There are many exciting developments in the field of Alzheimer’s that I am hopeful about. I would like to think that sometime in the future, we will be able to identify persons in their 30s or 40s who are starting to develop very early signs of brain changes that will lead to Alzheimer’s and will be able to offer those individuals a treatment to halt or slow down the insidious changes that occur over years before any symptoms arise. We are learning the painful lesson that treatments given after the diagnosis is established do not significantly alter the natural course of Alzheimer’s disease.
What are some key things that we can do to help keep our brains healthy?
I encourage all of my patients to do three things: stay active, stay connected and stay curious. The experts at the National Institutes of Health who study persons in their 90s who remain independent and clear in their thinking repeatedly find similar patterns in life choices. These men and women do something physical on a regular basis, they maintain healthy social connections with family and friends, and they make a habit of trying things that are mentally challenging.
What’s the most fun—outside of medicine—that you’ve recently had?
Our kids love to spend the Fourth of July at Seabrook on the Washington coast. They love the bike parade and running with the dog on the beach and riding around on the (mostly free of cars) streets and paths. Just simple, unplugged fun. Active, connected and curious.
Neurology is a multidisciplinary field. What intersections excite you most?
I am most excited by the power of computing to bring doctors closer to their patients. I know that sounds contrary to how most doctors feel about computers in health care. Part of my professional time is spent helping my colleagues use our computer systems more efficiently. With an open mind and a willingness to change, physicians can learn to use the incredible data-gathering and decision-support abilities of computing to actually devote more time to direct person-to-person care that we all went into medicine for. In the exam room, I rarely use the computer. I am focused, entirely, on the patient: what they say, what they don’t say, the expressions and, of course, how their nervous system is working. I can do this because I have made extensive use of the computer to gather the information I need and create a record in the chart that tells the story of how the patient got to this visit on this day. The time I might have spent typing or dictating a note is now given to listening, clarifying and coming up with a shared plan. I want our computing system to be working at 110 percent so we can all be present to our patients 110 percent.
What are some new treatments that we can look forward to in your specialty in the next 5–10 years?
I believe that we are already seeing the benefit of rethinking how to treat early multiple sclerosis. A large group of MS experts across the Kaiser Permanente system nationwide has developed a treatment plan that identifies persons who we can see have high risk of developing disability later in life. We offer those individuals a highly potent yet very safe treatment early on that reduces their risk of losing independence later on. This treatment is not only effective, safe and well tolerated, it is also far more affordable than any of the existing MS medications, something that matters a lot to patients with MS who have to pay for a share of their medication costs. I feel honored to be part of a nationwide program led by a team of MS experts from many states. We are actually in the process of building out a multiple sclerosis program to support this work.
What is the most baffling case you’ve encountered?
I have “cured” a few patients who had been previously diagnosed with Parkinson’s disease by a neurologist by simply having them stop a medication that is known to cause side effects that look like Parkinson’s disease.
Is there a patient behavior that you wish you could change?
I would encourage all of my patients to write down the two or three most important goals for their doctor visit and to make those known at the start of the visit. Just writing down a few goals will help make the best use of time in the visit. Bringing a friend to take notes helps as well.
We are actually launching a telemedicine program where, for selected conditions where an office visit may not be necessary, a patient has a scheduled phone meeting with a specialist who has reviewed his or her chart, develops a collaborative plan of action and sends a copy of the entire visit note to the patient at the end of the phone call. Answers to questions about the condition are solicited well in advance of the visit. Those responses become part of the note so that the final record truly contains the voice of the patient. These questions give our patients time to put their thoughts down and to express how the plan of care we come up with should reflect their wishes and values. The patients who have participated with me in these visits have been delighted to have their questions answered thoughtfully without having to take time off from work, sit in our challenging traffic or pay for a visit copay. These visits also create more availability for those persons who prefer to come in for an in-clinic visit.
What’s the biggest misconception that patients—or the public—have about what you do?
Other doctors think that neurologists are nerdy bean counters. There is also the misperception that we treat diseases that can’t be cured or that there are no treatments for. That could not be further from the truth. In the course of my 26 years of practice, we have developed powerful treatments for MS, epilepsy, Parkinson’s, and we may be on the cusp of finding similarly effective treatments for Alzheimer’s or, perhaps, ALS [Lou Gehrig’s disease]. There are new acute stroke treatments that have had profound effects on persons for whom we previously had few options. New understanding about migraine has led to several discoveries that can have a profound effect on this debilitating disease. Some of them are completely free.