MS Patient, Ph.D.: The Neuro Exam Chronicles
The good, the bad, and the ugly of neurological exams
I had my first-ever neurological exam in 2008, having been referred to a neurologist after I went to my primary care physician about several months of creeping right foot wonkiness. The neurologist didn’t administer the exam; instead, a technician did, and she seemed pretty thorough to me at the time. One discovery I made from that exam was that I am not very good at processing spoken instructions into a motor response, which explains my lifetime inability to do group aerobics.
In a neurological exam, this problem has amounted to a delay in response to such instructions, and that has led to some … entertaining? … outcomes. For example, I’ve found that some neurologists I’ve encountered often don’t even notice that I haven’t responded to their instruction by pushing back or up or against or down before they’ve moved on to the next step in their investigation. That observation does not foster, shall we say, trust in their conclusions.
Since that first exam, thanks to several other referrals to increasingly specialized neurologists and moves to two different states, I’ve had the opportunity to make a pretty broad comparison of how neurological exams are conducted. Because of a 3-day workup I had with a top neurologist at a huge medical center, I have experienced what has to have been the most masterful neurological exam possible. He was thorough. He asked for each measure twice, which gave me the processing time I needed to respond appropriately. He performed a complete and careful investigation, and although he was brisk, it still required almost an hour to complete. He’s at the “best” end of the neuro exam spectrum of my experience.
At the opposite end is a neurologist I saw for a second opinion early on. He was a Parkinson’s specialist, which became relevant to the mode of treatment he later offered me (which will be the subject of another post). I also got my first inkling during this particular visit of something I’ve since noticed as a pattern: The doctors I’ve seen for myself and my children—with a couple of exceptions—seem to ask questions as part of a mental flow chart, their differential diagnosis algorithm. If your response contains a key word from that flow chart that indicates the next step, it doesn’t really matter what else your response contains.
In the case of this neurologist, I had another insight: In some cases, he wasn’t even listening to my responses at all. He whipped a safety pin from a desktop and started poking it down my leg, telling me to report on the sensation. The thing was, he did it so fast that I had no opportunity even to register the sensation and respond before he’d gone to the next one. So in the end, I just stopped answering at all—and he didn’t even seem to notice. I mean, I had literally quit saying anything. His exam overall lasted fewer than 5 minutes.
I’d say that his was at the “cursory” end of the neuro exam spectrum, but actually, there is one more that has him beat, and that’s the “said I did an exam I didn’t do” neurologist I saw. I always request the clinical notes from my and my children’s MD visits. In this case, the MD reported having done a neuro exam on me when in fact, he hadn’t done anything except ask me a few questions and send me on my way, making clear that he was in a hurry.
Patients on neurological community boards discuss these issues with one another. Some have come away from neuro visits feeling flummoxed and confused by what they—even if otherwise uninitiated—felt was a cursory and half-hearted exam. They post questions about their experiences, and other, more veteran patients fill them in on what constitutes a thorough evaluation, especially at an initial visit. Even when we don’t know anything about neurology, we know who has spent time with us and who has listened to our responses to their questions. And as I’ll discuss in later posts, the upshot of a less-than-thorough exam and less-than-listening ear can carry genuine consequences for the patient.