Allan M. Block, MD

He’s 24 years younger than I am, recently married, no kids. Just starting out as a neurologist. He also has a full head of hair, something I’m admittedly jealous of.

He’s always in a sweater, something that seems oddly out of place in Phoenix, Arizona.

He’s the picture on my hospital ID.

I don’t go to the hospital much anymore, but he still sits in my car, greeting me whenever I open the center console to get my sunglasses or phone charger. He looks very enthusiastic about starting his career. I clearly remember the day I had the picture taken, as a newly-minted attending getting his first hospital privileges.

Sometimes I talk to him. Usually it’s just silly advice (“bet on the ’16 Cubs”). Other times I wonder what he’d do in certain situations, with all his youthful enthusiasm. I’m sure he wonders the same about me, with my 24 years of experience.

To a large extent we are the same people we started out as, but time changes us, in ways besides the obvious (like my hairs jumping off like lemmings). We learn from experience, both good and bad.

Looking back at him (or even the older pic on my medical school application) I have no complaints about where life and my career have taken me. Would there be a few things I might have changed if I could go back?

Realistically, maybe one or two, both involving my father, but neither of them would likely change where I am.

But as far as medicine goes? Not really. The things I liked then, that got me into the field? I still enjoy them. The horse hockey? Yeah, it’s always there, probably has gotten worse over time, and it still bothers me. But there isn’t a job that doesn’t have its share of cow patties. It’s just a matter of trying not to step in them more than necessary as you do the parts you enjoy.

Sometimes I look at my younger self, and wonder what I’d really say to him if we actually met.

Probably just “good luck, enjoy the ride, and ditch the sweater.”
 

We measure our gains out in luck and coincidence

Lanterns to turn back the night.

And put our defeats down to chance or experience

And try once again for the light.

– Al Stewart

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

He’s 24 years younger than I am, recently married, no kids. Just starting out as a neurologist. He also has a full head of hair, something I’m admittedly jealous of.

He’s always in a sweater, something that seems oddly out of place in Phoenix, Arizona.

He’s the picture on my hospital ID.

I don’t go to the hospital much anymore, but he still sits in my car, greeting me whenever I open the center console to get my sunglasses or phone charger. He looks very enthusiastic about starting his career. I clearly remember the day I had the picture taken, as a newly-minted attending getting his first hospital privileges.

Sometimes I talk to him. Usually it’s just silly advice (“bet on the ’16 Cubs”). Other times I wonder what he’d do in certain situations, with all his youthful enthusiasm. I’m sure he wonders the same about me, with my 24 years of experience.

To a large extent we are the same people we started out as, but time changes us, in ways besides the obvious (like my hairs jumping off like lemmings). We learn from experience, both good and bad.

Looking back at him (or even the older pic on my medical school application) I have no complaints about where life and my career have taken me. Would there be a few things I might have changed if I could go back?

Realistically, maybe one or two, both involving my father, but neither of them would likely change where I am.

But as far as medicine goes? Not really. The things I liked then, that got me into the field? I still enjoy them. The horse hockey? Yeah, it’s always there, probably has gotten worse over time, and it still bothers me. But there isn’t a job that doesn’t have its share of cow patties. It’s just a matter of trying not to step in them more than necessary as you do the parts you enjoy.

Sometimes I look at my younger self, and wonder what I’d really say to him if we actually met.

Probably just “good luck, enjoy the ride, and ditch the sweater.”
 

We measure our gains out in luck and coincidence

Lanterns to turn back the night.

And put our defeats down to chance or experience

And try once again for the light.

– Al Stewart

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

He’s 24 years younger than I am, recently married, no kids. Just starting out as a neurologist. He also has a full head of hair, something I’m admittedly jealous of.

He’s always in a sweater, something that seems oddly out of place in Phoenix, Arizona.

He’s the picture on my hospital ID.

I don’t go to the hospital much anymore, but he still sits in my car, greeting me whenever I open the center console to get my sunglasses or phone charger. He looks very enthusiastic about starting his career. I clearly remember the day I had the picture taken, as a newly-minted attending getting his first hospital privileges.

Sometimes I talk to him. Usually it’s just silly advice (“bet on the ’16 Cubs”). Other times I wonder what he’d do in certain situations, with all his youthful enthusiasm. I’m sure he wonders the same about me, with my 24 years of experience.

To a large extent we are the same people we started out as, but time changes us, in ways besides the obvious (like my hairs jumping off like lemmings). We learn from experience, both good and bad.

Looking back at him (or even the older pic on my medical school application) I have no complaints about where life and my career have taken me. Would there be a few things I might have changed if I could go back?

Realistically, maybe one or two, both involving my father, but neither of them would likely change where I am.

But as far as medicine goes? Not really. The things I liked then, that got me into the field? I still enjoy them. The horse hockey? Yeah, it’s always there, probably has gotten worse over time, and it still bothers me. But there isn’t a job that doesn’t have its share of cow patties. It’s just a matter of trying not to step in them more than necessary as you do the parts you enjoy.

Sometimes I look at my younger self, and wonder what I’d really say to him if we actually met.

Probably just “good luck, enjoy the ride, and ditch the sweater.”
 

We measure our gains out in luck and coincidence

Lanterns to turn back the night.

And put our defeats down to chance or experience

And try once again for the light.

– Al Stewart

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

A long time ago, as a fourth-year medical student, I did a neurology rotation at a large academic center.

One of the attendings was talking to me about reading, and how, once learned, it became innate: a function that, like breathing, couldn’t be turned off.

He was right, as is obvious to anyone. Driving down the road, walking past a newsstand, even opening a fridge covered with magnets from various other medical businesses ... it’s impossible NOT to process the letters into words and words into meanings, even if just for a second. Advertisers and headline-writers figured this out long ago. The key is to make those few words something that grabs our attention and interest, so we’ll either want to read more or retain it.

So too is being a doctor. Once that switch is on, you can’t flip it off. We all come to this field with varying degrees of curiosity and analytical ability, and once those are refined by experience they don’t shut down.

Recently Queen Elizabeth II died. In reading the news stories, without intending to, I found my mind trying to pick out details about her medical condition, formulate a differential ... after all these years of being in medicine it’s second nature to do that.

Of course, it’s none of my business, and I greatly respect personal privacy. But the point is there. At some point, like reading, we can’t turn off the doctor circuit (for lack of a better term). We do it all the time, analyzing gait patterns and arm swings as people go by. Noticing facial asymmetries, tremors, speech patterns. It may be turned down a few notches from when we’re in the office or hospital, but it’s still there.

It becomes second nature, a part of who we are.

It’s not just doctors. Architects casually notice building details that no one else would. Software engineers off-handedly see program features (good and bad) that the rest of us wouldn’t. Teachers and editors pick up on grammatical errors even when they’re not trying to.

None of these (aside from basic observation) are things that brains originally started out to do. But through training and experience we’ve adapted them to do this. We never stop observing, collecting data, and processing it, in ways peculiar to our backgrounds.

Which, if you think about it, is pretty remarkable.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

A long time ago, as a fourth-year medical student, I did a neurology rotation at a large academic center.

One of the attendings was talking to me about reading, and how, once learned, it became innate: a function that, like breathing, couldn’t be turned off.

He was right, as is obvious to anyone. Driving down the road, walking past a newsstand, even opening a fridge covered with magnets from various other medical businesses ... it’s impossible NOT to process the letters into words and words into meanings, even if just for a second. Advertisers and headline-writers figured this out long ago. The key is to make those few words something that grabs our attention and interest, so we’ll either want to read more or retain it.

So too is being a doctor. Once that switch is on, you can’t flip it off. We all come to this field with varying degrees of curiosity and analytical ability, and once those are refined by experience they don’t shut down.

Recently Queen Elizabeth II died. In reading the news stories, without intending to, I found my mind trying to pick out details about her medical condition, formulate a differential ... after all these years of being in medicine it’s second nature to do that.

Of course, it’s none of my business, and I greatly respect personal privacy. But the point is there. At some point, like reading, we can’t turn off the doctor circuit (for lack of a better term). We do it all the time, analyzing gait patterns and arm swings as people go by. Noticing facial asymmetries, tremors, speech patterns. It may be turned down a few notches from when we’re in the office or hospital, but it’s still there.

It becomes second nature, a part of who we are.

It’s not just doctors. Architects casually notice building details that no one else would. Software engineers off-handedly see program features (good and bad) that the rest of us wouldn’t. Teachers and editors pick up on grammatical errors even when they’re not trying to.

None of these (aside from basic observation) are things that brains originally started out to do. But through training and experience we’ve adapted them to do this. We never stop observing, collecting data, and processing it, in ways peculiar to our backgrounds.

Which, if you think about it, is pretty remarkable.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

A long time ago, as a fourth-year medical student, I did a neurology rotation at a large academic center.

One of the attendings was talking to me about reading, and how, once learned, it became innate: a function that, like breathing, couldn’t be turned off.

He was right, as is obvious to anyone. Driving down the road, walking past a newsstand, even opening a fridge covered with magnets from various other medical businesses ... it’s impossible NOT to process the letters into words and words into meanings, even if just for a second. Advertisers and headline-writers figured this out long ago. The key is to make those few words something that grabs our attention and interest, so we’ll either want to read more or retain it.

So too is being a doctor. Once that switch is on, you can’t flip it off. We all come to this field with varying degrees of curiosity and analytical ability, and once those are refined by experience they don’t shut down.

Recently Queen Elizabeth II died. In reading the news stories, without intending to, I found my mind trying to pick out details about her medical condition, formulate a differential ... after all these years of being in medicine it’s second nature to do that.

Of course, it’s none of my business, and I greatly respect personal privacy. But the point is there. At some point, like reading, we can’t turn off the doctor circuit (for lack of a better term). We do it all the time, analyzing gait patterns and arm swings as people go by. Noticing facial asymmetries, tremors, speech patterns. It may be turned down a few notches from when we’re in the office or hospital, but it’s still there.

It becomes second nature, a part of who we are.

It’s not just doctors. Architects casually notice building details that no one else would. Software engineers off-handedly see program features (good and bad) that the rest of us wouldn’t. Teachers and editors pick up on grammatical errors even when they’re not trying to.

None of these (aside from basic observation) are things that brains originally started out to do. But through training and experience we’ve adapted them to do this. We never stop observing, collecting data, and processing it, in ways peculiar to our backgrounds.

Which, if you think about it, is pretty remarkable.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Statins have, overall, been a remarkably beneficial class of drugs. Yes, you occasionally get patients who see them as part of some huge pharma-government conspiracy (along with vaccines and 5G, presumably) but the data are there to support them.

One of the issues with them is myalgias. We all see this to varying degrees. We all warn patients about it, as do their pharmacists, the information sheets from the pharmacy, some TV show, a Facebook friend, that guy in their Tuesday bowling league ... etc.

It is a legitimate concern. Some people definitely do get muscle cramps from them and need to come off. Scanning the medication list of someone who comes in with muscle cramps is a key part of the case.

Recently, the Lancet published a meta-analysis on the subject and found that, in 9 out of 10 patients who complained of muscle cramps on statins, the symptoms were unrelated to the drug. While previous data suggested rates of myalgias as high as 29%, this paper found it was closer to 7% compared with placebo. Only one in 15 of the muscle-related reports by patients while taking statins were clearly caused by the drug.

The power of suggestion is remarkable indeed.

The study is interesting. It might be correct.

But try telling that to the patients.

We all have patients who will get pretty much any side effect we mention, or that they read about online. That’s just human nature for some. But even reasonable adults can confuse things. The guy who starts Lipitor one week then helps his daughter move into her apartment the next. The lady who starts Crestor while training for a half-marathon. And so on.

The fact is that a lot of people take statins. And a lot of people (like, pretty much all of us) do things that can cause muscle injuries. Sooner or later these lines are going to intersect, but that doesn’t mean they have anything to do with each other.

It’s a lot harder to explain that, and have people believe it, once they’ve convinced themselves otherwise. Pravachol definitely did this, Dr. Google said so. It doesn’t help that trust in doctors, and health care science in general, has been eroded by political pundits and nonmedical experts during the COVID-19 pandemic. To some people our years of experience and training are nothing compared to what an anonymous guy on Parler told them.

Certainly this paper will help. A lot of people can benefit from statins. With this data maybe we can convince some to give them a fair shot.

But, as we’ve all experienced in practice, sometimes no amount of solid data will change the mind of someone who’s already made theirs up.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Statins have, overall, been a remarkably beneficial class of drugs. Yes, you occasionally get patients who see them as part of some huge pharma-government conspiracy (along with vaccines and 5G, presumably) but the data are there to support them.

One of the issues with them is myalgias. We all see this to varying degrees. We all warn patients about it, as do their pharmacists, the information sheets from the pharmacy, some TV show, a Facebook friend, that guy in their Tuesday bowling league ... etc.

It is a legitimate concern. Some people definitely do get muscle cramps from them and need to come off. Scanning the medication list of someone who comes in with muscle cramps is a key part of the case.

Recently, the Lancet published a meta-analysis on the subject and found that, in 9 out of 10 patients who complained of muscle cramps on statins, the symptoms were unrelated to the drug. While previous data suggested rates of myalgias as high as 29%, this paper found it was closer to 7% compared with placebo. Only one in 15 of the muscle-related reports by patients while taking statins were clearly caused by the drug.

The power of suggestion is remarkable indeed.

The study is interesting. It might be correct.

But try telling that to the patients.

We all have patients who will get pretty much any side effect we mention, or that they read about online. That’s just human nature for some. But even reasonable adults can confuse things. The guy who starts Lipitor one week then helps his daughter move into her apartment the next. The lady who starts Crestor while training for a half-marathon. And so on.

The fact is that a lot of people take statins. And a lot of people (like, pretty much all of us) do things that can cause muscle injuries. Sooner or later these lines are going to intersect, but that doesn’t mean they have anything to do with each other.

It’s a lot harder to explain that, and have people believe it, once they’ve convinced themselves otherwise. Pravachol definitely did this, Dr. Google said so. It doesn’t help that trust in doctors, and health care science in general, has been eroded by political pundits and nonmedical experts during the COVID-19 pandemic. To some people our years of experience and training are nothing compared to what an anonymous guy on Parler told them.

Certainly this paper will help. A lot of people can benefit from statins. With this data maybe we can convince some to give them a fair shot.

But, as we’ve all experienced in practice, sometimes no amount of solid data will change the mind of someone who’s already made theirs up.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Statins have, overall, been a remarkably beneficial class of drugs. Yes, you occasionally get patients who see them as part of some huge pharma-government conspiracy (along with vaccines and 5G, presumably) but the data are there to support them.

One of the issues with them is myalgias. We all see this to varying degrees. We all warn patients about it, as do their pharmacists, the information sheets from the pharmacy, some TV show, a Facebook friend, that guy in their Tuesday bowling league ... etc.

It is a legitimate concern. Some people definitely do get muscle cramps from them and need to come off. Scanning the medication list of someone who comes in with muscle cramps is a key part of the case.

Recently, the Lancet published a meta-analysis on the subject and found that, in 9 out of 10 patients who complained of muscle cramps on statins, the symptoms were unrelated to the drug. While previous data suggested rates of myalgias as high as 29%, this paper found it was closer to 7% compared with placebo. Only one in 15 of the muscle-related reports by patients while taking statins were clearly caused by the drug.

The power of suggestion is remarkable indeed.

The study is interesting. It might be correct.

But try telling that to the patients.

We all have patients who will get pretty much any side effect we mention, or that they read about online. That’s just human nature for some. But even reasonable adults can confuse things. The guy who starts Lipitor one week then helps his daughter move into her apartment the next. The lady who starts Crestor while training for a half-marathon. And so on.

The fact is that a lot of people take statins. And a lot of people (like, pretty much all of us) do things that can cause muscle injuries. Sooner or later these lines are going to intersect, but that doesn’t mean they have anything to do with each other.

It’s a lot harder to explain that, and have people believe it, once they’ve convinced themselves otherwise. Pravachol definitely did this, Dr. Google said so. It doesn’t help that trust in doctors, and health care science in general, has been eroded by political pundits and nonmedical experts during the COVID-19 pandemic. To some people our years of experience and training are nothing compared to what an anonymous guy on Parler told them.

Certainly this paper will help. A lot of people can benefit from statins. With this data maybe we can convince some to give them a fair shot.

But, as we’ve all experienced in practice, sometimes no amount of solid data will change the mind of someone who’s already made theirs up.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Medicare, like any other business (regardless of how you want to view it, it’s as much a business as any other insurance company), is dependent on cash flow. Money comes in from young people and their employers through withholding and taxes, and goes back out again in payments to doctors, hospitals, and all the others who bill Medicare for services and supplies in providing health care.

Unlike other businesses, it’s hampered by regulations and competing interests that affect its viability and capacity to adapt to changing markets and circumstances.

For a while, estimates were that Medicare would run out of cash in 2026, but with a stronger-then-expected COVID recovery, it’s been pushed back all the way to ... 2028.

Yeah.

The trouble here is that nobody wants to fix the system to keep it from happening. It’s easier to blame the other side for losing the game than it is to work together to win it. This isn’t a Republican or Democrat issue. Both of them are the problem.

Since Medicare started, the changes in American lifespan, population dynamics, and medical costs have meant that, as years go by, the spending on health care would eventually outstrip the cash coming in. Pushing it back 2 years doesn’t keep it from happening, though it does give more time to find a solution. But that’s only if you have people willing to do so.

Currently politicians favor a strategy of kicking the can down the road for the next congress to deal with. But we’re running out of road to kick it down, and the odds of the next generation of politicians being reasonable, functioning, adults seem to get lower each year.

Can you run your practice like that? In such a way that you know that in a few years your expenses will outweigh your income? And just figure that at some point you’ll get it figured out before your creditors come knocking?

Me neither.

If you were like me, or any other small business owner, you’d sit down and figure out what changes are needed so you’ll still have a viable business down the road.

Of course, that’s part of the issue. The people making these decisions for Medicare don’t have a vested interest in it. If it fails, they have other jobs and income sources to move on to, not to mention some pension-funded health insurance plan. It’s not their problem.

But for the patients, doctors, and other health care professionals who will be depending on it in 6 years, it is a problem, and a serious one.

Hopefully someone will listen before then.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Medicare, like any other business (regardless of how you want to view it, it’s as much a business as any other insurance company), is dependent on cash flow. Money comes in from young people and their employers through withholding and taxes, and goes back out again in payments to doctors, hospitals, and all the others who bill Medicare for services and supplies in providing health care.

Unlike other businesses, it’s hampered by regulations and competing interests that affect its viability and capacity to adapt to changing markets and circumstances.

For a while, estimates were that Medicare would run out of cash in 2026, but with a stronger-then-expected COVID recovery, it’s been pushed back all the way to ... 2028.

Yeah.

The trouble here is that nobody wants to fix the system to keep it from happening. It’s easier to blame the other side for losing the game than it is to work together to win it. This isn’t a Republican or Democrat issue. Both of them are the problem.

Since Medicare started, the changes in American lifespan, population dynamics, and medical costs have meant that, as years go by, the spending on health care would eventually outstrip the cash coming in. Pushing it back 2 years doesn’t keep it from happening, though it does give more time to find a solution. But that’s only if you have people willing to do so.

Currently politicians favor a strategy of kicking the can down the road for the next congress to deal with. But we’re running out of road to kick it down, and the odds of the next generation of politicians being reasonable, functioning, adults seem to get lower each year.

Can you run your practice like that? In such a way that you know that in a few years your expenses will outweigh your income? And just figure that at some point you’ll get it figured out before your creditors come knocking?

Me neither.

If you were like me, or any other small business owner, you’d sit down and figure out what changes are needed so you’ll still have a viable business down the road.

Of course, that’s part of the issue. The people making these decisions for Medicare don’t have a vested interest in it. If it fails, they have other jobs and income sources to move on to, not to mention some pension-funded health insurance plan. It’s not their problem.

But for the patients, doctors, and other health care professionals who will be depending on it in 6 years, it is a problem, and a serious one.

Hopefully someone will listen before then.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Medicare, like any other business (regardless of how you want to view it, it’s as much a business as any other insurance company), is dependent on cash flow. Money comes in from young people and their employers through withholding and taxes, and goes back out again in payments to doctors, hospitals, and all the others who bill Medicare for services and supplies in providing health care.

Unlike other businesses, it’s hampered by regulations and competing interests that affect its viability and capacity to adapt to changing markets and circumstances.

For a while, estimates were that Medicare would run out of cash in 2026, but with a stronger-then-expected COVID recovery, it’s been pushed back all the way to ... 2028.

Yeah.

The trouble here is that nobody wants to fix the system to keep it from happening. It’s easier to blame the other side for losing the game than it is to work together to win it. This isn’t a Republican or Democrat issue. Both of them are the problem.

Since Medicare started, the changes in American lifespan, population dynamics, and medical costs have meant that, as years go by, the spending on health care would eventually outstrip the cash coming in. Pushing it back 2 years doesn’t keep it from happening, though it does give more time to find a solution. But that’s only if you have people willing to do so.

Currently politicians favor a strategy of kicking the can down the road for the next congress to deal with. But we’re running out of road to kick it down, and the odds of the next generation of politicians being reasonable, functioning, adults seem to get lower each year.

Can you run your practice like that? In such a way that you know that in a few years your expenses will outweigh your income? And just figure that at some point you’ll get it figured out before your creditors come knocking?

Me neither.

If you were like me, or any other small business owner, you’d sit down and figure out what changes are needed so you’ll still have a viable business down the road.

Of course, that’s part of the issue. The people making these decisions for Medicare don’t have a vested interest in it. If it fails, they have other jobs and income sources to move on to, not to mention some pension-funded health insurance plan. It’s not their problem.

But for the patients, doctors, and other health care professionals who will be depending on it in 6 years, it is a problem, and a serious one.

Hopefully someone will listen before then.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Recently I was reading an article on the histories behind great songs, and one section featured Procol Harem’s “A Whiter Shade of Pale.” It mentioned the verse that incorporated a reference to Chaucer (“As the Miller told his tale”).

This surprised me, as, since I’d first heard the song (1983, in “The Big Chill”) until I read this piece, I thought the line was “As the mirror told its tale.” The idea that it was a misheard Chaucer reference had never occurred to me.

These are called mondegreens. The brain translates the phrase into what it hears, often giving it an entirely different meaning. Manfred Mann’s version of “Blinded by the Light” is absolutely full of them. Even the national anthem isn’t immune (“José can you see by the donzerly light?”)

I’m sure there’s an interesting study idea about the brain and mondegreens, probably involving PET scans, somewhere in there.

The whole thing reminded me of an incident early in residency, I suppose you could call it a medical mondegreen.

During training I never went anywhere without a clipboard and notepad, frantically scribbling tidbits down during rounds, lectures, meetings, whatever. I’d go home and reread them over dinner, trying to commit them to memory.

And somewhere, on rounds early in my first year of training, an attending told me that you can sometimes see a Bell’s palsy cause a mild ipsilateral hemiparesis. This surprised me, but hey, I was the newly minted doctor, there to learn. So I wrote it down, memorized it, and moved on.

Even then, though, it made no sense to me. Of course, I was too afraid to ask other residents about it, for fear they’d think I was an idiot (a point that’s still debatable). And questioning the attending involved seemed unthinkable.

But I wandered through my hospital library (back then, young ones, we used paper textbooks and journals) trying to figure out why a peripheral VII palsy could cause an ipsilateral hemiparesis. It would not let me be.

Nothing.

Finally, one day after a lecture, I asked the attending involved. He had no recollection of having tossed the point out a few months ago, and said there was no reason. This confirmed what I’d already realized – a standard Bell’s palsy couldn’t possibly cause an ipsilateral hemiparesis (I’m not going into the crossed-brainstem syndromes here).

Maybe he’d misspoken and not realized it. Maybe I hadn’t heard him correctly. Maybe a little of both. Hospital hallways are anything but quiet. He also had a pending vacation to the coast which could have distracted him.

Like mondegreens in songs, it was just an error, and looking back on it with 30 years perspective, it’s kind of funny. Fortunately I never sent anyone with a hemiparesis home from the ER thinking they had a Bell’s palsy.

But it makes you realize how flawed human communication can be. By the time I asked the attending about it I’d realized it couldn’t possibly be right. It still leaves me wondering about how much we think we heard correctly but we didn’t – and that we don’t notice.

Sometimes you may think your ears are open, but they might just as well be closed if you don’t hear correctly. In medicine the consequences of such can be a lot worse than screwing up on karaoke night.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Recently I was reading an article on the histories behind great songs, and one section featured Procol Harem’s “A Whiter Shade of Pale.” It mentioned the verse that incorporated a reference to Chaucer (“As the Miller told his tale”).

This surprised me, as, since I’d first heard the song (1983, in “The Big Chill”) until I read this piece, I thought the line was “As the mirror told its tale.” The idea that it was a misheard Chaucer reference had never occurred to me.

These are called mondegreens. The brain translates the phrase into what it hears, often giving it an entirely different meaning. Manfred Mann’s version of “Blinded by the Light” is absolutely full of them. Even the national anthem isn’t immune (“José can you see by the donzerly light?”)

I’m sure there’s an interesting study idea about the brain and mondegreens, probably involving PET scans, somewhere in there.

The whole thing reminded me of an incident early in residency, I suppose you could call it a medical mondegreen.

During training I never went anywhere without a clipboard and notepad, frantically scribbling tidbits down during rounds, lectures, meetings, whatever. I’d go home and reread them over dinner, trying to commit them to memory.

And somewhere, on rounds early in my first year of training, an attending told me that you can sometimes see a Bell’s palsy cause a mild ipsilateral hemiparesis. This surprised me, but hey, I was the newly minted doctor, there to learn. So I wrote it down, memorized it, and moved on.

Even then, though, it made no sense to me. Of course, I was too afraid to ask other residents about it, for fear they’d think I was an idiot (a point that’s still debatable). And questioning the attending involved seemed unthinkable.

But I wandered through my hospital library (back then, young ones, we used paper textbooks and journals) trying to figure out why a peripheral VII palsy could cause an ipsilateral hemiparesis. It would not let me be.

Nothing.

Finally, one day after a lecture, I asked the attending involved. He had no recollection of having tossed the point out a few months ago, and said there was no reason. This confirmed what I’d already realized – a standard Bell’s palsy couldn’t possibly cause an ipsilateral hemiparesis (I’m not going into the crossed-brainstem syndromes here).

Maybe he’d misspoken and not realized it. Maybe I hadn’t heard him correctly. Maybe a little of both. Hospital hallways are anything but quiet. He also had a pending vacation to the coast which could have distracted him.

Like mondegreens in songs, it was just an error, and looking back on it with 30 years perspective, it’s kind of funny. Fortunately I never sent anyone with a hemiparesis home from the ER thinking they had a Bell’s palsy.

But it makes you realize how flawed human communication can be. By the time I asked the attending about it I’d realized it couldn’t possibly be right. It still leaves me wondering about how much we think we heard correctly but we didn’t – and that we don’t notice.

Sometimes you may think your ears are open, but they might just as well be closed if you don’t hear correctly. In medicine the consequences of such can be a lot worse than screwing up on karaoke night.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Recently I was reading an article on the histories behind great songs, and one section featured Procol Harem’s “A Whiter Shade of Pale.” It mentioned the verse that incorporated a reference to Chaucer (“As the Miller told his tale”).

This surprised me, as, since I’d first heard the song (1983, in “The Big Chill”) until I read this piece, I thought the line was “As the mirror told its tale.” The idea that it was a misheard Chaucer reference had never occurred to me.

These are called mondegreens. The brain translates the phrase into what it hears, often giving it an entirely different meaning. Manfred Mann’s version of “Blinded by the Light” is absolutely full of them. Even the national anthem isn’t immune (“José can you see by the donzerly light?”)

I’m sure there’s an interesting study idea about the brain and mondegreens, probably involving PET scans, somewhere in there.

The whole thing reminded me of an incident early in residency, I suppose you could call it a medical mondegreen.

During training I never went anywhere without a clipboard and notepad, frantically scribbling tidbits down during rounds, lectures, meetings, whatever. I’d go home and reread them over dinner, trying to commit them to memory.

And somewhere, on rounds early in my first year of training, an attending told me that you can sometimes see a Bell’s palsy cause a mild ipsilateral hemiparesis. This surprised me, but hey, I was the newly minted doctor, there to learn. So I wrote it down, memorized it, and moved on.

Even then, though, it made no sense to me. Of course, I was too afraid to ask other residents about it, for fear they’d think I was an idiot (a point that’s still debatable). And questioning the attending involved seemed unthinkable.

But I wandered through my hospital library (back then, young ones, we used paper textbooks and journals) trying to figure out why a peripheral VII palsy could cause an ipsilateral hemiparesis. It would not let me be.

Nothing.

Finally, one day after a lecture, I asked the attending involved. He had no recollection of having tossed the point out a few months ago, and said there was no reason. This confirmed what I’d already realized – a standard Bell’s palsy couldn’t possibly cause an ipsilateral hemiparesis (I’m not going into the crossed-brainstem syndromes here).

Maybe he’d misspoken and not realized it. Maybe I hadn’t heard him correctly. Maybe a little of both. Hospital hallways are anything but quiet. He also had a pending vacation to the coast which could have distracted him.

Like mondegreens in songs, it was just an error, and looking back on it with 30 years perspective, it’s kind of funny. Fortunately I never sent anyone with a hemiparesis home from the ER thinking they had a Bell’s palsy.

But it makes you realize how flawed human communication can be. By the time I asked the attending about it I’d realized it couldn’t possibly be right. It still leaves me wondering about how much we think we heard correctly but we didn’t – and that we don’t notice.

Sometimes you may think your ears are open, but they might just as well be closed if you don’t hear correctly. In medicine the consequences of such can be a lot worse than screwing up on karaoke night.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Summer, since 1975, is traditionally a time for the BIG blockbusters to hit theaters. Some are new, others are sequels in successful franchises. Some anticipated, some not as much.

And, in summer 2022, we have the least-wanted sequel in modern history – Polio II: The Return.

Of course, this sequel isn’t in the theaters (unless the concessions staff isn’t washing their hands), definitely isn’t funny, and could potentially cost a lot more money than the latest Marvel Cinematic Universe flick.

Personally and professionally, I’m in the middle generation on the disease. I’m young enough that I never had to worry about catching it or having afflicted classmates. But, as a doctor, I’m old enough to still see the consequences. Like most neurologists, I have a handful of patients who had childhood polio, and still deal with the chronic weakness (and consequent pain and orthopedic issues it brings). Signing off on braces and other mobility aids for them is still commonplace.

One of my attendings in residency was the renowned Parkinson’s disease expert Abraham Lieberman. On rounds it was impossible not to notice his marked limp, a consequence of childhood polio, and he’d tell us what it was like, being a 6-year-old boy and dealing with the disease. You learn as much from hearing firsthand experiences as you do from textbooks.

And now the virus is showing up again. A few victims, a lot of virions circulating in waste water, but it shouldn’t be there at all.

We aren’t in the era when schoolchildren died or were crippled by it. Elementary school kids today don’t see classmates catch polio and never return to school, or see their grieving parents.

To take 1 year: More than 3,000 American children died of polio in 1952, and more than 21,000 were left with lifelong paralysis – many of them still among us.

When you think of an iron lung, you think of polio.

Those were the casualties in a war to save future generations from this, along with smallpox and other horrors.

But today, that war is mostly forgotten. And now scientific evidence is drowned out by whatever’s on Facebook and the hard-earned miracle of vaccination is ignored in favor of a nonmedical “social influencer” on YouTube.

So polio is back. The majority of the population likely has nothing to worry about. But there may be segments that are hit hard, and when they are they will never accept the obvious reasons why. It will be part of a cover-up, or a conspiracy, or whatever the guy on Parler told them it was.

As doctors, we’re in the middle. We have to give patients the best recommendations we can, based on learning, evidence, and experience, but at the same time have to recognize their autonomy. I’m not following someone around to make sure they get vaccinated, or take the medication I prescribed.

But we’re also the ones who can be held legally responsible for bad outcomes, regardless of the actual facts of the matter. On the flip side, you don’t hear about someone suing a Facebook “influencer” for doling out inaccurate, potentially fatal, medical advice.

So cracks appear in herd immunity, and leaks will happen.

A few generations of neurologists, including mine, have completed training without considering polio in a differential diagnosis. It would, of course, get bandied about in grand rounds or at the conference table, but none of us really took it seriously. To us residents it was more of historical note. “Gone with the Wind” and the “Wizard of Oz” both came out in 1939, and while we all knew of them, none of us were going to be watching them at the theaters.

Unlike them, though, polio is trying make it back to prime time. It’s a sequel nobody wanted.

But here it is.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Summer, since 1975, is traditionally a time for the BIG blockbusters to hit theaters. Some are new, others are sequels in successful franchises. Some anticipated, some not as much.

And, in summer 2022, we have the least-wanted sequel in modern history – Polio II: The Return.

Of course, this sequel isn’t in the theaters (unless the concessions staff isn’t washing their hands), definitely isn’t funny, and could potentially cost a lot more money than the latest Marvel Cinematic Universe flick.

Personally and professionally, I’m in the middle generation on the disease. I’m young enough that I never had to worry about catching it or having afflicted classmates. But, as a doctor, I’m old enough to still see the consequences. Like most neurologists, I have a handful of patients who had childhood polio, and still deal with the chronic weakness (and consequent pain and orthopedic issues it brings). Signing off on braces and other mobility aids for them is still commonplace.

One of my attendings in residency was the renowned Parkinson’s disease expert Abraham Lieberman. On rounds it was impossible not to notice his marked limp, a consequence of childhood polio, and he’d tell us what it was like, being a 6-year-old boy and dealing with the disease. You learn as much from hearing firsthand experiences as you do from textbooks.

And now the virus is showing up again. A few victims, a lot of virions circulating in waste water, but it shouldn’t be there at all.

We aren’t in the era when schoolchildren died or were crippled by it. Elementary school kids today don’t see classmates catch polio and never return to school, or see their grieving parents.

To take 1 year: More than 3,000 American children died of polio in 1952, and more than 21,000 were left with lifelong paralysis – many of them still among us.

When you think of an iron lung, you think of polio.

Those were the casualties in a war to save future generations from this, along with smallpox and other horrors.

But today, that war is mostly forgotten. And now scientific evidence is drowned out by whatever’s on Facebook and the hard-earned miracle of vaccination is ignored in favor of a nonmedical “social influencer” on YouTube.

So polio is back. The majority of the population likely has nothing to worry about. But there may be segments that are hit hard, and when they are they will never accept the obvious reasons why. It will be part of a cover-up, or a conspiracy, or whatever the guy on Parler told them it was.

As doctors, we’re in the middle. We have to give patients the best recommendations we can, based on learning, evidence, and experience, but at the same time have to recognize their autonomy. I’m not following someone around to make sure they get vaccinated, or take the medication I prescribed.

But we’re also the ones who can be held legally responsible for bad outcomes, regardless of the actual facts of the matter. On the flip side, you don’t hear about someone suing a Facebook “influencer” for doling out inaccurate, potentially fatal, medical advice.

So cracks appear in herd immunity, and leaks will happen.

A few generations of neurologists, including mine, have completed training without considering polio in a differential diagnosis. It would, of course, get bandied about in grand rounds or at the conference table, but none of us really took it seriously. To us residents it was more of historical note. “Gone with the Wind” and the “Wizard of Oz” both came out in 1939, and while we all knew of them, none of us were going to be watching them at the theaters.

Unlike them, though, polio is trying make it back to prime time. It’s a sequel nobody wanted.

But here it is.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Summer, since 1975, is traditionally a time for the BIG blockbusters to hit theaters. Some are new, others are sequels in successful franchises. Some anticipated, some not as much.

And, in summer 2022, we have the least-wanted sequel in modern history – Polio II: The Return.

Of course, this sequel isn’t in the theaters (unless the concessions staff isn’t washing their hands), definitely isn’t funny, and could potentially cost a lot more money than the latest Marvel Cinematic Universe flick.

Personally and professionally, I’m in the middle generation on the disease. I’m young enough that I never had to worry about catching it or having afflicted classmates. But, as a doctor, I’m old enough to still see the consequences. Like most neurologists, I have a handful of patients who had childhood polio, and still deal with the chronic weakness (and consequent pain and orthopedic issues it brings). Signing off on braces and other mobility aids for them is still commonplace.

One of my attendings in residency was the renowned Parkinson’s disease expert Abraham Lieberman. On rounds it was impossible not to notice his marked limp, a consequence of childhood polio, and he’d tell us what it was like, being a 6-year-old boy and dealing with the disease. You learn as much from hearing firsthand experiences as you do from textbooks.

And now the virus is showing up again. A few victims, a lot of virions circulating in waste water, but it shouldn’t be there at all.

We aren’t in the era when schoolchildren died or were crippled by it. Elementary school kids today don’t see classmates catch polio and never return to school, or see their grieving parents.

To take 1 year: More than 3,000 American children died of polio in 1952, and more than 21,000 were left with lifelong paralysis – many of them still among us.

When you think of an iron lung, you think of polio.

Those were the casualties in a war to save future generations from this, along with smallpox and other horrors.

But today, that war is mostly forgotten. And now scientific evidence is drowned out by whatever’s on Facebook and the hard-earned miracle of vaccination is ignored in favor of a nonmedical “social influencer” on YouTube.

So polio is back. The majority of the population likely has nothing to worry about. But there may be segments that are hit hard, and when they are they will never accept the obvious reasons why. It will be part of a cover-up, or a conspiracy, or whatever the guy on Parler told them it was.

As doctors, we’re in the middle. We have to give patients the best recommendations we can, based on learning, evidence, and experience, but at the same time have to recognize their autonomy. I’m not following someone around to make sure they get vaccinated, or take the medication I prescribed.

But we’re also the ones who can be held legally responsible for bad outcomes, regardless of the actual facts of the matter. On the flip side, you don’t hear about someone suing a Facebook “influencer” for doling out inaccurate, potentially fatal, medical advice.

So cracks appear in herd immunity, and leaks will happen.

A few generations of neurologists, including mine, have completed training without considering polio in a differential diagnosis. It would, of course, get bandied about in grand rounds or at the conference table, but none of us really took it seriously. To us residents it was more of historical note. “Gone with the Wind” and the “Wizard of Oz” both came out in 1939, and while we all knew of them, none of us were going to be watching them at the theaters.

Unlike them, though, polio is trying make it back to prime time. It’s a sequel nobody wanted.

But here it is.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Recently Sermo had an interesting case report. A young woman, a few hours after undergoing cupping and acupuncture to her upper back, developed dyspnea and presented to the emergency department. There she was found to have a pneumothorax requiring chest tube placement.

I’m certainly not an expert on pneumothoraces, cupping, or acupuncture. Maybe the occurrence is coincidental, though it certainly is temporally concerning.

If I were to cause a pneumothorax doing an electromyography and nerve conduction velocity of the chest wall or upper back, I’m sure I’d have a lot to answer for. Beyond just arranging care for the patient and explaining things to her and her family members, I’d probably have to deal with a board investigation and/or malpractice claim.

Yet, in my experience, people who provide such services rarely face legal accountability, whereas their counterparts in allopathic medicine regularly do so. How many late-night TV attorney ads have you seen that say “have you been injured by an acupuncturist?”

Me, neither.

I’m not going to go into the questions of whether acupuncture, or even cupping, do anything at all. But this case also raises the point that people tend to think of “alternative” medical treatments as things that, while of unclear benefit, are generally harmless.

The fact is that there is no such thing as a risk-free medical procedure. There probably never will be. No matter how well trained and intentioned the person doing it is, there is always the chance of something going wrong. Human error, mechanical failure, bad luck. As they say, dung happens.

In medicine we think about the risk-benefit ratio and proceed accordingly. But the risk, no matter how low, is never zero. People need to understand this applies to pretty much everything health-related. Even over-the-counter supplements, no matter how great their claims may sound (also unproven) have their issues.

Caveat emptor.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Recently Sermo had an interesting case report. A young woman, a few hours after undergoing cupping and acupuncture to her upper back, developed dyspnea and presented to the emergency department. There she was found to have a pneumothorax requiring chest tube placement.

I’m certainly not an expert on pneumothoraces, cupping, or acupuncture. Maybe the occurrence is coincidental, though it certainly is temporally concerning.

If I were to cause a pneumothorax doing an electromyography and nerve conduction velocity of the chest wall or upper back, I’m sure I’d have a lot to answer for. Beyond just arranging care for the patient and explaining things to her and her family members, I’d probably have to deal with a board investigation and/or malpractice claim.

Yet, in my experience, people who provide such services rarely face legal accountability, whereas their counterparts in allopathic medicine regularly do so. How many late-night TV attorney ads have you seen that say “have you been injured by an acupuncturist?”

Me, neither.

I’m not going to go into the questions of whether acupuncture, or even cupping, do anything at all. But this case also raises the point that people tend to think of “alternative” medical treatments as things that, while of unclear benefit, are generally harmless.

The fact is that there is no such thing as a risk-free medical procedure. There probably never will be. No matter how well trained and intentioned the person doing it is, there is always the chance of something going wrong. Human error, mechanical failure, bad luck. As they say, dung happens.

In medicine we think about the risk-benefit ratio and proceed accordingly. But the risk, no matter how low, is never zero. People need to understand this applies to pretty much everything health-related. Even over-the-counter supplements, no matter how great their claims may sound (also unproven) have their issues.

Caveat emptor.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Recently Sermo had an interesting case report. A young woman, a few hours after undergoing cupping and acupuncture to her upper back, developed dyspnea and presented to the emergency department. There she was found to have a pneumothorax requiring chest tube placement.

I’m certainly not an expert on pneumothoraces, cupping, or acupuncture. Maybe the occurrence is coincidental, though it certainly is temporally concerning.

If I were to cause a pneumothorax doing an electromyography and nerve conduction velocity of the chest wall or upper back, I’m sure I’d have a lot to answer for. Beyond just arranging care for the patient and explaining things to her and her family members, I’d probably have to deal with a board investigation and/or malpractice claim.

Yet, in my experience, people who provide such services rarely face legal accountability, whereas their counterparts in allopathic medicine regularly do so. How many late-night TV attorney ads have you seen that say “have you been injured by an acupuncturist?”

Me, neither.

I’m not going to go into the questions of whether acupuncture, or even cupping, do anything at all. But this case also raises the point that people tend to think of “alternative” medical treatments as things that, while of unclear benefit, are generally harmless.

The fact is that there is no such thing as a risk-free medical procedure. There probably never will be. No matter how well trained and intentioned the person doing it is, there is always the chance of something going wrong. Human error, mechanical failure, bad luck. As they say, dung happens.

In medicine we think about the risk-benefit ratio and proceed accordingly. But the risk, no matter how low, is never zero. People need to understand this applies to pretty much everything health-related. Even over-the-counter supplements, no matter how great their claims may sound (also unproven) have their issues.

Caveat emptor.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

News reports this week indicate that the U.S. Department of Justice is investigating Cassava Sciences over the investigational Alzheimer’s disease agent simufilam. An article in Science alleged that the company’s research included altered or duplicated brain images.

Cassava, not surprisingly, denies this. And I’m not going to take sides. Maybe they’ll be exonerated, maybe not.

But the bigger point here is the importance of checking such things. Alzheimer’s disease, beyond being a horrible neurological disease, is also big money. REALLY big money. If a company were to develop a truly effective treatment for it, they’d be poised to reap a worldwide financial windfall.

I’m not criticizing that, either. If such a drug were to be developed, with all of the time and money that goes into such things, they’d have earned every penny.

But the financial incentives certainly do increase the risk of less-than-ethical behavior. This isn’t just in Alzheimer’s disease, but across the board in medicine. The main plot line of the 1993 Harrison Ford flick “The Fugitive” was based on a drug company using falsified data, bribes, and other criminal activities (like murder) to bring a potentially dangerous (but high-profit) drug to market.

Less-than-ethical behavior is not new in research either. In 1926 Paul Kammerer’s attempt to prove Lamarckian evolution was shown to be a fraud. Cover-ups of potentially dangerous drugs have also occurred, or been alleged, and resulted in some being withdrawn from the market.

I’m not sure this is any worse than the multitude of over-the-counter products I see in the store saying they promote brain health, joint health, immune health, whatever ... then, in tiny letters, adding “these statements have not been authorized by the FDA. This drug is not intended to cure, prevent, or treat any disease.” This is no different than guys selling snake oil and other worthless elixirs out of a horse-drawn wagon. Why they aren’t regulated in the same way Pfizer or Lilly are is beyond me.

Even beyond the old method of making up figures, data can still be iffy. We use the phrase “numbers don’t lie” – and generally they don’t – but the ability to “spin” them to suit any narrative has become an art form. If you can’t change the data, make them fit into a better scenario. Somehow.

Which brings me back to why it’s critically important that such studies be open to review by people who don’t have a conflict of interest in the success or failure of the drugs. No matter how well-intentioned a company and its scientists may be, no person is entirely immune to the pressures involved to succeed. And there are many: from shareholders, from executives, even from the knowledge that a bad outcome may mean they’re out of a job.

Fraud is nothing new in medicine. I also don’t see it going away anytime in the future. It’s not the nature of medicine, but it is the nature of some people. And a few of them increase the need for legitimacy in everyone else.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

News reports this week indicate that the U.S. Department of Justice is investigating Cassava Sciences over the investigational Alzheimer’s disease agent simufilam. An article in Science alleged that the company’s research included altered or duplicated brain images.

Cassava, not surprisingly, denies this. And I’m not going to take sides. Maybe they’ll be exonerated, maybe not.

But the bigger point here is the importance of checking such things. Alzheimer’s disease, beyond being a horrible neurological disease, is also big money. REALLY big money. If a company were to develop a truly effective treatment for it, they’d be poised to reap a worldwide financial windfall.

I’m not criticizing that, either. If such a drug were to be developed, with all of the time and money that goes into such things, they’d have earned every penny.

But the financial incentives certainly do increase the risk of less-than-ethical behavior. This isn’t just in Alzheimer’s disease, but across the board in medicine. The main plot line of the 1993 Harrison Ford flick “The Fugitive” was based on a drug company using falsified data, bribes, and other criminal activities (like murder) to bring a potentially dangerous (but high-profit) drug to market.

Less-than-ethical behavior is not new in research either. In 1926 Paul Kammerer’s attempt to prove Lamarckian evolution was shown to be a fraud. Cover-ups of potentially dangerous drugs have also occurred, or been alleged, and resulted in some being withdrawn from the market.

I’m not sure this is any worse than the multitude of over-the-counter products I see in the store saying they promote brain health, joint health, immune health, whatever ... then, in tiny letters, adding “these statements have not been authorized by the FDA. This drug is not intended to cure, prevent, or treat any disease.” This is no different than guys selling snake oil and other worthless elixirs out of a horse-drawn wagon. Why they aren’t regulated in the same way Pfizer or Lilly are is beyond me.

Even beyond the old method of making up figures, data can still be iffy. We use the phrase “numbers don’t lie” – and generally they don’t – but the ability to “spin” them to suit any narrative has become an art form. If you can’t change the data, make them fit into a better scenario. Somehow.

Which brings me back to why it’s critically important that such studies be open to review by people who don’t have a conflict of interest in the success or failure of the drugs. No matter how well-intentioned a company and its scientists may be, no person is entirely immune to the pressures involved to succeed. And there are many: from shareholders, from executives, even from the knowledge that a bad outcome may mean they’re out of a job.

Fraud is nothing new in medicine. I also don’t see it going away anytime in the future. It’s not the nature of medicine, but it is the nature of some people. And a few of them increase the need for legitimacy in everyone else.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

News reports this week indicate that the U.S. Department of Justice is investigating Cassava Sciences over the investigational Alzheimer’s disease agent simufilam. An article in Science alleged that the company’s research included altered or duplicated brain images.

Cassava, not surprisingly, denies this. And I’m not going to take sides. Maybe they’ll be exonerated, maybe not.

But the bigger point here is the importance of checking such things. Alzheimer’s disease, beyond being a horrible neurological disease, is also big money. REALLY big money. If a company were to develop a truly effective treatment for it, they’d be poised to reap a worldwide financial windfall.

I’m not criticizing that, either. If such a drug were to be developed, with all of the time and money that goes into such things, they’d have earned every penny.

But the financial incentives certainly do increase the risk of less-than-ethical behavior. This isn’t just in Alzheimer’s disease, but across the board in medicine. The main plot line of the 1993 Harrison Ford flick “The Fugitive” was based on a drug company using falsified data, bribes, and other criminal activities (like murder) to bring a potentially dangerous (but high-profit) drug to market.

Less-than-ethical behavior is not new in research either. In 1926 Paul Kammerer’s attempt to prove Lamarckian evolution was shown to be a fraud. Cover-ups of potentially dangerous drugs have also occurred, or been alleged, and resulted in some being withdrawn from the market.

I’m not sure this is any worse than the multitude of over-the-counter products I see in the store saying they promote brain health, joint health, immune health, whatever ... then, in tiny letters, adding “these statements have not been authorized by the FDA. This drug is not intended to cure, prevent, or treat any disease.” This is no different than guys selling snake oil and other worthless elixirs out of a horse-drawn wagon. Why they aren’t regulated in the same way Pfizer or Lilly are is beyond me.

Even beyond the old method of making up figures, data can still be iffy. We use the phrase “numbers don’t lie” – and generally they don’t – but the ability to “spin” them to suit any narrative has become an art form. If you can’t change the data, make them fit into a better scenario. Somehow.

Which brings me back to why it’s critically important that such studies be open to review by people who don’t have a conflict of interest in the success or failure of the drugs. No matter how well-intentioned a company and its scientists may be, no person is entirely immune to the pressures involved to succeed. And there are many: from shareholders, from executives, even from the knowledge that a bad outcome may mean they’re out of a job.

Fraud is nothing new in medicine. I also don’t see it going away anytime in the future. It’s not the nature of medicine, but it is the nature of some people. And a few of them increase the need for legitimacy in everyone else.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

There was a recent post on Sermo about medical office staff cross-training. It talked about the importance of the scheduler being able to cover for the medical assistant (to an extent), a billing person being able to room patients, and so on.

Here, in my little three-person office, the only thing my staff can’t do is see patients.

Actually, more than 2 years out since the pandemic changed everyone’s lives, we’ve settled into a very different cross-training routine. I’m the only one at my office. My medical assistant works from home, far north of me, and so does my scheduler, who is across town.

So, at the office, I handle it all. I check people in, copy insurance cards, collect copays, see patients, and make follow-ups.

At this time, I’ve not only gotten used to it, but really don’t mind it.

We don’t worry about freeway traffic. My staff starts at the exact time each day, and so I don’t worry about one of them being an hour late, trapped behind a rush-hour pile-up on the 101. Staying at home with a sick kid isn’t an issue either, anymore. If my secretary has to make her young daughter lunch, or run her over to a birthday party, I don’t even notice it. If there are any problems, she knows how to reach me. Same with my medical assistant.

Nobody worries about what to throw together for dinner if they get home late.

In an era where other businesses want to reverse the work-from-home trend, I don’t see an issue with its continuing for some jobs. It saves money on rent, and money and time on transportation.

Gas prices, at least for driving to and from work for them, don’t have to be factored into the wage equations. I’d guess it’s about 1,000 gallons of gas a year saved. On a national scale that’s nothing, but to my staff right now that’s $3,000-$4,000 more in their pockets at the end of the year. Not to mention it’s two more cars off the road.

Granted, this doesn’t change what I’m doing. Seeing patients in person is a key part of being a doctor. Some things can be handled equally well over the phone or Zoom, but many can’t. It’s what I signed up for, and I really don’t mind it. Seeing patients is still what I enjoy.

My staff is a lot happier with this arrangement, and I don’t mind it either. I always, by nature, kept a reasonably paced schedule. Trying to shoehorn patients in has never been my way, so I have time to run a credit card or scan insurance information.

When one of my staff goes out of town, the other covers her calls and relays messages to me. Yes, it’s extra work, but no more so than if they were here in person. Probably less.

I’m sure many physicians wouldn’t agree with my office model, but it suits me fine. Cross-training and all.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

There was a recent post on Sermo about medical office staff cross-training. It talked about the importance of the scheduler being able to cover for the medical assistant (to an extent), a billing person being able to room patients, and so on.

Here, in my little three-person office, the only thing my staff can’t do is see patients.

Actually, more than 2 years out since the pandemic changed everyone’s lives, we’ve settled into a very different cross-training routine. I’m the only one at my office. My medical assistant works from home, far north of me, and so does my scheduler, who is across town.

So, at the office, I handle it all. I check people in, copy insurance cards, collect copays, see patients, and make follow-ups.

At this time, I’ve not only gotten used to it, but really don’t mind it.

We don’t worry about freeway traffic. My staff starts at the exact time each day, and so I don’t worry about one of them being an hour late, trapped behind a rush-hour pile-up on the 101. Staying at home with a sick kid isn’t an issue either, anymore. If my secretary has to make her young daughter lunch, or run her over to a birthday party, I don’t even notice it. If there are any problems, she knows how to reach me. Same with my medical assistant.

Nobody worries about what to throw together for dinner if they get home late.

In an era where other businesses want to reverse the work-from-home trend, I don’t see an issue with its continuing for some jobs. It saves money on rent, and money and time on transportation.

Gas prices, at least for driving to and from work for them, don’t have to be factored into the wage equations. I’d guess it’s about 1,000 gallons of gas a year saved. On a national scale that’s nothing, but to my staff right now that’s $3,000-$4,000 more in their pockets at the end of the year. Not to mention it’s two more cars off the road.

Granted, this doesn’t change what I’m doing. Seeing patients in person is a key part of being a doctor. Some things can be handled equally well over the phone or Zoom, but many can’t. It’s what I signed up for, and I really don’t mind it. Seeing patients is still what I enjoy.

My staff is a lot happier with this arrangement, and I don’t mind it either. I always, by nature, kept a reasonably paced schedule. Trying to shoehorn patients in has never been my way, so I have time to run a credit card or scan insurance information.

When one of my staff goes out of town, the other covers her calls and relays messages to me. Yes, it’s extra work, but no more so than if they were here in person. Probably less.

I’m sure many physicians wouldn’t agree with my office model, but it suits me fine. Cross-training and all.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

There was a recent post on Sermo about medical office staff cross-training. It talked about the importance of the scheduler being able to cover for the medical assistant (to an extent), a billing person being able to room patients, and so on.

Here, in my little three-person office, the only thing my staff can’t do is see patients.

Actually, more than 2 years out since the pandemic changed everyone’s lives, we’ve settled into a very different cross-training routine. I’m the only one at my office. My medical assistant works from home, far north of me, and so does my scheduler, who is across town.

So, at the office, I handle it all. I check people in, copy insurance cards, collect copays, see patients, and make follow-ups.

At this time, I’ve not only gotten used to it, but really don’t mind it.

We don’t worry about freeway traffic. My staff starts at the exact time each day, and so I don’t worry about one of them being an hour late, trapped behind a rush-hour pile-up on the 101. Staying at home with a sick kid isn’t an issue either, anymore. If my secretary has to make her young daughter lunch, or run her over to a birthday party, I don’t even notice it. If there are any problems, she knows how to reach me. Same with my medical assistant.

Nobody worries about what to throw together for dinner if they get home late.

In an era where other businesses want to reverse the work-from-home trend, I don’t see an issue with its continuing for some jobs. It saves money on rent, and money and time on transportation.

Gas prices, at least for driving to and from work for them, don’t have to be factored into the wage equations. I’d guess it’s about 1,000 gallons of gas a year saved. On a national scale that’s nothing, but to my staff right now that’s $3,000-$4,000 more in their pockets at the end of the year. Not to mention it’s two more cars off the road.

Granted, this doesn’t change what I’m doing. Seeing patients in person is a key part of being a doctor. Some things can be handled equally well over the phone or Zoom, but many can’t. It’s what I signed up for, and I really don’t mind it. Seeing patients is still what I enjoy.

My staff is a lot happier with this arrangement, and I don’t mind it either. I always, by nature, kept a reasonably paced schedule. Trying to shoehorn patients in has never been my way, so I have time to run a credit card or scan insurance information.

When one of my staff goes out of town, the other covers her calls and relays messages to me. Yes, it’s extra work, but no more so than if they were here in person. Probably less.

I’m sure many physicians wouldn’t agree with my office model, but it suits me fine. Cross-training and all.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

The shell game is probably the world’s oldest confidence game, going back 2,000-3,000 years. You still see people getting lured into it in cities today.

It’s also played, albeit legally, in physician offices and pharmacies around the country.

The medical equivalent of the shell game involves one of those ubiquitous manufacturer copay coupons. You know, the ones piled up in your sample cabinet. Get a month free of Whateveritscalled to try and/or have your copay reduced to $0 or something reasonably low. All, of course, subject to terms and conditions in the small print and that of your insurance carrier. Your mileage may vary.

In my experience these things often don’t work as well as advertised. Sometimes it’s because the patient doesn’t understand how to use them, other times because their pharmacy doesn’t want to have anything to do with the cards, and still other times because their insurance has some exclusion against them.

But they do sometimes work ... until they don’t. Sometimes, out of the blue, they’ll stop. Maybe there was an insurance change, or the pharmacy policy changed, or the manufacturer’s program changed, or the offer expired. I usually don’t know and rarely find out.

So the shell game begins. The patients call multiple pharmacies, trying to find one that may be able to honor the coupons. Then they call my office and ask me to switch the script. So I do. They they go to the pharmacy. Sometimes they can get the script, sometimes not. If not, they move to another pharmacy and call my office to switch it again. Wash, rinse, repeat.

Other times it’s more complicated. They want a new card for each try, so they show up at my office asking for one (usually they can be downloaded online so some try that. Others do both). Like pebbles under a shell, the prescriptions and cards get switched from pharmacy to pharmacy.

This isn’t exclusive to manufacturers’ copay cards. I see the same phenomenon with GoodRx and similar cost-saving programs. People move scripts around to find the best deal. It may be helping them, but it certainly doesn’t help me and my staff as we try to keep up, or the badly overworked pharmacy staff.

I’ve even had some patients take the audacious step of asking me to write a script in the name of their spouses so they can double their supply. Obviously, such requests are refused. I’m not going to play that game.

I understand new drugs are costly, and often outside the reach of many patients today. I know the manufacturers are trying to get their products tried, or even make them more affordable for those who need it.

But, in many cases, this becomes (unintentionally or intentionally; I’m not sure) a shell game. Legal, perhaps, but still equally frustrating for all of us who are trying to keep up with it.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

The shell game is probably the world’s oldest confidence game, going back 2,000-3,000 years. You still see people getting lured into it in cities today.

It’s also played, albeit legally, in physician offices and pharmacies around the country.

The medical equivalent of the shell game involves one of those ubiquitous manufacturer copay coupons. You know, the ones piled up in your sample cabinet. Get a month free of Whateveritscalled to try and/or have your copay reduced to $0 or something reasonably low. All, of course, subject to terms and conditions in the small print and that of your insurance carrier. Your mileage may vary.

In my experience these things often don’t work as well as advertised. Sometimes it’s because the patient doesn’t understand how to use them, other times because their pharmacy doesn’t want to have anything to do with the cards, and still other times because their insurance has some exclusion against them.

But they do sometimes work ... until they don’t. Sometimes, out of the blue, they’ll stop. Maybe there was an insurance change, or the pharmacy policy changed, or the manufacturer’s program changed, or the offer expired. I usually don’t know and rarely find out.

So the shell game begins. The patients call multiple pharmacies, trying to find one that may be able to honor the coupons. Then they call my office and ask me to switch the script. So I do. They they go to the pharmacy. Sometimes they can get the script, sometimes not. If not, they move to another pharmacy and call my office to switch it again. Wash, rinse, repeat.

Other times it’s more complicated. They want a new card for each try, so they show up at my office asking for one (usually they can be downloaded online so some try that. Others do both). Like pebbles under a shell, the prescriptions and cards get switched from pharmacy to pharmacy.

This isn’t exclusive to manufacturers’ copay cards. I see the same phenomenon with GoodRx and similar cost-saving programs. People move scripts around to find the best deal. It may be helping them, but it certainly doesn’t help me and my staff as we try to keep up, or the badly overworked pharmacy staff.

I’ve even had some patients take the audacious step of asking me to write a script in the name of their spouses so they can double their supply. Obviously, such requests are refused. I’m not going to play that game.

I understand new drugs are costly, and often outside the reach of many patients today. I know the manufacturers are trying to get their products tried, or even make them more affordable for those who need it.

But, in many cases, this becomes (unintentionally or intentionally; I’m not sure) a shell game. Legal, perhaps, but still equally frustrating for all of us who are trying to keep up with it.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

The shell game is probably the world’s oldest confidence game, going back 2,000-3,000 years. You still see people getting lured into it in cities today.

It’s also played, albeit legally, in physician offices and pharmacies around the country.

The medical equivalent of the shell game involves one of those ubiquitous manufacturer copay coupons. You know, the ones piled up in your sample cabinet. Get a month free of Whateveritscalled to try and/or have your copay reduced to $0 or something reasonably low. All, of course, subject to terms and conditions in the small print and that of your insurance carrier. Your mileage may vary.

In my experience these things often don’t work as well as advertised. Sometimes it’s because the patient doesn’t understand how to use them, other times because their pharmacy doesn’t want to have anything to do with the cards, and still other times because their insurance has some exclusion against them.

But they do sometimes work ... until they don’t. Sometimes, out of the blue, they’ll stop. Maybe there was an insurance change, or the pharmacy policy changed, or the manufacturer’s program changed, or the offer expired. I usually don’t know and rarely find out.

So the shell game begins. The patients call multiple pharmacies, trying to find one that may be able to honor the coupons. Then they call my office and ask me to switch the script. So I do. They they go to the pharmacy. Sometimes they can get the script, sometimes not. If not, they move to another pharmacy and call my office to switch it again. Wash, rinse, repeat.

Other times it’s more complicated. They want a new card for each try, so they show up at my office asking for one (usually they can be downloaded online so some try that. Others do both). Like pebbles under a shell, the prescriptions and cards get switched from pharmacy to pharmacy.

This isn’t exclusive to manufacturers’ copay cards. I see the same phenomenon with GoodRx and similar cost-saving programs. People move scripts around to find the best deal. It may be helping them, but it certainly doesn’t help me and my staff as we try to keep up, or the badly overworked pharmacy staff.

I’ve even had some patients take the audacious step of asking me to write a script in the name of their spouses so they can double their supply. Obviously, such requests are refused. I’m not going to play that game.

I understand new drugs are costly, and often outside the reach of many patients today. I know the manufacturers are trying to get their products tried, or even make them more affordable for those who need it.

But, in many cases, this becomes (unintentionally or intentionally; I’m not sure) a shell game. Legal, perhaps, but still equally frustrating for all of us who are trying to keep up with it.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.