Last Year of Neurology Residency

I recently completed my neurology residency at Duke (June 2024), bringing to a close one of the most formative chapters of my life. This past four-year journey—marked by long hours, immense learning, and meaningful connections—has been nothing short of transformative. When I first matched into Duke Neurology’s inaugural all-female cohort, I had no idea that we would begin our training in the middle of a global pandemic. Starting residency in June 2020 was both an honor and a challenge. The camaraderie within our cohort, combined with the support of my mentors, molded me into the neurologist I am today.

Reflecting on this period, I’m reminded of the highs and lows that come with such an intense training environment. Residency was rigorous in ways I hadn’t anticipated, but it was also deeply rewarding. I faced moments of exhaustion and frustration, but there were also times filled with laughter, fulfillment, and a renewed passion for patient care. The program's structure pushed me to grow as both a clinician and a person, and for that, I am immensely grateful. My fiancé, family, friends, and mentors played a crucial role in helping me navigate the ups and downs along the way.

As I conclude this chapter, I’m excited to share a few clinical stories and key experiences from residency in a later post. But first, I’d like to walk through some of the travel experiences that have shaped this past year—each trip a learning adventure in its own right. From professional conferences to workshops, these opportunities not only broadened my horizons in neurology but also gave me a chance to explore new cities and enjoy some incredible food.

January 2024: Clinical Neurological Society of America Annual Meeting, Key Largo, Florida

At the Clinical Neurological Society of America (CNSA) meeting, I experienced the unique value of a small, close-knit community. Despite each person’s specialized focus, there was a shared passion for comprehensive neurological care. The focused learning sessions, particularly the "Meet the Professor" sessions, were immensely valuable. I felt like I was not only learning but also growing into a better general neurologist with each small group interaction. The organization’s commitment to diversifying its members and speakers was another significant highlight for me.

One of the personal highlights of the trip was grabbing a Baja Beach Chicken Burger at The Burger Den—it was delicious and definitely added to the positive experience.

March 2024: Diversifying CNS meeting in San Francisco, and Workshop on Contextual Data Resources for Understanding the Role of the Exposome in Aging, USC in Los Angeles, CA

March took me to San Francisco, where I, as a member of Diversifying CNS (a group dedicated to nurturing underrepresented neuroscience researchers), attended a powerful event focused on diversifying the field of clinical neuroscience. It was incredibly moving to hear the stories of researchers who have taken nonlinear paths, overcoming not only academic but also personal challenges, such as racism and self-doubt. One moment that stuck with me was a black male faculty member being mistaken for a cleaner—a stark reminder of the work still needed in our field. However, seeing these individuals rise through it all was nothing short of inspiring. The practical advice on setting up a lab, negotiating in academia, and even statistical coding made this trip invaluable.

Outside of the academic experience, the reality of San Francisco’s homelessness crisis was impossible to ignore. Walking/driving through the city, I was struck by the sheer scale of the issue—tents lined many streets, and people experiencing homelessness were a visible part of many parts that we passed through. The contrast between the bustling academic discussions inside the conference rooms, where we spoke about research and professional advancement, and the profound social inequities just outside the doors was jarring. It was a sobering reminder of the challenges that exist beyond our academic bubble, and how disconnected the worlds of research and policy can sometimes feel from the pressing human crises happening in real time. It left me reflecting deeply on the broader social determinants of health that are inextricably linked to the very issues we're studying in our fields—how can we adequately address one's health without acknowledging the fundamental need for stable housing and social support?

April 2024

North Carolina Central University (NCCU) Career Day
At the NCCU Neurosciences Career Exploration Day, hosted by Duke and held at the JB Duke Hotel in Durham, I had the chance to speak with undergraduate students interested in neuroscience. Sharing my journey and watching their excitement as they learned about the field was incredibly rewarding. It reminded me how important it is to inspire the next generation of neurologists and researchers.

AAN Conference - Denver, Colorado
The American Academy of Neurology (AAN) conference in Denver was, as always, an incredible experience. With a massive array of lectures, networking events, and career development opportunities, it remains one of my favorite professional gatherings. I appreciated the opportunity to connect with colleagues and mentors, and there was no shortage of knowledge to be gained in the various learning tracks.

Physicians Foundation Board Meeting - Boston Harbor Hotel
As a 2024 Physicians Foundation Drivers of Health fellow, attending the Physicians Foundation Board meeting at the Boston Harbor Hotel was a highlight of my spring. The discussions focused on improving physician well-being, fostering leadership, and addressing social drivers of health. It was a productive and energizing experience that left me motivated to continue advocating for the voices of physicians.

June 2024: Boston - Stress Neurobiology Workshop

In June, I attended and gave an oral presentation about my work at the Stress Neurobiology Workshop in Boston, a pivotal opportunity to learn about the latest research in the field. It provided a deeper understanding of the mechanisms behind stress-related neurological conditions, and I came away with fresh ideas for future projects.

July 2024: Wedding Day

On July 13, 2024, Derrick and I were married! I can write an entirely separate entry on this. After months of tireless planning, it was finally our big day. It was truly one of the best days of our lives. The day wasn't without its challenges, but the support of our family and friends made everything perfect. The joy and love we felt were immeasurable, and we’re grateful for everyone who shared the day with us.

August 2024: Broadmoor (Physicians Foundation Board Meeting), Seattle (APA Convention & LEAP Bootcamp)

In August, I attended the Physicians Foundation board meeting at the Broadmoor in Colorado Springs. This picturesque setting was the perfect backdrop for discussions on physician well-being and leadership. Shortly after, I traveled to Seattle for the American Psychological Association (APA) Convention and LEAP (Leadership and Education Advancement Program) Grant Writing Bootcamp. The bootcamp provided countless practical tips on grant writing, negotiation, and other important professional topics. A couple of topics that resonated deeply with me were discussions on imposter syndrome and dealing with difficult leaders. Also, I had the chance to fly Alaska Airlines straight from Baltimore to Seattle—it was a surprisingly pleasant and restful experience!

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As I reflect on my journey through residency, the academic experiences and conferences were certainly pivotal, but some of the most profound lessons came directly from the clinical cases I encountered. The transition from textbooks to real-life patients revealed the complexity of treating neurological disorders, where psychological, emotional, and social factors often play as much of a role as the medical symptoms themselves. In this next section, I’d like to share two particularly memorable cases involving pediatric patients that deeply impacted my approach to medicine. These cases not only challenged my clinical knowledge but also highlighted the importance of treating the patient as a whole—beyond just their symptoms—and understanding the broader context of their lives.

I can distinctly recall two pediatric cases that had a profound impact on my clinical practice and personal growth. These cases not only tested my medical knowledge but also taught me invaluable lessons about the importance of holistic patient care and the critical role of psychological and social factors in health.

The Complexity of Symptoms Beyond Diagnosis

While I was covering the Pediatric Neurology consultant pager overnight, the ED contacted me about an 8-year-old girl with a history of anxiety and migraines. Let's call her Lisa. She presented to the ED with a range of symptoms, including shortness of breath, dysphagia, muscle weakness, sensory disturbances (burning sensations in her hands and feet), and urinary urgency that prompted the use of a diaper. Her symptoms were further complicated by many episodes of stridor that resolved in the blink of an eye with heliox treatment, suggesting a possible stress-related component. 

"Can you help us put her together and figure out if there may be a neurological cause of these symptoms?"

There wasn't. I knew this immediately. The history the ED provided already gave me the answer.

Lisa's parents described her as a very "sensitive" child, and their high levels of stress were palpable during our interactions. They had lost another child to cancer when they were 8 years old, the same age Lisa was now. This tragic loss undoubtedly contributed to their anxiety and hypervigilance regarding Lisa's health.

Despite extensive diagnostic workups, including an MRI of the brain and respiratory evaluations, her symptoms did not localize to a specific neurological territory. The MRI only showed minor changes consistent with migraines, which did not explain the breadth of her symptoms. Her episodes of stridor, which resolved with distraction, further pointed to a psychosomatic component.

The impact of her sibling's death on the family dynamics was profound. Her parents' stress and anxiety likely exacerbated Lisa's symptoms, creating a cycle where their concern intensified her anxiety and physical manifestations. It was clear that Lisa's health issues could not be addressed through medical interventions alone; her psychological well-being and the family's emotional health needed to be integral parts of the care plan.

From this case, I realized the importance of addressing the psychological and emotional aspects of patient care. Lisa's situation underscored the need for a multidisciplinary approach, involving not only neurologic evaluation but also psychiatric support. 

Family Dynamics and Social Context

I was contacted about a 14-year-old boy with a history of ADHD and depression—let's call him J. His presentation was a puzzle, filled with a myriad of symptoms that required a deep dive into both his medical history and social context to fully understand. J was admitted with severe hypersomnia and memory changes. His mother brought him to the ED due to increased episodes of urinary incontinence while sleeping, palpitations, numbness across the chest, and orthostasis. Additionally, he exhibited strange movements described as non-rhythmic jerking and rolling around in bed, which resolved immediately after the use of smelling salts. His hypersomnia was profound, with him sleeping up to 20 hours a day and experiencing hypnagogic (occurring when falling asleep) hallucinations.

Despite undergoing an extensive workup, including MRI, lumbar puncture, and testing for autoimmune encephalitis, no clear etiology emerged. The primary team suspected Klinefelter-Levine syndrome, but this diagnosis didn’t fully account for the range of his symptoms. His case presented a challenge that required looking beyond the typical medical explanations and considering other dimensions of his life.

One of the most critical, yet initially overlooked, aspects of J’s case was his family dynamics and social environment. His father had a history of schizophrenia and bipolar disorder, and J had reportedly been a victim of bullying at school. These factors were glaringly absent from the initial chart notes, and it was only after digging deeper into his background that we began to piece together the emotional and psychological influences that were likely contributing to his physical symptoms.

When I reviewed J’s chart, I was struck by the lack of attention to these crucial social stressors. Understanding the impact of his father’s psychiatric conditions and the bullying he endured at school was essential for creating a holistic approach to his care. It was perplexing that such significant aspects of his life had been overlooked in his medical records, underscoring the importance of considering the psychological and social context in patient care. This case highlighted the need to look beyond the purely clinical and to take into account the broader circumstances affecting the patient's health.

2023 - It's a Wrap

2023 has been tremendous. I cannot believe another year flew by. I am halfway through my PGY-4 Chief Year of Neurology residency at Duke.

I'd like to share a couple of learning points from my patient encounters, and a few trips I'm grateful to have been able to take this year for conferences or personal travel.

*To ensure HIPAA compliance, personally identifying information has been omitted/changed and certain details of these encounters have been modified to protect the patients and their families.

A few major learning points and fulfillments from my clinical encounters:

1. LISTEN to the patient. It's simple. I completed the first part of my Psychiatry rotation this past summer, and this was one of the salient lessons. It sounds simple and generic, right? But it's unfortunately a lesson that many of us in healthcare need. Psychiatrists LISTEN.

They wait, they pause, they STOP talking so much so the patient can talk, and when the patient sees that they’re not being interrupted, they go on to speak more. This adds to our ability to diagnose their condition. I cannot tell you how many cases I was able to confidently diagnose by just the HISTORY and LISTENING (i.e. I diagnosed a patient with a seizure disorder after fighting tooth and nail to reach a family member when the patient came into the ED (Emergency Department) with no history, no documentation in the chart, and no ability to speak directly about their symptoms). Admittedly, my listening isn't always great, but it's an ongoing work in progress!

2. One of the biggest fulfillments of my clinical encounters is with patients who look like me. One day, a *45-year old black woman came into the ED with numbness on the left side of her face that progressed next to her left arm and leg. All of this was in the context of a headache. She came in as a stroke code with the paramedics given the unilateral nature of her symptoms. I was more suspicious for migraine with aura instead of a stroke, but I took a more thorough history from both the patient and her husband. She was understandably anxious so I tried to calm her down. At the end of the encounter, her husband told me, “Representation matters, I appreciate everything you’ve done for us today.” This was such a good feeling.

3. We have to remember that it is a privilege to take care of patients. I received a note from a patient's spouse after I took care of her following a stroke code.

"Dear Dr. Rose,

It was truly a pleasure meeting you this morning when you examined my wife due to the stroke-like symptoms she experienced last night. It was a joy watching you in action. Thank you for your kindness and the thorough examination you performed. I agree with my wife, you are superb. Healthcare in the U.S. would be a lot better if we had more doctors like you."

I was both shocked and incredibly grateful to receive such a thoughtful note like this. It is helpful for us to be reminded of how much of a privilege it is for us to care for patients who need us.

Trips:

July 2023 - REACH Reunion in Atlanta, GA

REACH is an Addiction program that strives to build the capacity of the workforce to better care for racial and ethnic minoritized patients with substance use disorders. REACH stands for Recognizing and Eliminating Disparities in Addiction through Culturally Informed Healthcare. We had a reunion in Atlanta this past summer to gather all of the cohorts from this program over the past several years for a massive learning and networking event. It was incredible.

I didn't get the chance to explore as much as I would've liked, but I was able to grab a nice quick meal from a laid-back, good-quality, reasonably priced, grab-on-the-go food place: Rock's Chicken and Fries - it serves exactly that, plus a little more (salads, other types of sandwiches, and more).

September 2023 - American Neurological Association (ANA) Meeting in Philadelphia

The annual meeting for the ANA was held this year in Philadelphia! It was such a great time. The IDEAS (Inclusion/Diversity/Equity/Anti-Racism/Social Justice) committee held a reception one evening during the conference. As one of the recipients of the IDEAS Junior Member Award, I gave a brief presentation about my research. Admittedly, I was much too excited while preparing the PowerPoint and added more preliminary data than necessary :) We were also given the opportunity to share a little bit about what inspired us to pursue our respective areas of research.

Let's talk food! I ate from a few different places and they were pretty delicious:

• Dan Dan Noodles: I ordered Shrimp Fried Rice and vegetables :) Super delicious.

• Marathon Grill: I grabbed a Grilled Chicken Cobb Salad from this spot, which was pretty tasty and very filling.

• Toms Dim Sum: I ordered Shanghai Wonton Soup with shrimp dumplings. DELICIOUS. This was the perfect cure for a cold I was suffering from at the time. 
  

October 2023 - Charlotte, NC and Atlanta, GA

I'm honored to have been invited to speak at a couple of churches in Charlotte and Atlanta for HEAL Collaborative’s series on Alzheimer’s Disease and Dementia! HEAL Collaborative is a nonprofit organization focused on Health Education Advocacy and Learning. It was wonderful raising awareness about Alzheimer's Disease's disproportionate impact on racial and ethnic minoritized communities.

November 2023

• Society for Neuroscience (SfN) - DC
• 
  SfN is the largest professional society dedicated to the study of the nervous system, with nearly 40,000 members, and over 30,000 attendees at this past meeting!
• I have to talk about the delicious food that I ate while here:
• Clyde's of Gallery Place: They had one of the best crab cakes I ever ate. I ordered the Jumbo Lump Crab Cake and the banana bread pudding for dessert. Both were incredible, though the banana bread pudding was quite sweet!
• Founding Farmers DC: I had to have the Glazed Cedar Plank salmon and the butterscotch bread pudding. Are you seeing a theme here? Haha. Bread pudding is one of my favorite desserts. I'd rate this entire meal a 10 out of 10.

• Thanksgiving in GA - It was so nice getting to spend the holidays in South Georgia with my fiance's family, and to take a few engagement photos!

Jamaica - Summer 2023

My family had a reunion in our ancestral home of Jamaica. My mother's side of the family gathered together at the end of June to celebrate our history, culture, and to enjoy each other's company.

Our trips/adventures throughout the week consisted of some of the following:

Visiting my great-grandmother's birthplace in Nottingham,                          YS Falls, Jamaica

                              Spur Tree with the family

                            Treasure Beach                                                                        YS Falls

Incredible food: shrimp, festival (fried dough),                                              Oswald's

               and breadfruit at Oswald's

This was also the first time my boyfriend Derrick traveled to Jamaica, so it was wonderful going through this new experience with him.

More to come!

End of 2022 through early 2023: Midwest, Southeast, and Northeast US

Big News

I am so grateful to share that after residency, starting in July 2024, I will pursue a Behavioral Neurology & Neuropsychiatry fellowship at Johns Hopkins and research training as a clinical fellow at the NINDS/NIA. This opportunity truly wouldn't have been possible if it weren't for my mentors who fiercely advocated for me.

Chicago in October 2022

The end of 2022 has brought great joy and new personal beginnings. As for career development, I'm grateful for the opportunity to have traveled to Chicago in October for the American Neurological Association (ANA) meeting. Several talks given at this conference transformed the approach I plan to take with my research, and I made connections that changed the trajectory of my fellowship training plans.

Of course, I had to meet up with a couple of colleauges from my time in Chicago during medical school. One of my mentors and I stopped by Roots Handmade Pizza for dinner, which was quite filling. The following night, one of my old med school classmates and I grabbed dinner at Wilde Bar and Restaurant (an Irish pub named after Oscar Wilde, the author), which was absolutely delicious. 

Naples, FL in December 2022

I also attended the American Academy of Addiction Psychiatry (AAAP) conference in December 2022 as part of the REACH program (Recognizing and Eliminating Disparities in Addiction through Culturally informed Healthcare). I have pursued participation in this program given my early life interest in and personal exposure to addiction in my own family. I started the Addiction Medicine Interest Group in medical school (at Loyola University Stritch School of Medicine) and really desired to bring greater awareness to students about the opioid crisis and the disease of addiction. I have a particular interest in examining how addiction, psychosocial stressors (including early life adversity), and other neuropsychiatric illnesses may play a role in the development of Alzheimer's Disease and other cognitive disorders. 

This trip was transformative. Outside of the conference, I unfortunately didn't have much time to explore (especially the food; I think I just grabbed P.F. Chang's for dinner one night, which was mediocre). 

New York, Jan 2023

I spent a week in NYC at the John Jay College of Criminal Justice for the R25 Multidisciplinary Conference on Child Abuse and Neglect. I gained a better understanding of how to maximize my learning as a future physician-scientist as I plan to actively address the impact of adverse childhood experiences (ACEs) in my clinical practice. I also broadened my understanding of the pressing public health problem of child maltreatment and NIH grant funding mechanisms and guidance for researchers in this area.  One of the biggest learning points for me during the week was the utility and strength of longitudinal studies in child abuse and neglect research. In the near future, I plan to work with multiple longitudinal retrospective cohorts of older adults and examine the associations between ACEs and cognitive impairment.

During the training institute, we had catered meals from really good places, including: 

• Hummus Kitchen (9th ave)
• Sophie's Cuban Cuisine 
• Two Boots Pizzeria 
• OBAO Noodles & BBQ
• Mint Masala 
• Pink's Cantina 
• Gracefully 

Asheville, NC

During a weekend in February, my boyfriend and I took a trip to Asheville. Some highlights: 

• Checking out a bookstore and purchasing a few good books, including "So You Want to Talk about Race?", which I'm hooked on right now.

• Grabbing brunch at The Med, which is quite possibly one of, if not the, best breakfast/brunch place I've been to. We both ordered French Toast, sausage, scrambled eggs (with cheese), and some fruit. Sounds like a basic breakfast, right? The sausage patties were seasoned to perfection, the scrambled eggs had the texture of soft clouds melting in our mouths, and the melted cheese was done perfectly. HIGHLY recommend this place if you're dropping by Asheville one day.

• On one of the days we grabbed dinner at 131 Main, a steak and seafood restaurant. I enjoyed the crab cakes and dessert (ice cream and brownie below), but my boyfriend felt that the slow roasted chicken left much to be desired.

Baltimore, MD

I was most recently at Hopkins for a workshop about disparities in Alzheimer's Disease and Related Dementias (ADRD). It was such a tremendously informative experience. 

The catered breakfasts and lunches were on point and through Rouge Fine Catering. The sandwiches and salads were delectable (i.e. potato egg salad, tuna, lime chicken, stuffed bell peppers).

For dinner on our own, I branched out and checked out a Mediterranean place called The Kabul Fresh Grill. Their fried ground beef samosas, shrimp salad, and mango lassi were out of this world. The following day I was craving a Cobb salad with chicken, so I ordered one from Huck's American Craft as well as a blueberry cobbler. It was a heavenly experience. 

From Coast to Coast - Addiction, Research, and Alzheimer's

San Diego, CA

Third year of residency has started off with a bang. I spent a few days in July at a research meeting in Minneapolis and another few days in DC for the REACH orientation program (Recognizing and Eliminating disparities in Addiction through Culturally informed Healthcare). In early August, I was fortunate to travel to San Diego for the Alzheimer's Association International Conference. To the right is the view from my hotel room. Isn't this unreal? 

Minneapolis

I flew to Minneapolis in early July for the Diversifying CNS Workshop, a program that is committed to retaining diverse investigators (including underrepresented minorities) in neuroscience research. It was nice not to experience the chilling winter weather that the Midwest is known for. In July, the sun was out, it was 70s, and the breeze felt amazing on my face (unlike in North Carolina where it is currently 90s and very sticky and humid). It was a refreshing time learning about the neuroscience research that the other participants (post-docs, early-stage investigators, and graduate students) are carrying out in their careers. The support and advice we offered to each other, as well as the community-building activities, were energizing. Outside of our 2-day meeting, I'm grateful for the chance to meet with a friend from high school who is currently a medical student at the University of Minnesota. We grabbed food from French Meadow, a nice, organic, cafe and bakery in Minneapolis. I am not a vegetarian, but the veggie burger from this place was the absolute bomb. On another night, I ordered takeout from Tea House, a popular Chinese restaurant nearby the Graduate Hotel. That Chinese food was also pretty bomb.

DC

After the 2-day stay in Minneapolis, I returned to NC for my afternoon Neurology clinic, then drove to DC the following morning to attend the orientation for REACH. REACH is an Addiction program that strives to build the capacity of the workforce to better care for racial and ethnic minoritized patients with substance use disorders. REACH stands for Recognizing and Eliminating Disparities in Addiction through Culturally Informed Healthcare. 

This orientation was much more broadly applicable to my career and personal life than I realized. Our discussion about the social determinants of mental health, in particular, completely transformed how I should be thinking about the broader policies and structures that contributed significantly to the inequities and disparities we are seeing in healthcare. It was incredible to hear Dr. Ruth Shim (from UC Davis, who actually gave one of the Duke Psych Grand Rounds) discuss how it is actually more important for us to consider the social determinants of health and the policies and structures that have affected our patients. 

San Diego - Alzheimer's Association International Conference

Finally, I left for San Diego very early the morning after a two-week stint on the consults service at the end of July. Highlights include the view from my hotel room (see photo above), networking, meeting people from all over the world (there were >7,000 registrants for the conference), learning about the latest research in the field of Alzheimer's, and the amazing jerk chicken I ordered from the Rock Steady Jamaican Restaurant. Am I crazy to not have known that there are Jamaicans in San Diego?! They make up a small part of the population, though. 

It was wonderful also meeting with a friend from medical school who is currently in residency at UC San Diego. We went to Oscar's Mexican Seafood, and the shrimp tacos were to die for. Ice cream at the Baked Bear also comes highly recommended.

JAR Year Part 2

I cannot believe it is already the end of my second year of residency. Where has the time gone? Stepping into my new role as a Neurology resident for the first time in July 2021 was overwhelming. Now, I can't believe I can say that I am able to go to a stroke code with a level head and clear mind, ready to help the primary team choose the next best course of action for the patient.

Below is a picture of many residents, fellows, and faculty in the Department of Neurology at Duke University Medical Center. (This is not the entire department.) It was such a privilege to stand next to these folks and celebrate our community that day (June 2022).

Duke Neurology
June 2022 

I'd like to share a couple of patient encounters this year that have left an indelible mark on me (many did, but these stood out a bit more).

To ensure HIPAA compliance, personally identifying information has been omitted/changed and certain details of these encounters have been modified to protect the patients and their families.

What Did You Just Say?

One day in Neurology clinic, I had a follow-up appointment with a patient for tremor. He was 80 years old and from rural North Carolina (about a two-hour drive away). Let's call him Mr. S. He always brought his daughter to the visits.

"How are you doing today, Mr. S?" I greeted the patient and his daughter warmly upon entering the room. Ie made my way over to the chair with the computer and we proceeded with our visit. I was glad to hear that he was doing well on the topiramate (an anti-seizure medication that is considered second or third-line for essential tremor). Initially, he tried propranolol, but he did not tolerate it due to gastrointestinal upset. Primidone was not tried because it could interfere with another medication he was taking for long-term immunosuppression after a transplant.

Mr. S was pleasant, though oftentimes he went on tangents about random topics, such as the part-time work he was still doing in construction and his family (he always bragged about his 18 grandchildren. Yes, 18). He could also be quite interruptive whenever I spoke (but not as interruptive of our male supervising attendings, might I add), so today I tried hard to keep us on track. 

Just as we wrapped up our chat and I began to stand to do the neurological exam, Mr. S started another story, this time about his previous neurologist. He spoke with disdain about this physician, who practiced closer to Mr. S's hometown two hours away. "The propranolol he gave me helped at first, but it really made me sick," Mr. S said. I wasn't quite sure why we were rehashing something that was already established several visits ago, but I quietly listened anyway. "You know, I don't like that neurologist. He was dark-skinned, from India."

Whoa. All I could do was stare at Mr. S. A million thoughts ran through my mind:

Is he even hearing what he's saying?! And to ME, no less?

If he doesn't like this other physician who is dark-skinned, then what is he trying to say to me about me?

How is this at all relevant to the visit?

Should I just cut him off and get back to the exam?

The neurologist might not be from India, maybe he's from another South Asian country, the Middle East, or even somewhere in Europe or Africa. Why the automatic assumption that this "dark-skinned" physician with "Indian" features is from India?

The latter thought was, in the grand scheme of things, an irrelevant response to Mr. S's completely inappropriate comment. I decided to counter with, "But I'm dark-skinned, Mr. S." Then I stared at him while resting my chin in my hand to see how he would respond to that. I just wanted him to have some semblance of self-awareness about the words that were coming out of his mouth.

Mr. S stumbled a little. "No, I know you're dark-skinned. But that's different. He's a foreigner, from Iraq or India or something like that. He was born out there. You're from here." 

I noticed that the daughter was completely silent this entire time. I couldn't help but wonder what she was thinking. Was she embarrassed about her father's behavior? 

I didn't have time for this nonsense. We were getting too far off track and I needed to see my next patient. I immediately changed the subject and brought us back to the issue at hand. When he returned to the clinic months later, we carried on as if he'd never made any racist comments and revealed his true self. I shared the story with a few of my colleagues and my family. My colleagues were astonished, and my family found it humorous. "Well, you're in the South, Deb," they told me. 

When I told my mother the story, her immediate question was, "Did your patient have any mental or cognitive issues?" In fact, he did not. All of his cognitive faculties were intact, but given his overt racist ideology, I'd argue that my mother wasn't too far off to wonder if he had some issues with his mind. Racism is a reflection of moral failure, likely lack of education and enriching exposure to cultural diversity throughout one's life, and quite frankly, utter stupidity. The foundation of racism is the belief that a group of people are inferior to another simply because they have more melanin in their skin.... and look "different". That's really what it comes down to. And that is foolishness.

It is easy for us to recognize the faults in our patients who might come to us with this ideology, but it's just as important for us to recognize any biases within ourselves. I'm personally passionate about addressing health disparities among groups that have experienced socioeconomic disadvantages historically, but I'm far from perfect myself. It should be our goal as providers to practice constant self-reflection and strive to recognize any ounce of bias within ourselves that can potentially impede our interactions with our patients or the care we're providing for them.

"The only way to prevent unconscious biases from influencing our actions is to scrutinize our social behaviors, even in situations when we believe ourselves to be above discrimination." - Donald Barr, MD, PhD, Health Disparities in the U.S. (2019).

Why So Stubborn?

Earlier this spring 2022, I saw a 70-year-old male patient in the Neurology clinic at the VA Hospital with one of our well-known attendings in the Department. When asked why he presented to our clinic for the first time, his response was a shrug and a "I don't know. It should be in the records." (I can't tell you how often we hear this, especially at the VA). Review of his medical records revealed that his primary care physician was concerned about memory and walking issues. The description in the note was scarce, but it did mention that he had a heavy drinking history. There was no other contact information in the chart. No one was listed as an emergency contact. The patient, who we will call Mr. M, came to the clinic visit alone. Whenever a patient is coming in with "memory issues", he/she should always come with a loved one who can provide collateral information.

I learned that Mr. M lived alone, was not married, had no children, did not have many friends, and did not speak to his family. Unfortunately, trying to speak with Mr. M about the memory issues was like a painful climb uphill. I was not getting anywhere, and the information he provided was not helpful.

I started off open-ended. "Mr. M, tell me about these memory problems you have been having."

"My memory is fine," he shrugged.

Great start.

I thought that offering some examples might be useful. "Have you been having any difficulty remembering things like conversations from earlier in the day, tasks that you need to complete throughout the day, or perhaps words that used to come quickly to your mind when speaking with others?"

"No."

"Have your family or friends ever expressed any concern about your memory?"

"I don't have no friends. And I don't talk to my family. My sister owes me $5,000."

"Do you have a support system around here?" I asked.

"I used to have friends. They would always just call me "crazy" whenever we went out to drink. So I don't hang out with them no more."

I waited for him to offer more information but none came. "What do you mean by 'crazy', Mr. M?" 

He shrugged. "I don't know, they just called me crazy."

Dear Lord. I began to feel like I was being punished. Again, I provided some options. "Did they call you crazy because of something you did? Was it the way you were dressed? Your speech? Did you drink too much? Why were they calling you crazy?"

"It wasn't because I drank too much. I don't know why."

"Can you think of anything at all, Mr. M?" I felt myself trying to control my annoyed tone. This was probably the best I was going to get for collateral information.

He paused. "Well, they thought I stumbled on my feet a lot, and that I'd say things that don't make sense."

OK maybe this was going somewhere. I decided to address the stumbling first. "Have you noticed that you've been stumbling on your feet too?"

Mr. M proceeded to describe, with more painful prompting, a picture of syncopal episodes; in his mind, however, the "blacking out" and frequent falling were due to vertigo. (Vertigo, by definition, refers to a sensation of false motion, which he did not at all describe). He refused to use a cane or any assistive walking device because it "made him feel old". (You are 70 years old, Mr. M, I wanted to say). “I just don’t have to fall backward and I’ll be good."

As for "saying things that don't make sense", he explained that months ago, his friends told him he'd forget conversations and had word-finding difficulties from time to time. Throughout all of this, he continued to dismiss his friends' concerns and adamantly state that his memory was fine. I couldn't help but wonder if a denial of the memory problems led him to cut off his friends.

He denied having any problems with his activities of daily living (bathing, dressing, toileting, eating) or instrumental activities of daily living (managing finances and medications, going grocery shopping, driving, etc). Truthfully, I didn't believe some of this because I could already tell that the information he provided wasn't very reliable. He reported drinking only 2 beers/day and 4 on the weekends (also didn't quite believe this given a significantly documented heavy drinking history). He scored a 16/30 on the Montreal Cognitive Assessment (MoCA), our most commonly used neurocognitive test in the Neurology clinic. 16/30 is a poor score, but the MoCA has cultural, language, and educational biases. His highest level of education was high school.

My attending (who has practiced neurology for over 40 years) and I spent a long time trying to convince Mr. M to speak with our Social Worker and see the cardiologists for his episodes of loss of consciousness that were consistent with syncope. He spent 20 minutes alone insisting to my attending (again, who has practiced neurology for over 40 years) that his "blackout" episodes were due to vertigo, not syncope. I grew frustrated after we spent a long time (and multiple times) trying to patiently explain the difference to him. This also wasn't the primary reason for the visit in the first place. 

While writing the note after the visit, I couldn't help but feel discouraged. My initial frustration turned into sadness. We diagnosed the patient with mild cognitive impairment and insisted that he speak with our Social Worker for resources (including an assistive device to help protect against the falls, and get plugged in to a VA support program for individuals with cognitive impairment. We felt particularly strongly about getting him connected to these resources because he had no family or friends around. I was discouraged because he was refusing help (which made me wonder why he even came to the appointment in the first place), and because there was a possibility in the near future he'd suffer another syncopal episode that could result in a massive head injury. Or continue to decline in his cognition, impairing his ability to even take care of himself and complete activities of daily living.

How do you help someone who doesn't want to be helped? This was a particularly challenging case because it hit close to home (I have had many personal experiences with struggling to help loved ones who do not wish to be helped), but I also found it galvanizing to strive to advocate for patients (especially those that have historically suffered from many social disadvantages) even when they cannot or refuse to demand for themselves the things they need to be in good health.

Neurology Junior Assistant Resident (JAR) Year Part 1

I am halfway through my second year of residency (first year of focused Neurology training), and I am both exhausted and thrilled to be doing what I love - saving people's brains (and spinal cords too, sometimes).

The learning curve as a JAR (Junior Assistant Resident) is much steeper. Not to mention the added responsibilities we are tasked with, including teaching interns and medical students, running to stroke codes, providing guidance to medical teams that have requested our expert advice on their patients, etc. 

As a PGY-2, I complete inpatient rotations such as Stroke, General Neurology, the Neurology consult service, the Neuroscience Intensive Care Unit, and outpatient rotations in neuroimmunology, headache, neurodegenerative (i.e. movement, memory disorders), and at the Durham VA Hospital. We also have a few weeks of elective time which we can use to complete rotations in certain sub-specialties and related areas such as neuro-ophthalmology, neuro-otology, sleep medicine, neuroradiology, and research. 

2021 was overall a tough year, what with the demands of residency and the stress of the persistent COVID pandemic, but truthfully, I am so grateful for the challenging experiences because they have made me into an even stronger and more mature individual. I am also grateful for my achievements this year, which would not have been possible without the mentorship of incredible faculty. This includes the Duke R38 Research Grant to study some of the mechanisms underlying racial disparities in Alzheimer's Disease. I appreciate the opportunity to share more about my research interests on the Duke website through a Resident Spotlight interview. I've grown more passionate about cognitive impairment over the last few years and decided to take up volunteering as a Community Educator through the Alzheimer's Association. 

I'm tired but these activities are fulfilling and honestly, they keep me going. Dr. Siddhartha Muckherjee's 2018 article in the NY Times entitled "For Doctors, Delving Deeper as a Way to Avoid Burnout" encapsulates how much the extracurricular pursuits we're passionate about can keep us engaged in our medical careers. Throughout the article, in discussing his and a few of his former medical school classmates' research pursuits, he states, "We survived, I think, by deepening our commitments to research. We tried to increase our mastery within peculiar medical niches. And powerful, autonomous interests kept us going." Importantly, however, the support of my family, friends, co-residents, and therapist has been critical for my mental health and overall survival in residency.

I cannot forget the sheer exhaustion I have experienced just over the past few months, especially during my time rotating through the Neurology consult service. I remember that one of my busiest nights was in early August 2021, a couple of months into my first year as a Neurology resident (PGY-2). Things got so crazy that I didn’t get the chance to eat for the entire night and I barely drank any water. (Truthfully, I could and should have taken a break but unwisely chose to power through). I only ate a raspberry cheesecake cookie from the Subway downstairs nearby our cafeteria. I’m not sure I even went to the bathroom. It was a busy night. We had about 5 stroke codes and 6 consults in 12 hours. I guess it could’ve been worse, but it was still bad.

By the way, just for reference, one consult alone takes a lot of time - it involves chart review, seeing the patient to chat with them about their illness and to do a physicial exam (or even contacting family members if the patient is not able to explain what brought them to the hospital), relaying recommendations to the primary team (main medical team that is taking care of the patient), assisting with the disposition (where the patient will end up, i.e. home, admission to the hospital, etc), and writing the consult note, which consists of documentation of the HPI (history of present illness: the patient's narrative), physical exam, and assessment and plan. All of this can take quite some time.

Regardless, when I am woken up out of sleep and have to drag myself out of the cozy, dark, and warm on-call room to see that 3AM seizure consult in the emergency room, I remind myself why I chose this career in the first place.... and all becomes right in the world once more. It's truly a privilege to see patients who are suffering from neurologic emergencies and conditions like stroke, seizure, acute demyelinating diseases in the brain or spinal cord, etc, and to be able to get them the treatment they need (i.e. thrombectomy to remove the clot that's causing the stroke, anti-seizure medication, steroids for the demyelinating diseases such as multiple sclerosis, etc).

Localization in neurology is also pretty cool (and scary, depending on how you look at it). Believe it or not, one very tiny stroke in a small part of the brain (i.e. brainstem) can cause multiple tremendously debilitating symptoms, such as eye problems, weakness, speech changes, sensory deficits, and/or other symptoms. 

Stroke is certainly the biggest neurologic issue that we deal with and are consulted for in the hospital. What's the biggest risk factor for stroke? High blood pressure. Other risk factors include high cholesterol, diabetes, obesity, obstructive sleep apnea, heart disease, tobacco use, etc. We have to get our blood pressure under control! Let's also get that cholesterol under control by modifying what we consume on a regular basis. Let's try to be more active in our day-to-day as well. And the diabetes? We need to keep that in check too. If you snore and are overweight, you might consider asking your doctor to order a sleep study for you (keep in mind though that sleep apnea can also occur in people who are not overweight). If you have sleep apnea, that needs to be treated. Stop smoking! Go to your follow-up doctor visits. Take your medications. It's simple! An estimated 80% of strokes are preventable. Can you believe that?

Anyway, I'll get off my soapbox now. I will try to post another entry sometime this spring highlighting some interesting cases.

Thanks for reading! :)