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Editorial commentary

Clinical neurology: a changing role? Michael Swash Nicholl and Appleton1 suggest that the classical technique of history and examination, a skill assiduously acquired by generations of physicians, perhaps especially by neurologists, has begun to fall into disuse, even neglect. This is not a new issue, but has it become more evident as the scope, sensitivity and accuracy of diagnostic investigations, especially neuroimaging, has increased? Neurologists do not follow the ‘full examination’ protocol described in undergraduate textbooks2 but use heuristic processes to shortcut the process.3 Thus, the old adage ‘if you don’t know the diagnosis a few minutes after you meet the patient you probably never will’. Imaging has changed this dependence on clinical intuition but, as the late Bryan Matthews wrote in his little book, Practical Neurology, ‘if (investigations) can be carried out by the signing of a form requesting someone else to do them there is a temptation to obtain as much information as possible by this simple method’.4 However, therein lies much cost to the healthcare funder, and not a little potential discomfort to the patient, plus a wealth of possibly conflicting information.5 In an era when diagnosis may be established by scientific tests, the clinical assessment has a rather different role. Granted, it should direct investigation, but in reality the patient presents Correspondence to Professor Michael Swash, Department of Neurology, The Royal London Hospital, The Royal London Hospital, London EC2Y 8BL, UK; [email protected]

not with a diagnosis but with symptoms and disabilities. The physician’s role is to manage these problems and, hopefully, to reverse them. Thus, the neurologist will treat spasticity, pain, seizures, headache, neurogenic bladder problems, dizziness and dementia as problems in their own right. Although treatment of an underlying causative condition may be helpful, too often the underlying cause, even in 2014, will not be directly curable. It is, therefore, the patient’s understanding of their problem, not the academic diagnosis, that is of cardinal importance.4 The story given by the patient represents the database from which all else stems.2 3 Nicholl and Appleton1 rightly make the point that economically efficient assessment, driven by careful clinical assessment, is good for the healthcare system, and also for the healthy taxpayer’s pocket, but this is not something that is of concern for the patient and their family. Understandably, they simply want the best regardless of cost. Such aspirations may lead to a mismatch between expectation and outcome, and therefore to escalating medicolegal costs. The clinical assessment is driven by the patient’s account of the problem, the history. For example, in a patient with sciatica, don’t start with funduscopy. The issue we face today is simply an extension of previous debates. How should the rapidly evolving modern investigations be integrated into diagnosis and management? This problem will not go away, and it will be the focus of coming contemporary political discussion in developed

Western countries, and perhaps especially in countries with smaller budgets. Nicholl and Appleton promote medical education as the way forward, but the issues are wider than that. They deserve much further research to derive algorithms for effective and sustainable usage of healthcare budgetary resources. Competing interests None. Provenance and peer review Commissioned; internally peer reviewed.

To cite Swash M. J Neurol Neurosurg Psychiatry 2015;86:123. Received 5 May 2014 Accepted 17 May 2014 Published Online First 4 June 2014

▸ http://dx.doi.org/10.1136/jnnp-2013-306881 J Neurol Neurosurg Psychiatry 2015;86:123. doi:10.1136/jnnp-2014-308495

REFERENCES 1

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4 5

Swash M. J Neurol Neurosurg Psychiatry February 2015 Vol 86 No 2

Nicholl DJ, Appleton JP. Clinical neurology: why this still matters in the 21st century. J Neurol Neurosurg Psychiatry 2015;86:229–33. McCauley J, Swash M. Nervous system. In: Swash M, Glynn M, Eds. Hutchison’s clinical methods; an integrated approach to clinical practice. 22nd edn. Edinburgh: Saunders Elsevier,2007;178–247. Vickrey BG, Samuels MA, Ropper AH. How neurologists think: a cognitive psychology perspective on missed diagnosis. Ann Neurol 2010;67:425–33. Matthews B. Practical neurology. Oxford: Blackwell Scientific Publications, 1963;1–256 ( page 2). Pewsner D, Battaglia M, Minder C, et al. Ruling a diagnosis in or out with “SpPin” and “SnNOut”: a note of caution. BMJ 2004;329:209–13.

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Clinical neurology: a changing role? Michael Swash J Neurol Neurosurg Psychiatry 2015 86: 123 originally published online June 4, 2014

doi: 10.1136/jnnp-2014-308495 Updated information and services can be found at: http://jnnp.bmj.com/content/86/2/123

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