“ Of course , my apologies .” Classic . It would probably make sense to wait for a response to the knock before entering , dude .
I wait for a few moments until the nurse walks out .
With a handshake and a smile , I introduce myself as the medical student working on neurology . The daughter is receptive , but I notice the patient ( Mom ) is a bit withdrawn and has a flat affect .
I ask Mom some questions from her HPI and inquire about any updates overnight . No acute events . Good . I give them both a rundown as to what the latest labs and tests have shown and then proceed to the beloved neurologic examination . The neurologic exam can be a bear , but it is gratifying once you ’ re proficient at it . Perhaps with more than any other exam , you can glean a lot of specific information to help narrow your differential diagnoses .
Remembering what my resident told me , I make sure to include some Parkinson specific maneuvers : testing for cogwheel rigidity , resting tremor , slowed movements and shuffling gait . I noted what I thought was cogwheel rigidity , but her gait was normal , and she did not have a resting tremor . Other than a slight intention tremor , the rest of her neurological exam was unremarkable .
The daughter had some questions for me about Parkinson ’ s disease . I sat down , put my reflex hammer aside and listened . She asked the all too familiar phrase in medicine :
“ Does she have it ?”
I talked to both about what Parkinson ’ s disease is . I explained the loss of dopaminergic neurons , the symptoms required to make the diagnosis and the general prognosis . I explained to them that the only finding I deemed concerning was the cogwheel rigidity . I also reiterated what the other tests had showed up to that point .
The EEG did not show any abnormalities , and there was no mention of a postictal state in the HPI , thus we had reason to be less suspicious of seizures . From a cardiac standpoint , her echocardiogram reflected a good ejection fraction , but the EKG demonstrated some suspicious conduction abnormalities . In summary , I felt her syncope was more likely cardiac related than neurologic , and this possibility of Parkinsonism could just be an incidental finding . Knowing that Parkinsonism exists on a spectrum with many different subtypes ( could I have stumbled upon a case of multiple systems atrophy ??) I didn ’ t want to get too cocky .
“ My attending will come by later this morning to give his assessment and answer any other questions you may have ,” I assure them .
I felt the daughter ’ s gaze soften when I made eye contact . The patient nodded her head in understanding . They smiled and thanked me profusely for sitting down and talking to them — about Parkinson ’ s disease and about the significance of the various tests that had been performed . There was a much different energy leaving the room now than when I had walked in initially . It felt as if no matter what the day was to bring , they were ready for it .
I left the room smiling .
The rest of the morning was slow . Rounding came quickly , and I was curious to see what my attending thought about my patient .
As it turns out , my attending felt that the cogwheel rigidity that I ( along with my resident ) perceived on the exam was really muscle hypertonia and voluntary resistance . When the attending got her to loosen up fully , he did not appreciate any cogwheeling . What a relief . The patient relayed to the attending that she had a good understanding of what the other tests meant – her daughter glanced at me and smiled .
At 3:00 p . m ., my residents decided to set me loose . I took the elevators down to the first floor . Another shift in the books . I walked through the sliding doors that I had walked through just hours ago . The cold air hit my face . Retracing my morning steps , I begin to recount the day . Despite the attending ultimately disagreeing with my assessment , I felt like I was a pivotal player in the care of my patient . At this stage of training , I often find myself in this sort of mixture of emotions .
There ’ s always the scrutinizing over failures — real or self-perceived . Something as simple as finding differences on an exam with an attending can shoot this scrutiny into full force . Yet on the other hand , I am proud of the conversation I executed with the patient and her daughter . I felt competent , compassionate and in command . I ’ ve come to realize that intense reflection is a critical component to sculpting a proper physician . The only person a physician talks to more than his patients is himself . This internal process has dominated my third year .
Brain MRI is complicated … what is GRE and T2 again ? It often takes me longer to sift through the overnight labs . My list of differentials may be a diagnosis short — even shorter is my white coat next to my attending ’ s . And somehow my reflex hammer doesn ’ t always work like the residents ’ does .
But I know what Parkinson ’ s disease is . I cannot yet give a patient a therapy , but I can give them my time . I can sit down and explain things . Imparting some of the knowledge I have amassed grants me the ability to empower patients . And if I ’ m lucky I ’ ll receive in return an outward hint that I made them feel better : a smile , thank you or handshake . I ’ ll have a moment to hold onto , and that ’ s good enough for me right now .
That ’ s the best part of my day .
“ You got your passion , you got your pride But don ’ t you know that only fools are satisfied ? Dream on , but don ’ t imagine they ’ ll all come true ( Oooh )
When will you realize , Vienna waits for you ?”
Cole Dowdy is a fourth-year medical student at the University of Louisville School of Medicine .
This essay was a submission to the 2023 Richard Spear , MD , Memorial Essay Contest .
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