Dante Alighieri, the author of The Divine Comedy, had a guide, Virgil, the Roman poet, who escorted him through hell, purgatory, and heaven. At least metaphorically, we all have been there at some level, at some time, and in some way. As neurologists, we have had our own guides: mentors, colleagues, and students. However, the guidance from poets is different.
As doctors and scientists, we work to expand knowledge and poets seek not expansion but compression, into essentials. What are the essentials in medicine, research, and life? Different answers apply to everyone, but I will share mine.
Since antiquity, poets echoed the thought that “In the end, there is only love,” a sentiment expressed by other poets in different ways and with different meanings. Mine is not the Greek “eros” of romantic love, but “agape,” selfless love, of family, friends, country, and other human beings.
One of the first lessons one learns in medicine is its limitations; there is only so much that one can do for our patients. Then, we learn that our most grateful patients are not the ones we do the most for, that is expected from modern medicine, but the ones we can do the least for, whom we offer our deeply felt empathy or love.
Another early lesson is to always tell the truth. Trust can only be lost once. However, the truth does not have to be delivered like a news bulletin. Here, another poet can be a guide. T.S. Eliot wrote “Humankind cannot bear much reality” not initially, but if offered gradually, sympathetically, and truthfully, we will keep the patients’ trust, and when we cannot cure, we can comfort.
Most of us are researchers, whether implicitly or explicitly. After all, every day when we see a patient, we gather the information, make a hypothesis as to the diagnosis, and try to confirm it. That is the scientific method, the foundation of most research. Here, Andrés Eloy Blanco, a beloved Venezuelan poet, can be a guide. He states, “Unravelling embroideries, I will re-grasp the thread.”
Many of us have had the experience of being asked to give a second, third, or even more opinions about patients who have attended famous clinics. Typically, they would have had a “workup”—a large series of tests, many unnecessary, risking having false-positive results. Many laboratory test thresholds are set at a probability of 0.05, meaning that if one does 20 tests, one will be out of bounds. That test, in turn, has to be explored by other tests, and if another 20 tests are done, another one will be out of bounds and so on. Eventually, after chasing irrelevant results, the doctor is back to the start and the confused patient off to another opinion.
Finally, the patient may get a physician willing to “unravel embroideries and regrasp the thread.” The doctor sets aside all irrelevancies and begins with a new history and examination, formulates a hypothesis, and examines selectively what has been done. More often than not, comes up, if not with a definite answer, a definite plan that most patients will be relieved to accept.
One of my experiences illustrates the point. A number of years ago, I was asked to see an important general in a South American country. The story was that he was walking on the beach and became aware of weakness in his right arm. He was seen by his military doctor who had qualified as a general practitioner. The doctor made a diagnosis but referred the general to a specialist because he did not want to risk missing an alternate diagnosis given the general’s importance. The same applied to the sequential specialists who saw the general. They did not spare the tests. The tests included a myelogram, a cerebral angiogram, and a spinal angiogram, a risky procedure. Each of the tests had incidental findings that posed additional questions that no one could resolve definitely, again for the fear of being wrong.
I was taken to see the patient in great secrecy, my hosts fearing that if the word got out that a foreign specialist was seeing the general, people would conclude that the general must be very sick.
I was offered a thick binder of his medical records and a pile of X-rays and results of tests. I said that I would look at them later.
I speak Spanish so I was able to take a history from the beginning and conduct a detailed examination. Then I asked for the plain X-ray of the cervical spine and agreed with the initial diagnosis of the military physician of “cervical spondylosis.”
I did not want to run the risk of being wrong either, so I browsed through the relevant tests to make sure that I had not missed anything. I had not.
The patient had recovered, and his confidence in his doctor was renewed. I was glad it was so straightforward, but it made me reflect. Poor people often do not get good health care because they do not get to see a doctor. Ironically, rich individuals might not get good care either because they see too many doctors. I saw many more examples of this after providing a definite diagnosis to the relieved and grateful general.
The best bargain in neurology remains a good clinician who empathizes with the patient, takes a thorough history, and conducts a focused examination, ordering the least number of investigations that will confirm the diagnostic hypothesis.
The poetic principles of distilling complexities in essentials also apply to research. When I finished training in neurology in Canada, I went to the National Hospital for Nervous Diseases, Queen Square, London, England. I had become interested in patients who had acute stroke and wanted to learn cerebral blood flow techniques to study them. I was told that stroke was not a neurologic condition and that patients who had stroke were not admitted to Queen Square. At the time, a controversy raged in the British medical literature as to whether patients who had stroke should be admitted to any hospital at all because nothing could be done for them. My professor said that if I wanted to do a project in 6 months, it could only be on dementia. He offered me a choice; take it or leave it. I took it and began reading the literature on dementia. Apart from specific syndromes such as Picks disease, there were no agreed definitions of vascular dementia (then the dominant paradigm) or senile dementia, the other main ill-defined category. I remembered Andrés Eloy Blanco’s “undoing embroideries, I will re-grasp the thread” and concluded that when vascular dementia caused dementia, it was through the agency of multiple infarcts.1 The importance of the concept was that some strokes were preventable even then, so by preventing stroke, we could also prevent some dementias.
Since that time, acute stroke has become highly treatable; patients who have stroke are admitted to Queen Square; and the first professor of cerebrovascular medicine in the United Kingdom was Martin Brown, one of my British stroke fellows. Our dementia study showed that there was no evidence of chronic ischemia in “vascular dementia”2 that marked the beginning of the end of a “cerebral vasodilators” industry. It had grown on the false assumption that there was chronic ischemia in the brain and that their products improved brain blood flow and the symptoms of dementia. Actually, they only improved the cash flow of the drug manufacturers.
The dominant vascular paradigm was replaced by an even more commanding one. Science thrives on hypotheses, and on their proof or rejection, and yet it can also fall victim to a phenomenon that the German polymath and poet Johannes Wolfgang Goethe (1749–1832) warned about in the 18th century:For at the point where concepts fail.
At the right time a word is thrust in there.
With words we fitly can our foes assail.
With words a system we prepare.
One such system is “Alzheimer disease” in older adults. Whatever it is, it is not an entity. The typical case of “Alzheimer disease” harbors up to 8 pathologies, and even these only explain two-thirds of the cognitive impairment.3 Four decades and billions of dollars later, the amyloid hypothesis has yielded not a silver bullet drug but lecanemab, with questionable clinical effects and unquestionable costs and complications.
However, recognizing the fact that dementia in older adults is multifactorial poses a knotty problem. So, how do we cut through this Gordian knot and “unravel embroideries and regrasp the thread?” One way is through the concept of “vascular cognitive impairment,” that is, any vascular cause or risk factor associated with dementia.4,5 Of all the known pathologies contributing to dementia, the only treatable and preventable one is the vascular, and we know how to treat and prevent it effectively.
One method of identifying the vascular, and hence the highly treatable and preventable component, is applying the ischemic score.2,6 In the embroideries of dementia, the vascular remains the sinewy binding thread as it does for stroke and ischemic heart disease, with which dementia shares the same treatable and preventable risk and protective factors providing a rationale for preventing them together.7
Finally, what do poets have to tell as a guide to life?
As our careers culminate and our responsibilities wane, we gain increasing freedom to pursue what we truly love: some part of our profession, a hobby, or spending time with renewed appreciation with family and friends. As T.S. Eliot put it,We shall not cease from exploration.
And the end of all our exploring.
Will be to arrive where we started.
And know the place for the first time.
As the poet said, “In the end, there is only love.”
- Received February 2, 2023.
- Accepted in final form May 10, 2023.
- © 2023 American Academy of Neurology
