Allan M. Block, MD

A recent study on the JAMA Network found that, as primary care doctor visit times shorten, the likelihood of inappropriate prescribing of antibiotics, opioids, and benzodiazepines increases.

Does this surprise anyone?

One of my friends, a pharmacist, has a sign in his home office: “Fast. Accurate. Cheap. You can’t have all 3.” A true statement. I’ve also seen it at car repair places, but they’re doctors in their own way.

The problem here is that physicians are increasingly squeezed for time. If your only revenue stream is seeing patients, and your expenses are going up (and whose aren’t?) then your options are to either raise your prices or see more patients.

Of course, raising prices in medicine can’t happen for most of us. We’re all tied into insurance contracts, which themselves are pegged to Medicare, as to how much we get paid. I mean, yes, you can raise your prices, but that doesn’t matter. The insurance company will still pay a predetermined amount set years ago, in better economic times, no matter what you charge.

So the only real option for most is to see more patients. Which means less time with each one. Which, inevitably, leads to more snap judgments, inappropriate prescriptions, and mistakes.

Patients may get Fast and Cheap, but Accurate gets sidelined. This is the nature of things. If you don’t have enough time to gather and process data, then you’re less likely to reach the right answer.

There’s also the fact that sometimes it’s easier for anyone to just take the path of least resistance. The patient wants an antibiotic, and you realize it’s going to take less time to hand them a script for one than to explain why they don’t need it for what’s probably a viral infection. Not only that, but then you run the risk of their giving you a bad Yelp review (“incompetent, refused to give me antibiotics when I obviously needed them, 1 star”) and who needs that? If you’re employed by a large health care system a bad online review will get you a talking-to by some nonmedical admin from marketing, saying you’re hurting the practice’s “brand.”

Years ago the satire site The Onion had an article about a doctor who specialized in “giving a shit” - assumedly where Accurate dominates. While none of us may intentionally rush through patients or do half-assed jobs, we also have to deal with pressures of time. There never seems to be enough in a workday.

Nowhere is this more true than in primary care, where the pressures of time, overhead, and a large patient volume intersect. There are patients to see, labs to review, phone calls to return, forms to complete, meetings to attend, samples to sign for ... and probably many other things I’ve left out.

The fact that this situation exists shouldn’t surprise anyone. People talk about “burnout” and “making health care better” but that just seems to be lip service. They give you a free subscription to a meditation app, phone access to a counselor, and a mandatory early morning meeting to discuss stress reduction. Of course, these things take time away from seeing patients, which sort of defeats the whole purpose. Unless you want to do them at home – taking time away from your family, or doing the taxes, or other things you have to do besides your day job.

This is not sustainable for patients, doctors, or the health care system as a whole. But right now the situation is only getting worse, and there aren’t any easy answers.

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

A recent study on the JAMA Network found that, as primary care doctor visit times shorten, the likelihood of inappropriate prescribing of antibiotics, opioids, and benzodiazepines increases.

Does this surprise anyone?

One of my friends, a pharmacist, has a sign in his home office: “Fast. Accurate. Cheap. You can’t have all 3.” A true statement. I’ve also seen it at car repair places, but they’re doctors in their own way.

The problem here is that physicians are increasingly squeezed for time. If your only revenue stream is seeing patients, and your expenses are going up (and whose aren’t?) then your options are to either raise your prices or see more patients.

Of course, raising prices in medicine can’t happen for most of us. We’re all tied into insurance contracts, which themselves are pegged to Medicare, as to how much we get paid. I mean, yes, you can raise your prices, but that doesn’t matter. The insurance company will still pay a predetermined amount set years ago, in better economic times, no matter what you charge.

So the only real option for most is to see more patients. Which means less time with each one. Which, inevitably, leads to more snap judgments, inappropriate prescriptions, and mistakes.

Patients may get Fast and Cheap, but Accurate gets sidelined. This is the nature of things. If you don’t have enough time to gather and process data, then you’re less likely to reach the right answer.

There’s also the fact that sometimes it’s easier for anyone to just take the path of least resistance. The patient wants an antibiotic, and you realize it’s going to take less time to hand them a script for one than to explain why they don’t need it for what’s probably a viral infection. Not only that, but then you run the risk of their giving you a bad Yelp review (“incompetent, refused to give me antibiotics when I obviously needed them, 1 star”) and who needs that? If you’re employed by a large health care system a bad online review will get you a talking-to by some nonmedical admin from marketing, saying you’re hurting the practice’s “brand.”

Years ago the satire site The Onion had an article about a doctor who specialized in “giving a shit” - assumedly where Accurate dominates. While none of us may intentionally rush through patients or do half-assed jobs, we also have to deal with pressures of time. There never seems to be enough in a workday.

Nowhere is this more true than in primary care, where the pressures of time, overhead, and a large patient volume intersect. There are patients to see, labs to review, phone calls to return, forms to complete, meetings to attend, samples to sign for ... and probably many other things I’ve left out.

The fact that this situation exists shouldn’t surprise anyone. People talk about “burnout” and “making health care better” but that just seems to be lip service. They give you a free subscription to a meditation app, phone access to a counselor, and a mandatory early morning meeting to discuss stress reduction. Of course, these things take time away from seeing patients, which sort of defeats the whole purpose. Unless you want to do them at home – taking time away from your family, or doing the taxes, or other things you have to do besides your day job.

This is not sustainable for patients, doctors, or the health care system as a whole. But right now the situation is only getting worse, and there aren’t any easy answers.

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

A recent study on the JAMA Network found that, as primary care doctor visit times shorten, the likelihood of inappropriate prescribing of antibiotics, opioids, and benzodiazepines increases.

Does this surprise anyone?

One of my friends, a pharmacist, has a sign in his home office: “Fast. Accurate. Cheap. You can’t have all 3.” A true statement. I’ve also seen it at car repair places, but they’re doctors in their own way.

The problem here is that physicians are increasingly squeezed for time. If your only revenue stream is seeing patients, and your expenses are going up (and whose aren’t?) then your options are to either raise your prices or see more patients.

Of course, raising prices in medicine can’t happen for most of us. We’re all tied into insurance contracts, which themselves are pegged to Medicare, as to how much we get paid. I mean, yes, you can raise your prices, but that doesn’t matter. The insurance company will still pay a predetermined amount set years ago, in better economic times, no matter what you charge.

So the only real option for most is to see more patients. Which means less time with each one. Which, inevitably, leads to more snap judgments, inappropriate prescriptions, and mistakes.

Patients may get Fast and Cheap, but Accurate gets sidelined. This is the nature of things. If you don’t have enough time to gather and process data, then you’re less likely to reach the right answer.

There’s also the fact that sometimes it’s easier for anyone to just take the path of least resistance. The patient wants an antibiotic, and you realize it’s going to take less time to hand them a script for one than to explain why they don’t need it for what’s probably a viral infection. Not only that, but then you run the risk of their giving you a bad Yelp review (“incompetent, refused to give me antibiotics when I obviously needed them, 1 star”) and who needs that? If you’re employed by a large health care system a bad online review will get you a talking-to by some nonmedical admin from marketing, saying you’re hurting the practice’s “brand.”

Years ago the satire site The Onion had an article about a doctor who specialized in “giving a shit” - assumedly where Accurate dominates. While none of us may intentionally rush through patients or do half-assed jobs, we also have to deal with pressures of time. There never seems to be enough in a workday.

Nowhere is this more true than in primary care, where the pressures of time, overhead, and a large patient volume intersect. There are patients to see, labs to review, phone calls to return, forms to complete, meetings to attend, samples to sign for ... and probably many other things I’ve left out.

The fact that this situation exists shouldn’t surprise anyone. People talk about “burnout” and “making health care better” but that just seems to be lip service. They give you a free subscription to a meditation app, phone access to a counselor, and a mandatory early morning meeting to discuss stress reduction. Of course, these things take time away from seeing patients, which sort of defeats the whole purpose. Unless you want to do them at home – taking time away from your family, or doing the taxes, or other things you have to do besides your day job.

This is not sustainable for patients, doctors, or the health care system as a whole. But right now the situation is only getting worse, and there aren’t any easy answers.

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

I was (probably) the bane of my elementary school nurse.

I hated PE (I know, who didn’t?). But I also had childhood asthma. So it was an easy out to go to the school nurse, Mrs. Reed, because I was having an asthma attack, or at least claiming to have one.

She’d put me in a chair to “keep an eye” on me, occasionally have me take the prescription drug my pediatrician had ordered (Marax – anyone else remember that?), and knew to send me back to class about 5 minutes before PE was over.

Maybe Mrs. Reed liked me. Maybe it was just the path of least resistance to let me dodge PE. Maybe she’d hated PE, too, and was sympathetic. Who knows?

So twice a week through years of elementary school she and I went through the same routine of my showing up in her office. No matter how busy she was, she always told me to take a seat and do a therapeutic application of her stethoscope. She often told others who noticed my frequent visits that I was “a sickly child” even though I knew she saw through me and said it with a sense of sarcasm and humor.

Of course, life goes on, and one day 20 years ago Mrs. Reed showed up on my hospital census as a new consult after she’d had a minor stroke.

She remembered me very well. Her first comment, said with the same tone I recalled, was that she was amazed I’d lived to adulthood after having been such “a sickly child.” We both laughed.

Now, in her late 80s, she still comes to see me for this and that. Sometimes we reminisce about the intertwined journey our lives have taken us on. Sometimes she asks if I’ve been to PE recently.

Like any patient, she occasionally shows up on the wrong day, or at the wrong time. I always do my best to see her, though.

After all, I owe her big time for letting me dodge PE.

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

I was (probably) the bane of my elementary school nurse.

I hated PE (I know, who didn’t?). But I also had childhood asthma. So it was an easy out to go to the school nurse, Mrs. Reed, because I was having an asthma attack, or at least claiming to have one.

She’d put me in a chair to “keep an eye” on me, occasionally have me take the prescription drug my pediatrician had ordered (Marax – anyone else remember that?), and knew to send me back to class about 5 minutes before PE was over.

Maybe Mrs. Reed liked me. Maybe it was just the path of least resistance to let me dodge PE. Maybe she’d hated PE, too, and was sympathetic. Who knows?

So twice a week through years of elementary school she and I went through the same routine of my showing up in her office. No matter how busy she was, she always told me to take a seat and do a therapeutic application of her stethoscope. She often told others who noticed my frequent visits that I was “a sickly child” even though I knew she saw through me and said it with a sense of sarcasm and humor.

Of course, life goes on, and one day 20 years ago Mrs. Reed showed up on my hospital census as a new consult after she’d had a minor stroke.

She remembered me very well. Her first comment, said with the same tone I recalled, was that she was amazed I’d lived to adulthood after having been such “a sickly child.” We both laughed.

Now, in her late 80s, she still comes to see me for this and that. Sometimes we reminisce about the intertwined journey our lives have taken us on. Sometimes she asks if I’ve been to PE recently.

Like any patient, she occasionally shows up on the wrong day, or at the wrong time. I always do my best to see her, though.

After all, I owe her big time for letting me dodge PE.

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

I was (probably) the bane of my elementary school nurse.

I hated PE (I know, who didn’t?). But I also had childhood asthma. So it was an easy out to go to the school nurse, Mrs. Reed, because I was having an asthma attack, or at least claiming to have one.

She’d put me in a chair to “keep an eye” on me, occasionally have me take the prescription drug my pediatrician had ordered (Marax – anyone else remember that?), and knew to send me back to class about 5 minutes before PE was over.

Maybe Mrs. Reed liked me. Maybe it was just the path of least resistance to let me dodge PE. Maybe she’d hated PE, too, and was sympathetic. Who knows?

So twice a week through years of elementary school she and I went through the same routine of my showing up in her office. No matter how busy she was, she always told me to take a seat and do a therapeutic application of her stethoscope. She often told others who noticed my frequent visits that I was “a sickly child” even though I knew she saw through me and said it with a sense of sarcasm and humor.

Of course, life goes on, and one day 20 years ago Mrs. Reed showed up on my hospital census as a new consult after she’d had a minor stroke.

She remembered me very well. Her first comment, said with the same tone I recalled, was that she was amazed I’d lived to adulthood after having been such “a sickly child.” We both laughed.

Now, in her late 80s, she still comes to see me for this and that. Sometimes we reminisce about the intertwined journey our lives have taken us on. Sometimes she asks if I’ve been to PE recently.

Like any patient, she occasionally shows up on the wrong day, or at the wrong time. I always do my best to see her, though.

After all, I owe her big time for letting me dodge PE.

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

A few weeks ago I wrote about my glasses and the discovery that they’d been made incorrectly. The headline for the story was “The Way I See It.”

That’s the opening line from Joni Mitchell’s 1974 song “Free Man in Paris.” But I grew up in a Neil Diamond household (Dad always had Neil Diamond on when he was working at home) so the first time I heard the song was in 1977, when Diamond covered it. In fact, I didn’t even realize it was originally Mitchell’s song until I was in my 50s.

It’s about a world that doesn’t exist anymore.

The song is about music promoter David Geffen and a trip he took to Paris. Back in southern California, he was always working. There were continual phone calls, deals, meetings, and people looking for favors.

But on his trip to Paris in the early 1970s, he became just another person. No one could find him to ask for help or cut a deal. He couldn’t be reached. He felt “unfettered and alive” and could go from “cafe to cabaret,” relax, and enjoy himself.

Medical practice was once that way. You’d check-out patients to your call partners, leave town, and relax for a week or two.

Try doing that today.

For better or worse, all of us now are attached to our phones. We even have a new psychiatric condition – nomophobia – for the fear of not having our mobile phone handy. Every time I leave my house or office I repeat a simple mantra “phone, wallet, keys” as I pat my pockets.

Unless you can part with your gadget – which ain’t easy – no one is a “free man in Paris” (or Tokyo, or Rio, or Beijing) anymore. Even ships have cell service at sea. There are still places on Earth remote enough that you can’t be reached, but they get fewer and smaller every year.

When was the last time you really went somewhere and had no communication with your office at all? Emails, texts, anything? Unless you’re in a shift-work branch of medicine, like ER or hospitalist, I’m going to guess it’s been a while. And even in those branches you probably get emails about administrative matters, scheduling questions, and pointless memos.

Being in solo practice I’ve come to accept this, but it’s a conscious decision on my part. It’s easier than finding a call partner, and if I’m handling my own stuff at least I’m not going to come home to any surprises. So I’ve covered patients from as far west as Hawaii, north as Juneau, south as Panama City, and east as Le Havre.

Granted, this is medicine, and many other jobs don’t require the degree of involvement that it does. But I suspect pretty much any professional - attorney, accountant, executive - still has to deal with work-related stuff while traveling. Back in the 1970s to 1980s my dad, a solo-practice lawyer, had a set time each vacation weekday afternoon where he’d call his secretary to go over stuff. Today it would be by email or texts.

We’ve done this to ourselves. We’ve accepted the trade-off of better connectivity with family and friends for expanding our time at work. The same technology that lets me send in prescription refills from London also lets me send family pictures back from Maui. It’s not easy to draw a solid line between them, and I’m not so sure many of us want to.

Today, 50 years after Ms. Mitchell wrote the song, the idea of being a “free man in Paris” – or anywhere – really doesn’t exist for most of us anymore. You can argue whether that’s good or bad, but it’s where we are.

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

A few weeks ago I wrote about my glasses and the discovery that they’d been made incorrectly. The headline for the story was “The Way I See It.”

That’s the opening line from Joni Mitchell’s 1974 song “Free Man in Paris.” But I grew up in a Neil Diamond household (Dad always had Neil Diamond on when he was working at home) so the first time I heard the song was in 1977, when Diamond covered it. In fact, I didn’t even realize it was originally Mitchell’s song until I was in my 50s.

It’s about a world that doesn’t exist anymore.

The song is about music promoter David Geffen and a trip he took to Paris. Back in southern California, he was always working. There were continual phone calls, deals, meetings, and people looking for favors.

But on his trip to Paris in the early 1970s, he became just another person. No one could find him to ask for help or cut a deal. He couldn’t be reached. He felt “unfettered and alive” and could go from “cafe to cabaret,” relax, and enjoy himself.

Medical practice was once that way. You’d check-out patients to your call partners, leave town, and relax for a week or two.

Try doing that today.

For better or worse, all of us now are attached to our phones. We even have a new psychiatric condition – nomophobia – for the fear of not having our mobile phone handy. Every time I leave my house or office I repeat a simple mantra “phone, wallet, keys” as I pat my pockets.

Unless you can part with your gadget – which ain’t easy – no one is a “free man in Paris” (or Tokyo, or Rio, or Beijing) anymore. Even ships have cell service at sea. There are still places on Earth remote enough that you can’t be reached, but they get fewer and smaller every year.

When was the last time you really went somewhere and had no communication with your office at all? Emails, texts, anything? Unless you’re in a shift-work branch of medicine, like ER or hospitalist, I’m going to guess it’s been a while. And even in those branches you probably get emails about administrative matters, scheduling questions, and pointless memos.

Being in solo practice I’ve come to accept this, but it’s a conscious decision on my part. It’s easier than finding a call partner, and if I’m handling my own stuff at least I’m not going to come home to any surprises. So I’ve covered patients from as far west as Hawaii, north as Juneau, south as Panama City, and east as Le Havre.

Granted, this is medicine, and many other jobs don’t require the degree of involvement that it does. But I suspect pretty much any professional - attorney, accountant, executive - still has to deal with work-related stuff while traveling. Back in the 1970s to 1980s my dad, a solo-practice lawyer, had a set time each vacation weekday afternoon where he’d call his secretary to go over stuff. Today it would be by email or texts.

We’ve done this to ourselves. We’ve accepted the trade-off of better connectivity with family and friends for expanding our time at work. The same technology that lets me send in prescription refills from London also lets me send family pictures back from Maui. It’s not easy to draw a solid line between them, and I’m not so sure many of us want to.

Today, 50 years after Ms. Mitchell wrote the song, the idea of being a “free man in Paris” – or anywhere – really doesn’t exist for most of us anymore. You can argue whether that’s good or bad, but it’s where we are.

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

A few weeks ago I wrote about my glasses and the discovery that they’d been made incorrectly. The headline for the story was “The Way I See It.”

That’s the opening line from Joni Mitchell’s 1974 song “Free Man in Paris.” But I grew up in a Neil Diamond household (Dad always had Neil Diamond on when he was working at home) so the first time I heard the song was in 1977, when Diamond covered it. In fact, I didn’t even realize it was originally Mitchell’s song until I was in my 50s.

It’s about a world that doesn’t exist anymore.

The song is about music promoter David Geffen and a trip he took to Paris. Back in southern California, he was always working. There were continual phone calls, deals, meetings, and people looking for favors.

But on his trip to Paris in the early 1970s, he became just another person. No one could find him to ask for help or cut a deal. He couldn’t be reached. He felt “unfettered and alive” and could go from “cafe to cabaret,” relax, and enjoy himself.

Medical practice was once that way. You’d check-out patients to your call partners, leave town, and relax for a week or two.

Try doing that today.

For better or worse, all of us now are attached to our phones. We even have a new psychiatric condition – nomophobia – for the fear of not having our mobile phone handy. Every time I leave my house or office I repeat a simple mantra “phone, wallet, keys” as I pat my pockets.

Unless you can part with your gadget – which ain’t easy – no one is a “free man in Paris” (or Tokyo, or Rio, or Beijing) anymore. Even ships have cell service at sea. There are still places on Earth remote enough that you can’t be reached, but they get fewer and smaller every year.

When was the last time you really went somewhere and had no communication with your office at all? Emails, texts, anything? Unless you’re in a shift-work branch of medicine, like ER or hospitalist, I’m going to guess it’s been a while. And even in those branches you probably get emails about administrative matters, scheduling questions, and pointless memos.

Being in solo practice I’ve come to accept this, but it’s a conscious decision on my part. It’s easier than finding a call partner, and if I’m handling my own stuff at least I’m not going to come home to any surprises. So I’ve covered patients from as far west as Hawaii, north as Juneau, south as Panama City, and east as Le Havre.

Granted, this is medicine, and many other jobs don’t require the degree of involvement that it does. But I suspect pretty much any professional - attorney, accountant, executive - still has to deal with work-related stuff while traveling. Back in the 1970s to 1980s my dad, a solo-practice lawyer, had a set time each vacation weekday afternoon where he’d call his secretary to go over stuff. Today it would be by email or texts.

We’ve done this to ourselves. We’ve accepted the trade-off of better connectivity with family and friends for expanding our time at work. The same technology that lets me send in prescription refills from London also lets me send family pictures back from Maui. It’s not easy to draw a solid line between them, and I’m not so sure many of us want to.

Today, 50 years after Ms. Mitchell wrote the song, the idea of being a “free man in Paris” – or anywhere – really doesn’t exist for most of us anymore. You can argue whether that’s good or bad, but it’s where we are.

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

A recent report in Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association suggested that, at least for now, we need to lower the bar in Alzheimer’s disease drug trials.

Their point is that there’s no consensus on “clinically meaningful benefit.” Does it mean a complete cure for Alzheimer’s disease, with reversal of deficits? Or stopping disease progression where it is? Or just slowing things down enough that it means something to patients, family members, and caregivers?

The last one is, realistically, where we are now.

The problem with this is that many nonmedical people equate “treatment” with “cure,” which isn’t close to the truth for many diseases. In Alzheimer’s disease, it’s even trickier to figure out. There’s a disparity between imaging (which suggests something that should be quite effective) and clinical results (which aren’t nearly as impressive as the PET scans).

So when I prescribe any of the Alzheimer’s medications, I make it pretty clear to patients, and more importantly the patient’s family, what they can and can’t expect. This isn’t easy, because most will come back a month later, tell me their loved one is no better, and want to try something else. So I have to explain it again. These people aren’t stupid. They’re hopeful, and also facing an impossible question. “Better” is a lot easier to judge than “slowed progression.”

“Better” is a great word for migraines. Or seizures. Or Parkinson’s disease. These are condition where patients and families can tell us whether they’ve seen an improvement.

But with the current treatments for Alzheimer’s disease we’re asking patients and families “do you think you’ve gotten any worse than you would have if you hadn’t taken the drug at all?”

That’s an impossible question to answer, unless you’re following people with objective cognitive data over time and comparing them against a placebo group, which is how these drugs got here in the first place – we know they do that.

But to a family watching their loved ones go downhill, such reassurances aren’t what they want to hear.

Regrettably, it’s where things stand. While I want to strive for absolute success in these things, today it’s simply not possible. Maybe it never will be, though I hope it is.

But, for now, I agree that we need to reframe what we’re going to consider clinically meaningful. Sometimes you have to settle for a flight of stairs instead of an elevator, but still hope that you’ll get to the top. It just takes longer, and it’s better than not going anywhere at all.

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

A recent report in Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association suggested that, at least for now, we need to lower the bar in Alzheimer’s disease drug trials.

Their point is that there’s no consensus on “clinically meaningful benefit.” Does it mean a complete cure for Alzheimer’s disease, with reversal of deficits? Or stopping disease progression where it is? Or just slowing things down enough that it means something to patients, family members, and caregivers?

The last one is, realistically, where we are now.

The problem with this is that many nonmedical people equate “treatment” with “cure,” which isn’t close to the truth for many diseases. In Alzheimer’s disease, it’s even trickier to figure out. There’s a disparity between imaging (which suggests something that should be quite effective) and clinical results (which aren’t nearly as impressive as the PET scans).

So when I prescribe any of the Alzheimer’s medications, I make it pretty clear to patients, and more importantly the patient’s family, what they can and can’t expect. This isn’t easy, because most will come back a month later, tell me their loved one is no better, and want to try something else. So I have to explain it again. These people aren’t stupid. They’re hopeful, and also facing an impossible question. “Better” is a lot easier to judge than “slowed progression.”

“Better” is a great word for migraines. Or seizures. Or Parkinson’s disease. These are condition where patients and families can tell us whether they’ve seen an improvement.

But with the current treatments for Alzheimer’s disease we’re asking patients and families “do you think you’ve gotten any worse than you would have if you hadn’t taken the drug at all?”

That’s an impossible question to answer, unless you’re following people with objective cognitive data over time and comparing them against a placebo group, which is how these drugs got here in the first place – we know they do that.

But to a family watching their loved ones go downhill, such reassurances aren’t what they want to hear.

Regrettably, it’s where things stand. While I want to strive for absolute success in these things, today it’s simply not possible. Maybe it never will be, though I hope it is.

But, for now, I agree that we need to reframe what we’re going to consider clinically meaningful. Sometimes you have to settle for a flight of stairs instead of an elevator, but still hope that you’ll get to the top. It just takes longer, and it’s better than not going anywhere at all.

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

A recent report in Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association suggested that, at least for now, we need to lower the bar in Alzheimer’s disease drug trials.

Their point is that there’s no consensus on “clinically meaningful benefit.” Does it mean a complete cure for Alzheimer’s disease, with reversal of deficits? Or stopping disease progression where it is? Or just slowing things down enough that it means something to patients, family members, and caregivers?

The last one is, realistically, where we are now.

The problem with this is that many nonmedical people equate “treatment” with “cure,” which isn’t close to the truth for many diseases. In Alzheimer’s disease, it’s even trickier to figure out. There’s a disparity between imaging (which suggests something that should be quite effective) and clinical results (which aren’t nearly as impressive as the PET scans).

So when I prescribe any of the Alzheimer’s medications, I make it pretty clear to patients, and more importantly the patient’s family, what they can and can’t expect. This isn’t easy, because most will come back a month later, tell me their loved one is no better, and want to try something else. So I have to explain it again. These people aren’t stupid. They’re hopeful, and also facing an impossible question. “Better” is a lot easier to judge than “slowed progression.”

“Better” is a great word for migraines. Or seizures. Or Parkinson’s disease. These are condition where patients and families can tell us whether they’ve seen an improvement.

But with the current treatments for Alzheimer’s disease we’re asking patients and families “do you think you’ve gotten any worse than you would have if you hadn’t taken the drug at all?”

That’s an impossible question to answer, unless you’re following people with objective cognitive data over time and comparing them against a placebo group, which is how these drugs got here in the first place – we know they do that.

But to a family watching their loved ones go downhill, such reassurances aren’t what they want to hear.

Regrettably, it’s where things stand. While I want to strive for absolute success in these things, today it’s simply not possible. Maybe it never will be, though I hope it is.

But, for now, I agree that we need to reframe what we’re going to consider clinically meaningful. Sometimes you have to settle for a flight of stairs instead of an elevator, but still hope that you’ll get to the top. It just takes longer, and it’s better than not going anywhere at all.

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

I’ve worn glasses since I was 8, when a routine school vision test showed I was nearsighted. Except for an ill-fated 3-month attempt at contact lenses when I was 16, glasses have been just another part of my daily routine.

The last time I got new ones was in 2018, and my vision always seemed “off” after that. I took them back to the store a few times and was told I’d adjust to them and that things would be fine, So after a few weeks of doggedly wearing them I adjusted to them. I still felt like something was slightly off, but then I was busy, and then came the pandemic, and then my eye doctor retired and I had to find a new one ... so going to get my glasses prescription rechecked kept getting pushed back.

As so many of us do over time, I’ve gotten used to taking my glasses off to read things up close, like a book, or to do a detailed jigsaw puzzle. This has gotten worse over time, and so finally I made an appointment with a new eye doctor.

I handed him my previous prescription. He did a reading off the lenses, looked at the prescription again, gave me a perplexed look, and started the usual eye exam, asking me to read different lines as he switched lenses around. This went on for 10-15 minutes.

“The right lens wasn’t made correctly,” he told me. “You’ve been working off your left eye for the last 5 years.”

He returned my glasses and I put them on. He covered my left eye and showed me how, without realizing it, I was tilting my head back to bring distant items into focus on the right – the opposite of what I should be doing – and with both eyes would adjust my position to use the left eye.

The next morning, while working at my desk, I realized for the first time that I had my head turned slightly right to bring the left eye a tad closer to the screen. In a job where we’re trained to look for such minutiae in patients I’d missed it on myself. A friend even suggested I submit my story as a case report – “An unusual cause of a head-tilt in a middle-aged male” – to a journal.

It’s an interesting commentary on how adaptable the brain is at handling vision changes. It was several hundred million years ago when the brain figured out how to invert images that were seen upside down, and it continues to find ways to compensate for field cuts, cranial nerve palsies, and other lesions. Including flawed spectacles.

When my new eyeglasses arrive, my brain will have to readjust. This time, though, I’m curious and will try to pay better attention to my own reactions. If I can.

One of the other remarkable things about the brain is how it works very hard to keep us from realizing what it’s doing in the background, so we don’t notice an issue.

Amazing stuff if you think about it.

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

I’ve worn glasses since I was 8, when a routine school vision test showed I was nearsighted. Except for an ill-fated 3-month attempt at contact lenses when I was 16, glasses have been just another part of my daily routine.

The last time I got new ones was in 2018, and my vision always seemed “off” after that. I took them back to the store a few times and was told I’d adjust to them and that things would be fine, So after a few weeks of doggedly wearing them I adjusted to them. I still felt like something was slightly off, but then I was busy, and then came the pandemic, and then my eye doctor retired and I had to find a new one ... so going to get my glasses prescription rechecked kept getting pushed back.

As so many of us do over time, I’ve gotten used to taking my glasses off to read things up close, like a book, or to do a detailed jigsaw puzzle. This has gotten worse over time, and so finally I made an appointment with a new eye doctor.

I handed him my previous prescription. He did a reading off the lenses, looked at the prescription again, gave me a perplexed look, and started the usual eye exam, asking me to read different lines as he switched lenses around. This went on for 10-15 minutes.

“The right lens wasn’t made correctly,” he told me. “You’ve been working off your left eye for the last 5 years.”

He returned my glasses and I put them on. He covered my left eye and showed me how, without realizing it, I was tilting my head back to bring distant items into focus on the right – the opposite of what I should be doing – and with both eyes would adjust my position to use the left eye.

The next morning, while working at my desk, I realized for the first time that I had my head turned slightly right to bring the left eye a tad closer to the screen. In a job where we’re trained to look for such minutiae in patients I’d missed it on myself. A friend even suggested I submit my story as a case report – “An unusual cause of a head-tilt in a middle-aged male” – to a journal.

It’s an interesting commentary on how adaptable the brain is at handling vision changes. It was several hundred million years ago when the brain figured out how to invert images that were seen upside down, and it continues to find ways to compensate for field cuts, cranial nerve palsies, and other lesions. Including flawed spectacles.

When my new eyeglasses arrive, my brain will have to readjust. This time, though, I’m curious and will try to pay better attention to my own reactions. If I can.

One of the other remarkable things about the brain is how it works very hard to keep us from realizing what it’s doing in the background, so we don’t notice an issue.

Amazing stuff if you think about it.

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

I’ve worn glasses since I was 8, when a routine school vision test showed I was nearsighted. Except for an ill-fated 3-month attempt at contact lenses when I was 16, glasses have been just another part of my daily routine.

The last time I got new ones was in 2018, and my vision always seemed “off” after that. I took them back to the store a few times and was told I’d adjust to them and that things would be fine, So after a few weeks of doggedly wearing them I adjusted to them. I still felt like something was slightly off, but then I was busy, and then came the pandemic, and then my eye doctor retired and I had to find a new one ... so going to get my glasses prescription rechecked kept getting pushed back.

As so many of us do over time, I’ve gotten used to taking my glasses off to read things up close, like a book, or to do a detailed jigsaw puzzle. This has gotten worse over time, and so finally I made an appointment with a new eye doctor.

I handed him my previous prescription. He did a reading off the lenses, looked at the prescription again, gave me a perplexed look, and started the usual eye exam, asking me to read different lines as he switched lenses around. This went on for 10-15 minutes.

“The right lens wasn’t made correctly,” he told me. “You’ve been working off your left eye for the last 5 years.”

He returned my glasses and I put them on. He covered my left eye and showed me how, without realizing it, I was tilting my head back to bring distant items into focus on the right – the opposite of what I should be doing – and with both eyes would adjust my position to use the left eye.

The next morning, while working at my desk, I realized for the first time that I had my head turned slightly right to bring the left eye a tad closer to the screen. In a job where we’re trained to look for such minutiae in patients I’d missed it on myself. A friend even suggested I submit my story as a case report – “An unusual cause of a head-tilt in a middle-aged male” – to a journal.

It’s an interesting commentary on how adaptable the brain is at handling vision changes. It was several hundred million years ago when the brain figured out how to invert images that were seen upside down, and it continues to find ways to compensate for field cuts, cranial nerve palsies, and other lesions. Including flawed spectacles.

When my new eyeglasses arrive, my brain will have to readjust. This time, though, I’m curious and will try to pay better attention to my own reactions. If I can.

One of the other remarkable things about the brain is how it works very hard to keep us from realizing what it’s doing in the background, so we don’t notice an issue.

Amazing stuff if you think about it.

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

It’s amazing how many phone calls I get from different agencies and groups:

The Drug Enforcement Administration – A car rented in your name was found with fentanyl in the trunk.

The Maricopa County Sheriff’s Department – There is a warrant for your arrest due to failure to show up for jury duty and/or as an expert witness.

Doctors Without Borders – We treated one of your patients while they were overseas and need payment for the supplies used.

The Arizona Medical Board – Your license has been suspended.

The Department of Health & Human Services – Your patient database has been posted on the dark web.

Of course, any of these problems can be fixed simply paying the caller a fee by credit card, Bitcoin, or purchasing gift cards and reading off the numbers to them.

Really.

As you’ve probably guessed, none of these calls are real, they’re just popular scams that have been circulating among doctors’ (and other) offices for the last several years. You may have gotten some of them yourself.

I’m sure the vast majority of us don’t fall for them, but the scammer on the other end doesn’t care. All that the scammers need is one sucker to hit the jackpot.

And, realistically, that sucker could be any of us on a bad day. Timing is everything. If we’re frazzled by office events, or aware that the local medical board is looking into something, or have just been up all night at the hospital and are exhausted ... that’s when we’re most vulnerable, our razor’s edge is dull, our thought process slowed, and maybe at that moment we are just not as able to think clearly.

If I were younger I’d probably be more inclined to waste time messing around with them for the entertainment, trying to get them to give up on me after a while. But nowadays I have neither the time nor interest for that. In the rare cases that they make it past my secretary (which is pretty hard) I just hang up.

I’m not sure if it says more about us or them that this happens. I suppose doctors’ offices are the low-hanging fruit where they assume there’s money and (hopefully) someone who’s either gullible, not paying attention, or just not on top of things. As with any other business, if it weren’t profitable they wouldn’t do it. The best we can do is to make it as unprofitable as possible.

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

It’s amazing how many phone calls I get from different agencies and groups:

The Drug Enforcement Administration – A car rented in your name was found with fentanyl in the trunk.

The Maricopa County Sheriff’s Department – There is a warrant for your arrest due to failure to show up for jury duty and/or as an expert witness.

Doctors Without Borders – We treated one of your patients while they were overseas and need payment for the supplies used.

The Arizona Medical Board – Your license has been suspended.

The Department of Health & Human Services – Your patient database has been posted on the dark web.

Of course, any of these problems can be fixed simply paying the caller a fee by credit card, Bitcoin, or purchasing gift cards and reading off the numbers to them.

Really.

As you’ve probably guessed, none of these calls are real, they’re just popular scams that have been circulating among doctors’ (and other) offices for the last several years. You may have gotten some of them yourself.

I’m sure the vast majority of us don’t fall for them, but the scammer on the other end doesn’t care. All that the scammers need is one sucker to hit the jackpot.

And, realistically, that sucker could be any of us on a bad day. Timing is everything. If we’re frazzled by office events, or aware that the local medical board is looking into something, or have just been up all night at the hospital and are exhausted ... that’s when we’re most vulnerable, our razor’s edge is dull, our thought process slowed, and maybe at that moment we are just not as able to think clearly.

If I were younger I’d probably be more inclined to waste time messing around with them for the entertainment, trying to get them to give up on me after a while. But nowadays I have neither the time nor interest for that. In the rare cases that they make it past my secretary (which is pretty hard) I just hang up.

I’m not sure if it says more about us or them that this happens. I suppose doctors’ offices are the low-hanging fruit where they assume there’s money and (hopefully) someone who’s either gullible, not paying attention, or just not on top of things. As with any other business, if it weren’t profitable they wouldn’t do it. The best we can do is to make it as unprofitable as possible.

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

It’s amazing how many phone calls I get from different agencies and groups:

The Drug Enforcement Administration – A car rented in your name was found with fentanyl in the trunk.

The Maricopa County Sheriff’s Department – There is a warrant for your arrest due to failure to show up for jury duty and/or as an expert witness.

Doctors Without Borders – We treated one of your patients while they were overseas and need payment for the supplies used.

The Arizona Medical Board – Your license has been suspended.

The Department of Health & Human Services – Your patient database has been posted on the dark web.

Of course, any of these problems can be fixed simply paying the caller a fee by credit card, Bitcoin, or purchasing gift cards and reading off the numbers to them.

Really.

As you’ve probably guessed, none of these calls are real, they’re just popular scams that have been circulating among doctors’ (and other) offices for the last several years. You may have gotten some of them yourself.

I’m sure the vast majority of us don’t fall for them, but the scammer on the other end doesn’t care. All that the scammers need is one sucker to hit the jackpot.

And, realistically, that sucker could be any of us on a bad day. Timing is everything. If we’re frazzled by office events, or aware that the local medical board is looking into something, or have just been up all night at the hospital and are exhausted ... that’s when we’re most vulnerable, our razor’s edge is dull, our thought process slowed, and maybe at that moment we are just not as able to think clearly.

If I were younger I’d probably be more inclined to waste time messing around with them for the entertainment, trying to get them to give up on me after a while. But nowadays I have neither the time nor interest for that. In the rare cases that they make it past my secretary (which is pretty hard) I just hang up.

I’m not sure if it says more about us or them that this happens. I suppose doctors’ offices are the low-hanging fruit where they assume there’s money and (hopefully) someone who’s either gullible, not paying attention, or just not on top of things. As with any other business, if it weren’t profitable they wouldn’t do it. The best we can do is to make it as unprofitable as possible.

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

“Go outside and play!”

How many times did your mother tell you that?

Turns out that, like with chicken soup, she was right.

A recent article in Occupational and Environmental Medicine found that urban dwellers who spent time outdoors in green areas, such as parks and forests, had lower use of antihypertensive, antidepressant, and antianxiety medications than those who didn’t. People who just looked at such areas from a window didn’t have lower medication use than those who weren’t exposed to them at all.

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

“Go outside and play!”

How many times did your mother tell you that?

Turns out that, like with chicken soup, she was right.

A recent article in Occupational and Environmental Medicine found that urban dwellers who spent time outdoors in green areas, such as parks and forests, had lower use of antihypertensive, antidepressant, and antianxiety medications than those who didn’t. People who just looked at such areas from a window didn’t have lower medication use than those who weren’t exposed to them at all.

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

“Go outside and play!”

How many times did your mother tell you that?

Turns out that, like with chicken soup, she was right.

A recent article in Occupational and Environmental Medicine found that urban dwellers who spent time outdoors in green areas, such as parks and forests, had lower use of antihypertensive, antidepressant, and antianxiety medications than those who didn’t. People who just looked at such areas from a window didn’t have lower medication use than those who weren’t exposed to them at all.

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

Hidden in the Dec. 1, 2022, issue of the New England Journal of Medicine was a small article on using deferiprone for Parkinson’s disease.

The idea behind it makes sense. A key factor in Parkinson’s disease is a loss of cells in the substantia nigra. The cells that have been lost have a build-up of iron content, suggesting that iron contributes to their demise. Therefore, maybe using an iron chelating agent to remove it may help.

Like I said, it makes sense.

Unfortunately, it didn’t quite work that way. In spite of a clear reduction of nigrostriatal iron, compared with the placebo group, the treated patients had worse MDS-UPDRS scores over 36 weeks than those on the placebo.

Back to the drawing board.

I’m not criticizing the people who did the study – it seemed like a reasonable hypothesis, and testing it is the only way we find out if it’s correct. We learn just as much, if not more, from a negative study as from a positive one, incrementally working toward the answer with each.

We face the same thing with the amyloid theory in Alzheimer’s disease. Getting rid of amyloid should fix the problem.

But it doesn’t, at least not completely. Even lecanemab, the latest-and-greatest of treatments, only shows a 27% slowing in disease progression. This is certainly meaningful – I’m not knocking it – but we’re still far from a cure. To date we haven’t even stopped disease progression, let alone reversed it.

Although the new drugs have a remarkable mechanism of action, the clinical results aren’t nearly as good as one would expect if amyloid was the whole issue.

Which, at this point, it probably isn’t, anymore than nigrostriatal iron deposition is the sole cause of Parkinson’s disease.

In medicine, as in so many other things, there’s simply a lot that we don’t know yet. Right now we’re better able to find planets 27,700 light years away (SWEEPS-11) than we are at knowing the cause of neuronal changes in the person sitting across the desk from us. That’s not saying we won’t have the answers someday, it just means we don’t have them now.

I was in my 3rd year of medical school in January of 1992, (surgery rotation at the Omaha VA, to be specific) when the first definitive planet outside our solar system was identified. Today, 31 years later, the number of exoplanets stands at 5,297.

But the laws of physics are generally a lot more predictable than those of biology.

That doesn’t mean we won’t find the answers, or more effective treatments, eventually. But it will take more time, work, and studies – with both positive and negative results – to get there.

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

Hidden in the Dec. 1, 2022, issue of the New England Journal of Medicine was a small article on using deferiprone for Parkinson’s disease.

The idea behind it makes sense. A key factor in Parkinson’s disease is a loss of cells in the substantia nigra. The cells that have been lost have a build-up of iron content, suggesting that iron contributes to their demise. Therefore, maybe using an iron chelating agent to remove it may help.

Like I said, it makes sense.

Unfortunately, it didn’t quite work that way. In spite of a clear reduction of nigrostriatal iron, compared with the placebo group, the treated patients had worse MDS-UPDRS scores over 36 weeks than those on the placebo.

Back to the drawing board.

I’m not criticizing the people who did the study – it seemed like a reasonable hypothesis, and testing it is the only way we find out if it’s correct. We learn just as much, if not more, from a negative study as from a positive one, incrementally working toward the answer with each.

We face the same thing with the amyloid theory in Alzheimer’s disease. Getting rid of amyloid should fix the problem.

But it doesn’t, at least not completely. Even lecanemab, the latest-and-greatest of treatments, only shows a 27% slowing in disease progression. This is certainly meaningful – I’m not knocking it – but we’re still far from a cure. To date we haven’t even stopped disease progression, let alone reversed it.

Although the new drugs have a remarkable mechanism of action, the clinical results aren’t nearly as good as one would expect if amyloid was the whole issue.

Which, at this point, it probably isn’t, anymore than nigrostriatal iron deposition is the sole cause of Parkinson’s disease.

In medicine, as in so many other things, there’s simply a lot that we don’t know yet. Right now we’re better able to find planets 27,700 light years away (SWEEPS-11) than we are at knowing the cause of neuronal changes in the person sitting across the desk from us. That’s not saying we won’t have the answers someday, it just means we don’t have them now.

I was in my 3rd year of medical school in January of 1992, (surgery rotation at the Omaha VA, to be specific) when the first definitive planet outside our solar system was identified. Today, 31 years later, the number of exoplanets stands at 5,297.

But the laws of physics are generally a lot more predictable than those of biology.

That doesn’t mean we won’t find the answers, or more effective treatments, eventually. But it will take more time, work, and studies – with both positive and negative results – to get there.

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

Hidden in the Dec. 1, 2022, issue of the New England Journal of Medicine was a small article on using deferiprone for Parkinson’s disease.

The idea behind it makes sense. A key factor in Parkinson’s disease is a loss of cells in the substantia nigra. The cells that have been lost have a build-up of iron content, suggesting that iron contributes to their demise. Therefore, maybe using an iron chelating agent to remove it may help.

Like I said, it makes sense.

Unfortunately, it didn’t quite work that way. In spite of a clear reduction of nigrostriatal iron, compared with the placebo group, the treated patients had worse MDS-UPDRS scores over 36 weeks than those on the placebo.

Back to the drawing board.

I’m not criticizing the people who did the study – it seemed like a reasonable hypothesis, and testing it is the only way we find out if it’s correct. We learn just as much, if not more, from a negative study as from a positive one, incrementally working toward the answer with each.

We face the same thing with the amyloid theory in Alzheimer’s disease. Getting rid of amyloid should fix the problem.

But it doesn’t, at least not completely. Even lecanemab, the latest-and-greatest of treatments, only shows a 27% slowing in disease progression. This is certainly meaningful – I’m not knocking it – but we’re still far from a cure. To date we haven’t even stopped disease progression, let alone reversed it.

Although the new drugs have a remarkable mechanism of action, the clinical results aren’t nearly as good as one would expect if amyloid was the whole issue.

Which, at this point, it probably isn’t, anymore than nigrostriatal iron deposition is the sole cause of Parkinson’s disease.

In medicine, as in so many other things, there’s simply a lot that we don’t know yet. Right now we’re better able to find planets 27,700 light years away (SWEEPS-11) than we are at knowing the cause of neuronal changes in the person sitting across the desk from us. That’s not saying we won’t have the answers someday, it just means we don’t have them now.

I was in my 3rd year of medical school in January of 1992, (surgery rotation at the Omaha VA, to be specific) when the first definitive planet outside our solar system was identified. Today, 31 years later, the number of exoplanets stands at 5,297.

But the laws of physics are generally a lot more predictable than those of biology.

That doesn’t mean we won’t find the answers, or more effective treatments, eventually. But it will take more time, work, and studies – with both positive and negative results – to get there.

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

How many of you hadn’t heard of ambroxol until the last few weeks?

How many of you have gotten at least one call asking for a prescription for it in that time?

I’ll raise my hand on both accounts.

Ambroxol seems relatively innocuous – an over-the-counter cold medication commonly used on planet Earth (though not approved in the U.S. for whatever reason). But in the last few years some interesting data have cropped up that it may help with Parkinson’s disease.

“May” being the key word here.

Now, I’m not saying it will or won’t do something. The trials that are being started will show that. It would be totally awesome if it did.

But we’ve been here before: The hope that some old, inexpensive, and widely available medication would turn out to have an amazing benefit we didn’t anticipate. We saw this with hydroxychloroquine and ivermectin during the pandemic. Before that we saw all kinds of speculative ideas that statins would be effective for diseases from multiple sclerosis to Alzheimer’s disease.

And, as with many incurable diseases, patients and their families are hoping for a breakthrough. We have plenty of treatments for Parkinson’s disease, but no cures yet. So any potentially effective drug news makes the rounds quickly on news sites, patient advocacy sites, Facebook, and others.

Like the childrens’ telephone game, each time the story is repeated it changes a bit. We’ve gone from an article saying the drug is starting clinical trials to see if it works, to it being a cure now on the marketplace.

Which is when people start calling my office. Most are disappointed to learn that its benefit (if any) is unknown and that it’s not even available. A few get confrontational, accusing me of withholding treatment, when “everyone knows” the drug works.

Believe me, if I had a cure I’d be thrilled to be able to offer it.

I understand that patients and families want a cure.

I understand hope.

I want ambroxol to work for Parkinson’s disease and make a huge difference in the lives of those affected by it. Maybe it will. Or maybe it won’t.

But these things take time to figure out. None of the amazing medications and hi-tech toys we have came about overnight. They were all years in the making.

That’s how science works, and medicine is as much a science as an art.

The art is being able to explain this to patients, and still allow them to hope.

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

How many of you hadn’t heard of ambroxol until the last few weeks?

How many of you have gotten at least one call asking for a prescription for it in that time?

I’ll raise my hand on both accounts.

Ambroxol seems relatively innocuous – an over-the-counter cold medication commonly used on planet Earth (though not approved in the U.S. for whatever reason). But in the last few years some interesting data have cropped up that it may help with Parkinson’s disease.

“May” being the key word here.

Now, I’m not saying it will or won’t do something. The trials that are being started will show that. It would be totally awesome if it did.

But we’ve been here before: The hope that some old, inexpensive, and widely available medication would turn out to have an amazing benefit we didn’t anticipate. We saw this with hydroxychloroquine and ivermectin during the pandemic. Before that we saw all kinds of speculative ideas that statins would be effective for diseases from multiple sclerosis to Alzheimer’s disease.

And, as with many incurable diseases, patients and their families are hoping for a breakthrough. We have plenty of treatments for Parkinson’s disease, but no cures yet. So any potentially effective drug news makes the rounds quickly on news sites, patient advocacy sites, Facebook, and others.

Like the childrens’ telephone game, each time the story is repeated it changes a bit. We’ve gone from an article saying the drug is starting clinical trials to see if it works, to it being a cure now on the marketplace.

Which is when people start calling my office. Most are disappointed to learn that its benefit (if any) is unknown and that it’s not even available. A few get confrontational, accusing me of withholding treatment, when “everyone knows” the drug works.

Believe me, if I had a cure I’d be thrilled to be able to offer it.

I understand that patients and families want a cure.

I understand hope.

I want ambroxol to work for Parkinson’s disease and make a huge difference in the lives of those affected by it. Maybe it will. Or maybe it won’t.

But these things take time to figure out. None of the amazing medications and hi-tech toys we have came about overnight. They were all years in the making.

That’s how science works, and medicine is as much a science as an art.

The art is being able to explain this to patients, and still allow them to hope.

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

How many of you hadn’t heard of ambroxol until the last few weeks?

How many of you have gotten at least one call asking for a prescription for it in that time?

I’ll raise my hand on both accounts.

Ambroxol seems relatively innocuous – an over-the-counter cold medication commonly used on planet Earth (though not approved in the U.S. for whatever reason). But in the last few years some interesting data have cropped up that it may help with Parkinson’s disease.

“May” being the key word here.

Now, I’m not saying it will or won’t do something. The trials that are being started will show that. It would be totally awesome if it did.

But we’ve been here before: The hope that some old, inexpensive, and widely available medication would turn out to have an amazing benefit we didn’t anticipate. We saw this with hydroxychloroquine and ivermectin during the pandemic. Before that we saw all kinds of speculative ideas that statins would be effective for diseases from multiple sclerosis to Alzheimer’s disease.

And, as with many incurable diseases, patients and their families are hoping for a breakthrough. We have plenty of treatments for Parkinson’s disease, but no cures yet. So any potentially effective drug news makes the rounds quickly on news sites, patient advocacy sites, Facebook, and others.

Like the childrens’ telephone game, each time the story is repeated it changes a bit. We’ve gone from an article saying the drug is starting clinical trials to see if it works, to it being a cure now on the marketplace.

Which is when people start calling my office. Most are disappointed to learn that its benefit (if any) is unknown and that it’s not even available. A few get confrontational, accusing me of withholding treatment, when “everyone knows” the drug works.

Believe me, if I had a cure I’d be thrilled to be able to offer it.

I understand that patients and families want a cure.

I understand hope.

I want ambroxol to work for Parkinson’s disease and make a huge difference in the lives of those affected by it. Maybe it will. Or maybe it won’t.

But these things take time to figure out. None of the amazing medications and hi-tech toys we have came about overnight. They were all years in the making.

That’s how science works, and medicine is as much a science as an art.

The art is being able to explain this to patients, and still allow them to hope.

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

When I was a resident (back in the Cretaceous era), the idea of autoimmune encephalitis was just beginning to take hold. It was kind of like Bigfoot. A few reports, vague articles, the occasional sighting of what may or may not be a case. …

Unlike Bigfoot, however, the evidence quickly added up until there was no question that such a disorder existed. Then disorder became disorders, and now it seems a few more types are added to the list each year.

This doesn’t change the fact that they’re still, in the grand scheme of general neurology, relatively rare, though no one questions that they exist.

Today people still wishfully take pictures of Bigfoot, but they turn out to be images of bears or other animals, or tricks of light and shadow.

This is an issue with human thought. Many times we see what we want to see, especially if it’s more interesting than a mundane alternative.

An autoimmune encephalitis article in the January 2023 issue of JAMA Neurology looked into this. On reviewing 393 patients diagnosed with the disorder, the researchers found that 27% of them actually didn’t have it at all. Such things as functional disorders, neurodegenerative diseases, and primary psychiatric diagnoses were, instead, the culprits.

I’m not criticizing those who made an incorrect diagnosis. We all do. That’s the nature of medicine.

Which is worse? Missing the diagnosis entirely and not treating, or diagnosing a patient with something else and treating incorrectly? I guess it depends on the disease and nature of treatment.

Certainly, finding a case of autoimmune encephalitis is more interesting than, say toxic-metabolic encephalopathy from a bladder infection, just as getting a picture of Bigfoot is way more cool than one of a bear with mange.

But we need to be careful when faced with equivocal labs and data lest we read too much into them. There are too many gray zones in medicine to lead you astray. Not to say we won’t be. Even well-intentioned physicians (which I assume is pretty much all of us) are going to make mistakes.

But it’s not just rare diseases. In the early 1990s two different studies found that 24% of patients diagnosed with Parkinson’s disease were found to have something else on autopsy.

That was 30 years ago. Now we have DaT scans to help. Maybe our abilities as neurologists have also gotten better (though I don’t think the neurological exam has changed much since Charcot).

Our gadgets, labs, and treatments get better every year. We have tools available to us now that were unthinkable a generation ago. For that matter, they were unthinkable when I began my career.

But they don’t change the fact that human error never goes away. All of us are susceptible to it, and all of us make mistakes.

Such is the way of medicine now, and likely always. All we can do is our best and keep moving forward.

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

When I was a resident (back in the Cretaceous era), the idea of autoimmune encephalitis was just beginning to take hold. It was kind of like Bigfoot. A few reports, vague articles, the occasional sighting of what may or may not be a case. …

Unlike Bigfoot, however, the evidence quickly added up until there was no question that such a disorder existed. Then disorder became disorders, and now it seems a few more types are added to the list each year.

This doesn’t change the fact that they’re still, in the grand scheme of general neurology, relatively rare, though no one questions that they exist.

Today people still wishfully take pictures of Bigfoot, but they turn out to be images of bears or other animals, or tricks of light and shadow.

This is an issue with human thought. Many times we see what we want to see, especially if it’s more interesting than a mundane alternative.

An autoimmune encephalitis article in the January 2023 issue of JAMA Neurology looked into this. On reviewing 393 patients diagnosed with the disorder, the researchers found that 27% of them actually didn’t have it at all. Such things as functional disorders, neurodegenerative diseases, and primary psychiatric diagnoses were, instead, the culprits.

I’m not criticizing those who made an incorrect diagnosis. We all do. That’s the nature of medicine.

Which is worse? Missing the diagnosis entirely and not treating, or diagnosing a patient with something else and treating incorrectly? I guess it depends on the disease and nature of treatment.

Certainly, finding a case of autoimmune encephalitis is more interesting than, say toxic-metabolic encephalopathy from a bladder infection, just as getting a picture of Bigfoot is way more cool than one of a bear with mange.

But we need to be careful when faced with equivocal labs and data lest we read too much into them. There are too many gray zones in medicine to lead you astray. Not to say we won’t be. Even well-intentioned physicians (which I assume is pretty much all of us) are going to make mistakes.

But it’s not just rare diseases. In the early 1990s two different studies found that 24% of patients diagnosed with Parkinson’s disease were found to have something else on autopsy.

That was 30 years ago. Now we have DaT scans to help. Maybe our abilities as neurologists have also gotten better (though I don’t think the neurological exam has changed much since Charcot).

Our gadgets, labs, and treatments get better every year. We have tools available to us now that were unthinkable a generation ago. For that matter, they were unthinkable when I began my career.

But they don’t change the fact that human error never goes away. All of us are susceptible to it, and all of us make mistakes.

Such is the way of medicine now, and likely always. All we can do is our best and keep moving forward.

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

When I was a resident (back in the Cretaceous era), the idea of autoimmune encephalitis was just beginning to take hold. It was kind of like Bigfoot. A few reports, vague articles, the occasional sighting of what may or may not be a case. …

Unlike Bigfoot, however, the evidence quickly added up until there was no question that such a disorder existed. Then disorder became disorders, and now it seems a few more types are added to the list each year.

This doesn’t change the fact that they’re still, in the grand scheme of general neurology, relatively rare, though no one questions that they exist.

Today people still wishfully take pictures of Bigfoot, but they turn out to be images of bears or other animals, or tricks of light and shadow.

This is an issue with human thought. Many times we see what we want to see, especially if it’s more interesting than a mundane alternative.

An autoimmune encephalitis article in the January 2023 issue of JAMA Neurology looked into this. On reviewing 393 patients diagnosed with the disorder, the researchers found that 27% of them actually didn’t have it at all. Such things as functional disorders, neurodegenerative diseases, and primary psychiatric diagnoses were, instead, the culprits.

I’m not criticizing those who made an incorrect diagnosis. We all do. That’s the nature of medicine.

Which is worse? Missing the diagnosis entirely and not treating, or diagnosing a patient with something else and treating incorrectly? I guess it depends on the disease and nature of treatment.

Certainly, finding a case of autoimmune encephalitis is more interesting than, say toxic-metabolic encephalopathy from a bladder infection, just as getting a picture of Bigfoot is way more cool than one of a bear with mange.

But we need to be careful when faced with equivocal labs and data lest we read too much into them. There are too many gray zones in medicine to lead you astray. Not to say we won’t be. Even well-intentioned physicians (which I assume is pretty much all of us) are going to make mistakes.

But it’s not just rare diseases. In the early 1990s two different studies found that 24% of patients diagnosed with Parkinson’s disease were found to have something else on autopsy.

That was 30 years ago. Now we have DaT scans to help. Maybe our abilities as neurologists have also gotten better (though I don’t think the neurological exam has changed much since Charcot).

Our gadgets, labs, and treatments get better every year. We have tools available to us now that were unthinkable a generation ago. For that matter, they were unthinkable when I began my career.

But they don’t change the fact that human error never goes away. All of us are susceptible to it, and all of us make mistakes.

Such is the way of medicine now, and likely always. All we can do is our best and keep moving forward.

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