I am a neurologist - a physician specializing in disorders of the nervous system. AMA!

Why is it that whenever I start a sentence, I cannot manage to water melon ping pong potato.

Aphasia.

Not sure what the Disney movie has to do with it, but I will take your bongo drum bacon bums for what they are Colin Firth.

The Lord is a shoving leopard.

how many cookies can you eat before youve had too many cookies

Eleven, maybe 12. That's just me. Other cookie eaters can eat many more.

What is the most unfortunate disorder you've come across? How did the family take care of that patient? What did you do to help?

The worst thing I have ever seen is a brainstem glioblastoma multiforme (malignant brain cancer) in a beautiful six year old child. The child was hospitalized for about 4 months while vital functions shut down one by one, and eventually died in his mother's arms. The parents were there most of the time and handled it as expected, which is to say, they went totally nuts and handled it ungracefully, shouting and abusing staff regularly. I feel I did nothing to help, found it the most unjust and sickening experience possible, and still have nightmares about it.

CYA - Cover Your Ass. You did it quite well in the description.

A few questions: What in our brain determines its internal clock speed? (i.e. how fast we process "stuff" in our brains). There is a radiolab episode on people who have insanely slow processing speed vs. people who have insanely high processing speed. What ever it is that controls how fast we "tick", is it possible to increase this internal clock of ours?

2) Have you ever worked with a savant? It seems to normal functioning people that they have an infinite storage for memory, but maybe lack communication skills (Example: Daniel Tammet - https://www.youtube.com/watch?v=AbASOcqc1Ss). Do you foresee down the road people being able to voluntarily expand their mental capabilities to perform huge calculations, phenomenal memory, etc..

Thanks for the AMA!

1) I have been interested in this question for a long time but do not feel science is very close to really knowing the answer to it. Neural processing doesn't 'tick' the way that CPUs do. One way of getting at neural resolution is visual flicker-fusion experiments and I play with these from time to time.

2) I have never enjoyed the opportunity to meet a savant. They are quite rare. As Oliver Sacks points out, savants are uniformly quite dysfunctional in their daily lives, so it is not clear to me that being able to expand capabilities in this way is actually a desirable thing. Brains aren't computers and I think it's a good idea to think a little bit about why we have them, before focusing on how to overclock them!

Oh, and: you're welcome. I love talking about my field, it is my passion in life.

Thanks brainman. Do you listen to radiolab or science talks and wish to participate in them as the guest speaker?

I have not listened to a radiolab talk, but it is on my list of things to do.

I don't know that I want to gain notoriety as a public figure; I am a working doc and am generally pleased to remain somewhat obscure. I'm also not really a world-class expert on anything; for anything I might speak about, you could find people who know more about it! But I will think more on it and not rule anything out; thank you.

What do you think is the most exciting new development in neurology?

I think the new invasive and non invasive electrical and magnetic techniques for brain stimulation are super exciting. This includes deep brain stimulation for movement disorders like Parkinson and tremor; closed-loop neurostimulators to detect and abort epileptic seizures; transcranial magnetic stimulation for depression, epilepsy, stroke rehab, and other things; and maybe direct transcranial electric field stimulation from outside the head (jury's still out on whether it is truly efficacious, I think.) As the technologists and materials scientists get together with the brain science folks, these modalities will just keep getting better and better.

What are closed-loop neurostimulators and how do they abort epileptic seizures? Could you go into more depth on that?

Northstar Neuroscience and Medtronic are two companies that have trialed this type of device.

Epileptic seizures are in a way electrical disorders. Neurons are electrical cells and they work in part by changing their electric potential - they move charged ions around and the inside of the cell becomes briefly more positive; that is called an 'action potential.' When a lot of neurons have action potentials at once, they are synchronized; when the entire brain synchronizes, that is abnormal: it causes an epileptic convulsion.

These devices have a sensing electrode, which is meant to detect the abnormal electrical synchronization as it starts; and a stimulating electrode, which delivers electric current to part of the brain in the hope of de-synchronizing or otherwise de-activating the epileptic seizure as it begins, before it spreads to involve the whole brain.

The trials have not shown ideal results. Some of the devices got infected, which is a catastrophe of course; other times they scarred over and quit working; other times they just didn't seem to work. Sometimes they did appear to work, however, and that is very encouraging. I tend to feel that these devices will be improved by scientists and that eventually, once the technology is better, they will be in widespread use.

Thanks for the reply; I have just enough education to be able to understand the gist of your answer.

Now I'm going to have to try to understand why magnetism would affect brain function. Sounds fascinating

A changing magnetic field is something that can be used to a) penetrate the skull and b) induce localized electric fields in actual brain cells. The effect that can be achieved is to temporarily inactivate part of the brain, at least if it is near the surface of the brain (deep structures are harder to access this way.)

I knew a radiologist who was playing with one of these TMS devices and made herself unable to speak for 2 weeks; they are clearly not toys.

One spectacular study that got a lot of press can be seen here: http://web.mit.edu/newsoffice/2010/moral-control-0330.html. Magnetic fields were applied to the right TPJ, affecting the moral judgments of subjects.

Username: seems legit

1. In med school did you ever feel like quitting?
2. What peaked your interest in neurobiology?

1. No. I loved every minute of med school. That probably sounds nuts but I had a really good experience. I recall a lot of anxiety and worry regarding tests, often the night before, but eventually that dampened down too.

2. Time-Life Science Library that I discovered on the shelf around age 11 sparked a lifelong interest in science. Matter and The Body were my favorite titles. My father was an aerospace engineer and he (and his golden-age SF collection) also went a long way towards making me a neuroscientist.

Hi there, i have something that i have been wondering about for quite some time. This is regarding my own mental state i guess; occasionally when i am doing something i have a moment where i sort of black out and my muscles slightly spasm, it can happen while i'm talking or gaming or whatever. Sometimes it is worse than other times, for instance, on the particularly bad spasms it's as if i go to sleep for less than a second and i come out unaware of my surrounding (i forget what specifically i was doing), also my extremities spasm during this. It happens primarily when i am tired, is this something that i should see a doctor about?

Also, it is implicitly acknowledged that you cannot be held accountable for any advice given in response to this post.

If something like that were happening to me I would go see a good neurologist.

Know of any good relief for fibramyalgia?

Some patients get good results with Lyrica which is FDA approved for fibro. Most patients do not get good results from anything. I am not convinced it is a neurological illness and in fact sometimes I wonder if we are lumping different illnesses under one label because we don't know enough about what is truly causing the problems.

SUDEP still seems somewhat controversial in the neurological community but is gaining ground in its acceptance and is finally getting some attention. What are your thoughts about it and do you approach the subject with your patients?

SUDEP is sudden unexplained death in epilepsy. I am fairly well convinced that it accounted for Margaux Hemingway's death and maybe Whitney Houston's as well.

I bring it up when I am asked, or when a patient seems not to understand why I think it's a bad idea to discontinue his anti-epilepsy medications. I do not always talk about it because it can be terrifying and because we know of no good way to prevent it, other than to do the things that we would do anyway. I have had people commit suicide just because they learned that they had epilepsy. God knows what these folks are thinking, but I do not want to put any more on their plate than they need to deal with.

I am not aware of much controversy about it, by the way.

What was your most interesting case?

My GF warned me I'd be asked this question. I don't have one single great answer; most cases have something interesting about them and I was trained to be able to look for that interesting angle and explain it on rounds. I diagnosed a young man with progressive multifocal leukoencephalopathy at the bedside once (confirmed with imaging and lab tests of course); he died not long after. Now that we have good AIDS drugs that doesn't happen much. I've diagnosed Creutzfeldt-Jakob disease, primary progressive aphasia, adrenoleukodystrophy, and weird strokes.

In general I like a case where I can use my clinical skills at the bedside to construct a proper differential diagnosis; that is where the mystery and the detective work come in, and I love that part of my job.

I feel like you are sitting at your computer, laughing as you make up words like "adrenoleukodystrophy".

Haha! Adrenoleukodystrophy even has a wikipedia page. The google is your friend.

Could you tell a story about one of those weird strokes?

Sure! My partner will remember this one if he ever reads this. He encountered a patient who had been referred for weakness in grasp of his right hand. The referring doc had quite correctly suspected palsy of the ulnar nerve, and my partner was a neuromuscular expert. Kicker was the fellow had recently lost his health insurance; I happened to know my partner was doing the nerve conduction study/EMG for free because I had to authorize that.

He asked me if I would take a look at the patient, knowing nothing else. I love that kind of challenge. Because he was asking me, I assumed the NCS/EMG had been nondiagnostic, though he told me nothing.

The fellow came out into the hallway and I offered him my right hand and insisted he shake with his own, the affected one. He indeed could barely grasp my hand. I observed - by feeling during the handshake - abnormal spastic and delayed recruitment in not only the hand but some of the wrist-flexor muscles. Simultaneously my nose detected that the fellow, who was wearing a plaid flannel shirt, just reeked of cigarette smoke - was the kind of fellow who is a deeply-inhaling 3 pack a day man. And I guessed his age to be about 50.

I let go his hand and stated, "Pseudo-ulnar palsy due to dominant superior parietal lobule ischemic infarction, likely due to embolus from symptomatic severe left carotid artery stenosis." My partner the nerve expert - he'd been with me 3 weeks at the time - looked at me like I had laid an egg: as I had just proposed stroke, in a patient who was thought to have a problem with the nerve in his arm, after meeting him for less than 5 seconds. A few phone calls later, a good friend had set him up for a free MRI and carotid ultrasound, which confirmed my diagnosis the next day. We got him hooked up with Medicaid and a surgeon fixed his busted artery not too long after that; the hand mostly recovered.

I'm not always that good, but I get a real kick out of it when I am. The guy still smokes tobacco, by the way.

Here's another: an 89 year old man came with a puzzling story. He was found at home by a friend, emitting gibberish nonsense speech. His speaking recovered and by the time I saw him he had slow speech, with trouble finding "low-frequency" words, but intact comprehension. He told the story that a day prior he had the sudden onset of difficulty speaking and difficulty using household appliances. He loaded the clothes washer with dishes, could not figure out how to operate the microwave, placed groceries requiring refrigeration in his underwear drawer, et cetera. He also displayed a bruise on his right arm, sustained when he bumped into a dresser "that shouldn't have been there." He was very clear that these symptoms were sudden in onset - not there one moment, present at full intensity the next.

My diagnosis was infarction of the anterior branch of left posterior cerebral artery. Clinical findings of aphasia, apraxia, and a transient right-sided visual neglect or visual deficit (the visual deficit had resolved by the time I saw him.)

Trouble with that was that his brain MRI, done just before I saw him, was normal - showed no stroke at all. I told 3 doctors and six nurses that I didn't care and that this man had had a stroke; one of the nurses wrote me up with a formal report that I was ignoring the MRI report and practicing inappropriately, which was why I had to speak to five other nurses.

The next day the repeat MRI which I insisted upon revealed the stroke. Turns out there is a thing called 'pseudonormalization' of the MRI scan which can occur in up to 2% of strokes. I call it "The neurologist was right and the radiologist was wrong." I like it, guarantees I will never be put out of business by machines.

Six weeks later the guy still could not operate his appliances and he had to move into an assisted living facility. Most neurology stories don't have a happy ending, so I try to at least remember the ones that make me out to be a modern-day Dr House.

I quit my job as a psychotherapist to pursue neuroscience. My research supervisor says that it is a bad idea and that the money just isn't there. I want to do research and clinical diagnosis. Is the pay worth the debt I am accruing by going back to school? I am in my early 30's, have a BA and an MA already but I am starting over to get a BS in molecular and then a PhD in Neuropsych or Neuropharm.

Wow, tough question. You are going to have six figures of debt once you're done unless you practice therapy on the side to fund your project. I don't employ neuropsychologists or neuropharmacologists, so I don't really know how much they make; I know that most will end up being affiliated with academic medical centers. I do believe that our economy will recover and that NINDS and NIMH will again begin to increase their research budgets; we need to know so much more about the brain.

Personally I never thought about any of that stuff; I just followed my passion and had the great good fortune to have parents who supported me every step of the way.

I'm going to college next year.

What's your opinion on majoring in neuroscience in hopes of going to medical school?

I have no particular opinion about this. About half my med school class majored in something non-sciency. The admissions committee also looks for evidence that you're a decent human being, have learned how to handle stress, and can take advantage of opportunities that you're offered - i.e., a self-starter. Research in a medical field is always looked well on. Fairly sure love of nipples is optional at best.

I'm an epileptic that has failed all available AEDs. I had a right temporal lobectomy in 2008. I had a VNS installed in 2011 that had to be removed due to infection. I have participated in 4 drug studies. My seizures are still uncontrolled. Considering the lack of research funding that epilepsy receives, will I see a cure in my lifetime?

You are in a special category of people whom we call "people with epilepsy that is medically and surgically refractory." My heart goes out to you; you have endured more than most people can ever imagine.

I do not know if we will ever have a good cure to offer folks like you. I hope so. I know it can't come soon enough.

I don't know if it has been asked yet, if so sorry, how do you feel about the Presidents announcement for the human brain mapping initiative?

I'm pretty excited about it. I support it, obviously.

I was studying through most of the "decade of the brain," which other people called the Nineties, and a lot of really good things for researchers, and practical stuff for patients, came out of that. I expect something similar out of the President's latest initiative.

What is the mechanism behind Attention Deficit Disorder?

A group of psychiatrists get together around a large table at a fancy resort and decide that they want to medicalize bad behavior in children so they can reap the benefit of lucrative sponsorships by drug companies.

The textbooks say it's a deficit in function of the norepinephrine system, which neuromodulates from its home in the locus ceruleus in the upper brainstem.

You can pick which of the above paragraphs you like better; quite honestly I favor the first one.

Are you honestly implying that you don't think ADHD is real? How do you explain adults with ADHD or children with inattentive type ADHD who are not troublemakers?

Am I correct in assuming you have no personal experience with ADHD sufferers?

I do not endorse the concept of ADHD as defined by current diagnostic criteria, as a 'real' entity. I therefore do not try to explain the things you're asking about because to do so would be to start by assuming that ADHD is in fact a 'real' entity.

I have seen kids who are troublemakers and adults who don't pay attention very well. My take on this: If it is desirable to give those people amphetamines, fine; just do it. Don't make up a fake disease to justify it.

I am aware that this is a fringe viewpoint and not accepted by mainstream medicine. AMA means "ask me anything," not "ask the mainstream medical textbook anything," and I am trying to be scrupulously honest.

Because of my feelings on this, I do not diagnose or treat ADHD, I refuse referrals along those lines, and I generally refrain from prescribing amphetamines for focus and attention issues because I think they do more harm than good. I do not harangue patients who carry these diagnoses - I do not bring it up unless asked - and I try not to get on a soapbox about it in any venue. That's the most ethical way I have found to reconcile my opinions and beliefs with the patients who come through my clinic.

Do you have any experience/opinions on using EEG biofeedback to treat ADD, depression, or addiction? Any opinions on binaural beats and similar things out there to listen to that can be downloaded that are advertised to help all sorts of things? Do you think they can be harmful? Thanks!

EEG biofeedback isn't regulated like a medical treatment and it is not taught as part of an epilepsy training program. I don't have much of an opinion about it one way or the other. Last I looked, the Cochrane Reviews, which I tend to trust, suggest it can be helpful in a variety of conditions but that larger scale trials should be performed.

Have you ever had any experience with Synesthesia?

Lots of migraine patients report it during their aura. I have always had visual impressions - colors and textures - with music and certain sounds and when I first read about synesthesia I had trouble understanding that it wasn't just a normal thing that everyone experiences.

Have you ever experienced Sleep Paralysis?

Yes, once during my residency when I was severely sleep deprived. I awoke unable to move or control my respirations with my eyes facing straight upward. I "knew" that if I turned my head to my right I would see a 12 foot tall demon slavering in the kitchen (I lived in a little studio apartment with high ceilings at the time.) I could sense the frightening presence of the monster.

Oddly enough, I also was aware that I was experiencing sleep paralysis/hypnagogic hallucination, but it didn't do anything to dispel the terrifying feeling.

After a few seconds it 'popped' and I could move and of course there was nothing there. I regard these things as sleep glitches.

Do you know of any long term side effects from taking benzodiazepines? I have been prescribed Xanax for years and do not see ever coming off of it (PTSD & GAD). I worry I will get Alzheimer's (or some brain disorder) from taking it but my quality of life stinks without it.

I do not know of any long term side effects from these drugs after the drugs wash out of the body. You will not get Alzheimer's or a brain disorder from taking Xanax.

Long term use of Xanax is not without its pitfalls, though, largely related to habit-forming and withdrawals. Do talk to your prescribing doc about these things from time to time.

Multiple Sclerosis: What common side effects do you see with YOUR patients for each of the drug therapies? What if I have a side effect that is serious and I need to switch medications – is this going to affect the progression of the disease?

Copaxone has little in the way of side effects for most patients. The interferons make most people feel sick - it's an intended effect, not a side effect; neurologists discovered interferon's utility in MS by observing the effect of catching influenza during an MS flare (it often aborts the flare in progress.) Tysabri is usually side effect free until it isn't. Steroids do their thing, mood destabilization, water retention, etc.

I don't have much experience with Gilenya, Tecfidera and the other treatments.

MS therapy in an individual patient (as opposed to a clinical trial) is a crapshoot. No one knows what is going to happen.

Can this disease eventually progress to serious, debilitating stage EVEN with MEDICINE ? What’s the latest statistics on this?

The answer is definitely yes. I don't know the stats off hand! I treat each patient one by one.

What's your view on concussions in youth sports? Should the issue be taken more seriously?

I am super interested in the new research in this field, not only as a doc but as a longstanding Oakland Raiders fan. I'll be watching tomorrow's AMA with Dr Kreutzer with great interest.

In general I think that the ongoing attitude of "he got his bell rung, send him back in" is harming a lot of kids and I think as a society we had better take a good close look at it. That's starting to happen but I think more needs to be done, and I think researchers like Dr Kreutzer and others are going to have to be the ones to tell us what to do; it's sure not always obvious to me when I see these young people in clinic.

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Not a whole lot. Diagnosed a couple people with it. Was present at operation once (I don't operate, but am occasionally in the OR) and saw agenesis of the sphenoid wing, which is occasionally part of the syndrome and made this guy's skull floor look different from usual. I was pleased to be able to explain it to the neurosurgeon who didn't know why his patient's skull looked unusual.

EDIT: The question was what do I know about neurofibromatosis.

One more.... My mother is a pharmacist and always say that the new healthcare has been affecting them.... Has it affected you? And if so how? Thanks for answering our questions!

There is a lot of regulation. Electronic medical record, silly hoops to jump through when charting patient notes (things like "please include 1 social fact" about the patient), prior authorization for routine tests, et cetera. Overall when inflation is taken into account my pay goes down every year too.

I don't get too worked up about it, I still love what I do. I expect things to get worse before they get better. I support anything that might improve access to care for the worst-off and I am hoping that the Affordable Care Act makes that happen at least to some extent.

Hello, Aspiring Psychology student here (Pre-Med). What is your views on the causes of schizophrenia?

Genetic factors, prenatal malnutrition, and harsh psychological environmental factors in childhood and adult life.

Neuregulin-1 is a gene that keeps coming up in large population-based genetic studies; the Dutch Hunger Winter is probably the best study about health outcomes after widespread famines (maybe double the incidence of schizophrenia in people gestated during it), and it's pretty clear that a very supportive, nurturing environment can "save" people who otherwise were destined to become schizophrenics.

Latest thinking, by the way, is that our classifications of the psychotic disorders into bipolar I with manic psychosis; schizophrenia; schizoaffective disorder; and major depression with psychotic features may be confusing things more than clarifying them. I tend to agree.

My old professor used to say that the psychiatrists had schizophrenia for now, but eventually the neurologists would take it back. On one level he was joking; on another level I tend to agree with him.

Does psychiatry play any role in consulting medical disorders?

Not sure I quite understood that question.

In the USA psychiatrists and neurologists are certified by the same specialty board, the ABPN. About a third of my board exam was psychiatry. I was surprised that it should be so much - I received very little formal training in psychiatry - and so I asked a professor why this was. He said "Wait till you get out in private practice - you may decide they didn't emphasize it enough." He was correct.

Do you know anything on migraines, like what the current theory behind them is? I'm a 17 year old male and I get migraines all the time. Currently I have one that has lasted 5 weeks and just ended steroids with no results. I'm just interested in theories that could cause them.

I know a great deal on the current theory of what is behind migraines. None of those theories have helped me treat a patient, ever, so I tend to take them with a grain of salt. My favorite book on migraine was written by Robert Cowan, MD; it is available on Amazon.

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I know nothing about that at all. My guess would be that the side effects would outweigh the benefits in the vast majority of patients ;)

Thanks, I'll have to look into that book. Also, I'm thinking about making my career in psychobiology. Anything you can tell me about it?

Yes, it's an awfully long word when 'neurology' would do just as well :)

I took a great class in psychobiology in college, it really stimulated my interest. The text was Carlsson's "Physiology of Behavior" and I would recommend that book to nearly anyone who can read at the college level; it is an excellent and endlessly fascinating book.

What is your feeling about massage? Do you feel that it is a respected part of the medical community?

It gets short shrift in my opinion. A talented massage worker can do wonders. I try to get a good work over at least 4 times a year. I was never taught anything about this in medical school; I learned about it on a trip to Esalen taken as part of a vacation.

Having suffered from severe febrile seizures (my parents were told when I was 4 that if I had one more as severe as my final seizure I'd be brain dead) as a child and now recently being diagnosed at age 19 with mild aspergers and severe ADHD.

I was wondering if you think there is correlation to mental disorders such as my own with childhood seizures as well as the medication that treats such seizures, including in my own experience a form of methamphetamines and Epilim until the age of 8 which since being diagnosed I've discovered are also used in the treatment of ADHD.

I'm not looking for medical advice or a diagnosis for how I ended up with severe ADHD with no family history of the disorder, but rather am just curious if there is a correlation between childhood seizures and the medication used for treatment of said seizures and the development of mental disorders as a whole.

It's well known that some of the more sedating medications, such as phenobarbital and valproic acid, when used in childhood do impair school performance and that the effect is lasting after they are stopped if they were used long enough. We know too little about questions like yours and thankfully a lot of research is underway now.

I wanted to say thank you. I have Chiari 1 Malformation, so I've dealt with quite a few of you guys, and I really appreciate the work that you do.

Have you ever dealt with a Chiari patient, and if so what was your plan for them? How difficult was it to treat?

Chiari I is tough. I have a few under my care and have diagnosed a few - it's an imaging diagnosis for me, I have never managed to catch it just based on my clinical exam. Surprising how few radiologists ever look at the foramen magnum on the sagittal MRI, which is the best way to detect a Chiari I.

The plan differs from case to case, but either it's surgical or nonsurgical. Nonsurgical management of the headaches is often unsatisfactory. When hard neurological symptoms are seen - eye movement problems, paralysis, incoordination, etc - then it's time to think seriously about an operation.

The operation sometimes leaves patients worse than when they started, which gives me a lot of pause when recommending it; it is one of the operations where the surgeon's hands - the surgeon's skilfulness, in other words - makes a lot of difference.

Thank you for answering this; I also have a Chiari I Malformation which was found incidentally during imaging after non-Chiari related headaches.

Do most patients with Chiari inevitably exhibit symptoms/complications, or is it possible for someone to go through life relatively normally?

Well, I don't think anyone knows about 'most' patients with Chiari I because so many of the scans I see show a Chiari I that has caused absolutely no symptoms at all. We don't know how many people are out there who have a Chiari I but have never been scanned!

A neurologist saved my boyfriends life. It was always assumed his seizures were solely Diabetes related, but turns out he also had Epilepsy as well.

IS there a link between Type 1 Juv. Onset Diabetics having seizure disorders develop as well?

Huh, that's an interesting question. I have a few patients like that in my clinic but the last I looked, which was last year, there was no known relationship.

As a RSPGT, what can I do to make your life easier?

Polysomnograms!

Seriously, my sleep apnea patients have such trouble finding mask and setting combinations that are comfortable. I know nothing about masks and when a good tech can haul out the box and help a patient get fitted with something she might actually tolerate, it's a huge help to me.

Why do people with depression hurt themselves?

The best explanation of this I have read is Karl Menninger's Man Against Himself, an insightful and compassionate book written in 1937 about the psychoanalytic grounds of depression.

TL;DR: life wish and death wish always struggle; death wish wins.

Have you ever heard of POTS (postural orthostatic tachycardia syndrome)? It's a form of dysautonomia and my wife has it, but it seems as if very few physicians have ever heard of it, let alone know how to really help her.

She also has trigeminal neuralgia, and is currently on a very high dose of gabapentin to manage it. Are there any long term effects of high dose gabapentin use? Would it be better for her to get a surgery of some sort to deal with the neuralgia?

POTS is pretty common; i'm not clear how naming it that is any better than the older names, which include "vasovagal syncope" and "orthostatic hypotension." I have endured the lecture from specialists about the differences, but the same medications help - sometimes - and sometimes it is totally refractory to treatment.

I'm not super comfortable giving you advice about your wife, who is presumably not my patient. I will tell you that the operation is not a minor one, and that I have had at least two patients have life threatening complications from it after I recommended they go have it done.

How would you compare a neurology residency to a internal medicine residency? I wanted to be a neurologist for a while, but kind of on the fence at the moment. As a prospective medical student, I've heard that getting into medical school is the hardest part of the schooling experience since there will no longer be any weed out science classes. What was your experience with that? I heard it was basically just a hardcore premed program from students at the university of washington school of medicine and most students don't even show up to class.

I have no respect for medical students who 'didn't show up to class'. They make bad doctors. I tried to attend every class. I certainly wouldn't take advice about what class was about from students who didn't attend.

Neurology and IM residencies aren't that different. Like most neurologists I did a medical internship and got to rotate through a bunch of IM wards in the hospital. The neurology residency was similar except the patients had neurological illnesses. The first year of neurology residency was like being an intern again. Most people now do subspecialty training whether they graduate from a neurology or an IM program.

So, do you get your M.D. first then take additional specialty courses in neurology? I'm curious.

Yes that's right, MD, then internship, then 3 years of neurology, then many go on to do subspecialty training in stroke, epilepsy, nerve/muscle, movement disorders, neuro-infectious diseases, neuro-immunology, cognitive neurology, or others.

What do you typically prescribe or how do you treat patients with serve, chronic migraines? I've seen several neurologists over the years and I'm always looking for more options. I've recently heard about nerve blocks for example, but I've never had that done. I'm not even sure if my neurologist does them.

(I am not looking for medical advise - just perhaps treatments I haven't heard of or tried.)

I have recommended a book in comments above. I follow the method outlined in that book.

First of all thank you for this AMA. :) I realise this is probably not the place to ask this kind of question as there are MUCH more interesting things people want to see answered... But I'm SO desperate.

Right, essay time. I suffer with severe migranes of which no doctor or neurologist has found the cause and/or triggers. I get what is known as Visual Migrane Aura/Aurora; I ALWAYS (and I mean ALWAYS) have a small blur in the right side of my vision, I'm about 1ft & a half feet away from my computer screen and it's about three cm to the right and is a tiny bit bigger than a centimetre in diameter. It is SO annoying and I see it even with my eyes closed.

When I have an attack, it cripples me to the point where I can't see a thing but a blurry mess on the right side of my vision. It grows from that spot to an arch-like shape and grows outwards Light is super-sensitive all the time, even on a cloudy day when I have no trace of an attack. When it passes I get an extreme headache/migrane on the left side of my head which puts me in bed for at least the rest of the day.

I've had numerous eye tests, checkups and tests/scans at hospitals. My old GP didn't even BELIEVE ME and thought I was lying to get attention.. hence why she is my old GP (I went private in the ende, waste of money), but I can see why some people would think that way, I've scoured the internet and never heard of any case similar to mine.

I've had to ditch plans, miss important family events and it made me lose a job a few years back as the attacks lasted 9 days straight, over and over. My dad suffers from severe epilepsy and my mum has migrane attacks but nowhere near as sever as mine, I always assume it's a mix of both of these and amplified, but I can't be sure. I work in Quality Control in a warehouse office so I'm infront of a computer screen 8 hours every weekday, I'm also a video game nut so that's more time infront of a screen and I'm part time studying video games creation; my point is it's not staring at screens which is what my parents are adamant of. The attacks are seemingly random and can range from a couple of days apart to 9-10 months, that's the longest it's ever been, since I can remember. Any help or advice would be tremendously appreciated.

Sorry for the essay, lol.

The story sounds pretty typical. Not everyone can be helped, but a headache neurologist is the right place to start.

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Thanks for throwing me an easy question. I'd hate to see a difficult one.

I think consciousness, the sensation of consciousness, comes from the language area and its mirror area in the other hemisphere, which is always self-stimulating with this constant flow of words and thoughts trying to interpret our experiences. Others believe differently. The question will probably never be answered as it is ill-formed in terms of generating a testable hypothesis.

I've wanted to be a neurologist (an epilepsy specialist no less!) since I was a child, and I've never lost my interest. I made it through undergrad prereqs and the MCAT pretty darn neatly, but I'm nearly thirty and I have a connective tissue disorder and sleep problems that add up to "attempting a challenging schedule for any length of time = massive pain". Last year my application process got lost somewhere in burnout due to the health challenges I was facing; I never completed most of my secondaries and lost a lot of time to being run-down and disillusioned and uncertain.

Now I'm not sure what to do. There really doesn't seem to be an accessible way for me to become an MD - I have the mind for it, but not the body.

So now I'm career-idling, and I really desperately hope you see my question and have the time to answer it.

What other roads are there through graduate or professional school that allow people to become involved with neurological research? Most of what I see under the heading of "neuroscience" isn't what I'm interested in doing (computer models and animal models) but that doesn't preclude degrees existing that do focus on what I'm interested in - seizure disorders, sleep disorders, migraines, and similar. I just haven't heard of such degrees and programs. I'm considering a public health degree, but I'm just not sure if it would give me access to the kind of work I want to do.

In short, along the way, have you encountered non-MDs who were doing research in your field, what degrees did they have, and what did you see of their career paths?

Research design in particular is a strong point in my cognitive abilities, and I'd really like to be able to use it to help someone sometime. Oh, and not starve. The not starving would be nice, and I'll settle for it at this point. Making the big bucks is totally optional.

There are always folks around the university research environment without advanced degrees - secretaries, assistants, office managers, lab managers, data processing clerks, EEG techs, physical/occupational/speech therapists, etc. They participate daily and help the work along. If you want to design and run a research program, however, you need an MD or PhD.

How close are we to seeing a cure for Parkinson's?

50 years. Let's try to find out what causes it first, or if what we call PD is actually a single disorder- a lot of us think Parkinson's diseases would have been a better phrase.

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Some patients try TENS, which is a transcutaneous electrical stimulation. I am not convinced that the data supports it for regaining muscle bulk after amyotrophic brachial neuritis.

ABN is a bizarre condition. If it were really an autoimmune condition targeting specific antigens in the brachial plexus, why is it almost always (95+%) confined to one side of the body? Do the left and right sides look different to the immune system somehow?? I have never heard a satisfactory answer to this question!

EDIT: The original question was about regaining muscle bulk after Parsonage-Turner brachial neuritis (amyotrophic brachial neuropathy).

Have you ever had the experience of an anticonvulsant medication actually causing seizures? I just wonder if this paradoxical effect is ever heard of.

It happens sometimes. Carbamazepine (Tegretol) is notorious for worsening seizures in some patients who have one of the heritable generalized epilepsy syndromes, for instance. (Doesn't always happen! Some patients don't read the textbook and don't behave like they're supposed to.) There are other examples.

I have Spondylolisthesis and Spondylolysis trying to avoid surgery as I'm only 32 and I worry about complication. I've been seen by 3 Neuro MD's, who basically all told me "surgery and/or pain mgmt & PT."

1. Do you see any work coming up with these issues that excites you as a Neuro?
2. Am I stupid to think that losing more weight (lost over 15 lbs, will lose as much as I can but staying healthy) and good PT/Core strength will eventually help me to get off meds and hopefully be able to have a kid & carry it when it's a baby?

Just general advice-I know you can't truly diagnose. Thank you for doing this! All the Neuro's I've worked with have been...well...unsatisfying for various reasons and I'm totally charmed by a Neuro who would do an AMA!

Back pain is the most common neurological disorder and accounts for more days of lost work than all other neurological disorders put together.

It's tough stuff and there are never good answers. You're not stupid; those things that you mention are the things that invariably help my patients. Try to find a doc whom you feel cares about you; in my experience that, also, helps, maybe more than some of the other things we use.

Would you recommend this is a job to youth? I'm interested in the brain and science. What is a day like?

No youth can have this job. I was 35 before I saw a patient independently, without supervision. A precocious person might have gotten there by age 30, but not as well trained as I was. So you better enjoy being in school!

When I was young - 18 - a doctor asked me why I wanted to become a doctor. He then ignored my answer, which was something like "I'm interested in the brain and science," and told me that the only legit reason to become a doctor was because I wanted very badly to take care of sick people. At the time I thought he was being a pompous ass, but many years later I admit that he was 100% correct. (Last I checked on him, by the way, he held a very prominent position at the NIH, was world famous in his field, had achieved every personal success and professional laurel short of the Nobel.) Anyway, I discovered that I like to take care of sick people very late in the process, which was a stroke of good fortune for me.

A day is pretty routine. I am either in a hospital or in my clinic. Sometimes I am wearing a necktie and/or a white coat. A patient has a neurological problem, either a symptom, or something some other doctor has detected. I do my thing, which takes about 45 minutes to do but a lifetime to master, and at the end of that thing, I have some understanding about what is wrong and how to help. I tell the patient and their primary doctor what I have learned and what I think ought to be done about it. Rinse, repeat until end of day. Repeat until retirement.

I couldn't imagine doing anything else. If it suddenly became unprofitable I would do it as a hobby.

Have you had a patient with Complex Regional Pain Syndrome or RSD? How do they get relief from it?

I have diagnosed this condition more than a handful - maybe a double handful - of times. My partner is a nerve and muscle expert - that is a branch of neurology - and nowadays I usually leave those patients to him.

When I would diagnose it, I would refer the patient to a pain specialist. Not all cases of CRPS/RSD are painful, but the ones that are tend to be really difficult to treat.

Cellphones. Good or bad for the brain?

Depends on whether you're talking about Britney Spears all day, or if you're using them to browse reddit.

More seriously, my answer is "no."

Hi, thank you for doing this AMA. I am a sophomore in a 4-year BSN program with a minor in neuroscience. The study of the brain has always fascinated me, and I have begun considering what schooling I will pursue after becoming an RN. Are there opportunities for physician's assistants or nurse practitioners in the field of neuroscience? I have also considered pursuing an MD... but anything is possible :) Thanks again!

Some neurologists use NPs or PAs in their clinics. I am conservative and maybe a little cranky; I have found that NPs and PAs generally are dangerous when confronted with the neurologic patient, because they often do not even know enough to realize that they don't know anything - not thing one - about the practice of neurology.

I have actually received a 10 minute lecture about the proper way to do a neurologic exam, in an emergency room, by a PA fresh out of training, while ER docs and nurses with 20+ years of experience looked on in amusement. It wasn't very funny to me; that PA's ignorance killed people. Eventually she wasn't working in that ER any more. So don't be That Person.

I have considered training an NP or PA to assist me; I figure it'd take about 2 years of daily supervision and then there would be nothing preventing that person from leaving with their new knowledge and taking a better-paying job elsewhere. So I haven't bothered.

Have you seen any cases of ADEM?

Yes. Awful disease, very poorly understood. Tends to affect children predominantly. I have seen it kill a few kids; others survived and I am not sure they were better off than the ones who died.

After numerous trials showing unchanged or worse outcomes with administration of thrombolytics for stroke, why does neurology continue to believe thombolytics are helpful???

The indications for IV thrombolytics are pretty clearly stated and there are numerous trials and post-marketing data replicating the key finding, which is that of improved 90-day-post-stroke outcome status in survivors. The major Emergency Medicine professional societies have also recently endorsed that data and those indications, so I believe there are not many holdouts left.

This data changed the sleepy little clinic-based specialty that I trained to practice in, into one where I am expected to be sober, awake, and physically present in the emergency department within 29 minutes of being telephoned, at any hour of the day or night. I sure as hell would not continue to do that work if the data on benefit was not compelling.

The data on intra-arterial thrombolytics is much less compelling and I think that story is still being told - check back in a few years.

What are your views on Neurofeedback ( through EEG)?

Answered that above, the question was about biofeedback.

How close are we to be able to remove the brain and transplant it into another human body with the brain removed with the person still alive and well in a new body?

Not close. Technically it could easily be done in terms of blood supply, but there would be no way to connect the transplanted brain to the spinal cord, eyes, or other nervous system structures, so you'd end up with a live brain that had no inputs or outputs. We do not know how to make the central nervous system regenerate its connections; left to itself the brain will not regenerate.

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At my age would I do it over again? No, it was too grueling. If I were 20 again I wouldn't change a thing.

I dealt with debt the same way other people did, slowly paying it off. I recently met a couple, who met and married in med school, who have come out with $565,000 of debt. I kind of feel sorry for them; they picked family medicine and ER medicine and they are going to be living like grad students while paying that debt off for the next 30 years. I don't think I'd take that kind of debt on.

I have physicians in my family and I was advised not to go into medicine unless I wanted to take care of sick people. I thought taking care of sick people sounded fine. If you do not want to take care of sick people do not become a doctor.

Where did you train to be a neurologist? How long does it take?

I went to college at an Ivy, med school in my hometown and then residency and fellowship at programs that US News considers top 5 for neurology. College was 4 years, med school another 4, internship 1 year, neurology training 3 years, and epilepsy fellowship one year. I also got a 2 years master's degree along the way and I spent a second year in my epilepsy fellowship because I liked it and was doing research.

It seems like a long time, but most of it was fun. The residency caused me to be sleep deprived most of the time and that was not fun, although I enjoyed the work and the learning.

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Nope, I'm an adult neurologist. Some of these kids have epilepsy and they sometimes come under my care just for that problem, or as adults. I'm assuming you mean pervasive developmental disorder, by the way.

Good pediatric neurologists are rare; they have to have a little bit of Spock and a little bit of Mr Rogers. I have all the Spock, but none of the Mr Rogers, and I find that that combo tends not to meet families' needs.

How many Vestibular Schwannoma cases do you reckon you've seen?

Not very many other than incidentally, they are more often caught by ENT (ear nose and throat) doctors in my experience.

What made you want to start your small business rather than work at the regular hospitals?

I wanted to be my own boss. (Which is awesome, by the way.)

I do not believe this is a good reason to go into medicine today; I believe in ten years or so most US physicians will be employed, probably including myself.

Why is it so hard to get a working definition of autism? As a layperson, it looks like there is really a whole bunch of stuff going on there that people don't agree on. With the exception of some clear cut cases, diagnosis can depend as much on your professional as your symptoms it seems. Can you shed any light on this?

I have noticed that over the years, any diagnostic label used to mean that a child will never acquire normal intelligence or normal functioning will become heavily stigmatized. We obviously don't call kids imbeciles, idiots or morons any more, although when those terms were originally used most physicians used them without any malicious intent. Mental retardation, developmental delay (a silly term because those affected do not eventually 'catch up'), and even static encephalopathy are starting to be criticized on the grounds of being derogatory.

We now have a sheaf of new terms - autism, pervasive developmental disorder, et cetera - to apply to the same kids. Parents are universally extremely displeased - that is putting it mildly - to receive any news along these lines regarding their kids; and I think many folks would be surprised how strongly angry parents can influence both diagnostic and treatment thinking in the exam room.

It's a sensitive topic for these reasons and honestly I think that the need to be sensitive and dance around these issues to some extent, while important for good bedside manner and good patient care, also has the effect of complicating the science unduly.

In addition, the functions in question - social function, language function, executive function - are among the most complex and least well understood functions of the human brain. That doesn't make it any easier.

I've phrased this as politely as I can but I am sure the ideas I expressed are going to be displeasing to some. I apologize in advance to those I have offended.

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Exposure to small amounts of lead, mercury and arsenic are a natural byproduct of living in an industrialized society. There is a whole cottage industry of docs, not practicing within generally accepted medical guidelines, who identify these tiny amounts of metals in a patient's urine or blood, use it to explain all kinds of unrelated symptoms, and prescribe off-label, not-indicated, and sometimes dangerous therapies to 'treat' the bogus diagnosis.

There are, of course, published toxic levels of these metals and they can poison people. In that case, accepted treatments are to be used.

You can generally tell the two things I've mentioned above apart: the first one isn't covered by insurance and thousands of dollars are asked for out-of pocket. Observed benefits are due to the placebo effect. In the second case, insurance covers the treatment, no one gets rich, and the patient gets better.

For more, I recommend quackwatch.org - which is not perfect, but which in my opinion is a generally useful and accurate resource.

On this subject, I worked in a fluorescent light bulb factory for 5 years. I was exposed to mercury daily and was tested and found to have high blood levels for about 6 months straight. Could this be the a contributing factor to my adult onset TLE?

Not to my knowledge - but I don't know everything!

My dad had Alzheimer's Disease and was diagnosed at 62. He progressed pretty quickly and ended up dying from complications of pneumonia caused by food aspiration at the age of 67. He was also diagnosed with Parkinson's, which from what I understand, is fairly common among Alz. patients. He was a Vietnam Vet, and I know that Agent Orange can cause several cancers, and even Parkinsons....but I've never heard much about Alz. Do you see a lot of Vietnam Vets with this disease-even among those who weren't exposed? I met a LOT of them when my dad was in the VA who had early onset Alz, and I just wondered if you see a lot of this?

AD is extremely common and can be hard to differentiate from Parkinson-disease-related dementia prior to autopsy. The VA has accepted research that indicates that Agent-Orange-exposed vets have a much higher risk of developing PD; and indeed I have a handful of such patients in my clinic. I am not aware that Agent Orange increases the risk of developing AD.

AD is a far more common illness than PD; 1 in 3 people will meet diagnostic criteria for AD if they live to age 80. It is a silent epidemic.

Parkinsons is an ugly disease. I often wondered if my dad would have even wanted to be aware during the downhill slopes he suffered as a result of the PD, or really even the AD. While I'm sure you've seen the way they suffer...and the family suffers with them....do you ever find yourself absolutely fascinated by the progression of it? My dad had a doctorate degree and taught math at a fairly prestigious university....around early stage 3 he couldn't draw so much as a triangle or a legible number. I stayed dumbfounded by it all the way through...and it's just so heartbreaking to watch. Take care of those patients....and their families. It isn't an easy world to live in!

I enjoy treating Parkinson disease because, at least while the drugs still work, a really good doc can make a huge difference in a patient's quality of life. The illness always wins in the end though, and I think end-stage Parkinson disease must be among the most terrifying and horrible things that come to my clinic.

I do not find Alzheimer disease particularly interesting, I am sorry to say. There is very little for me to do in terms of using my specialized knowledge to improve a patient's lot. I can diagnose a lot of Greek words that begin and end with 'a' - alexia, agraphia, aphasia, asomatognosia, astereognosia, apathia, amnesia, anorexia, ageusia, and probably 20 more - but really, who cares? It doesn't mitigate the suffering of the family one bit.

My godfather suffered a fall in late '11. After that he complained of back problems but no matter what tests were done, nothing showed up. After that he began losing his speech. It is a year and some months later and they can't find anything. I'm convinced it's neurological. Is there any way his fall could've triggered something? His back is fine now but he can't string sentences together and barely speaks. It's heartbreaking.

In my experience, speaking and not-falling (i.e. staying upright) are both functions of the nervous system. When I have seen cases like this, most often both the fall and the speaking trouble have each been effects from some common cause, often a neurodegenerative disorder.

I can't comment on your godfather's case however. Your questions about him are best addressed to his neurologist, and if he doesn't have one, he probably ought to.

In what and from where did you get your undergraduate degree? I'm interested in going to graduate school for Neuroscience (eventually), but not everyone has an undergraduate program for future neuroscientists. I understand that you may not be able to give me much advice since you chose to go the medical route and I tend to be more interested in the research side of things; I just wondered if you had any tips or anything!

My undergrad degree was in Biochemistry. It doesn't matter where you study; it matters that you take full advantage of every opportunity you have and do as well as you possibly can, because at the next stage of the process, that's what your admissions committee wants to see.

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Um, neurology is great because you get to study brains which are more interesting than other organs? I don't have a great answer beyond that.

Neurologists are generally nerdy introverts; 75+% of them come out INTJs on Myers-Briggs inventories. You have to love a good mystery and have the kind of personality that enjoys memorizing tons of information and using that as a foundation for detailed speculative analyses.

I think we will have better diagnostics and better therapies. I doubt computers or non-physicians will ever displace the role of the bedside neurologist, at least in your lifetime.

I think that at least in the US it will become harder and harder to make a living as a neurologist because the agencies that determine reimbursement have made clear, over and over again, by word and deed, that they do not value the cognitive work that physicians do and which neurologists do more of than any other specialty.

I totally understand the 'nerdy introvert' type getting into studying brain weirdness, but as an epilepsy patient, I sometimes really wish hospitals would do a "bedside manner for neuros" seminar or something!

I often start off by apologizing for my crappy bedside manner; that way my patient isn't totally shocked later. I do my best, but neurologists are not famous for their warmth and empathy and I am certainly no exception. Frankly I think that by being able to type the above I am more insightful than 90% of neurologists.

Besides saving lives on a daily basis, what is something you love about your job?

It is endlessly fascinating. There is always a challenge - every day - and always a chance to help someone by being just a little smarter or more insightful than the last doc to see your patient. 99% of the time that is great.

There are occasionally days where the "always a challenge" feature is a bit of a drag. If I come to work tired or off my game, the same difficult challenges still present themselves, day after day after day. It is not a very routine job.

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I took a shot at that above. Brains are inherently interesting to me, always have been. I have one and use it and I feel like that is why I was interested in it. Surprised more people aren't more interested.

How do you prefer your eggs cooked?

Over easy, on top of a piece of toasted wheat bread which I use to mop up the yolk.

Can SSRIs permanently damage the nervous system?

When taken as indicated (not used in combination with drugs that the SSRI could interact with), my opinion is "no," they do not permanently damage the nervous system. I don't have much data to back up that statement but I do believe they are among the safest drugs currently in use by physicians.

Why is it that when I start discussing certain topics with people, I lose focus on my surroundings and kind of "space-out" with a feeling in the pit of my stomach that something horrible just happened? (it usually causes me quite a bit of difficulty finishing the conversation)

I don't know, because I haven't spent time interviewing and examining you. If it's really bugging you, go visit a neurologist - these kinds of symptoms are not foreign to us.

understandable... unfortunately i cannot afford that. Do you see a lot of patients who cannot afford treatment and diagnosis?

Yes, quite a few. I would be willing to take quite a pay cut if it would mean that everyone who actually needed my services could get them. The US is the only civilized country that ties the ability to work to the ability to get healthcare. If you think about it for a moment - if you can still go to work, you are not very sick, are you?

Most of my patients have serious neurological disorders and are often disabled by those illnesses; shortly after I diagnose them they often lose their jobs, and with it their insurance, so now on top of all the other problems these patients have, their doc is practicing medicine for free. Go Team USA!

I'm hoping the Affordable Care Act will help at least some folks; so far all it's done is make me hand out a bunch of unintelligible paperwork to my employees.

Greetings Good Doctor,

Do you see a higher (or lower) number of patients by profession? Say more athletes then truck drivers.

Can you tell the difference between a tricorder and a medical tricorder? Don't you dare wiki this. I can tell if you do.

Neurological illness doesn't discriminate; all kinds of folks come through my office. Where I live has more to do with the patients I see than what kind of doc I am.

Spock's tricorder looked like the portable Archer brand cassette tape recorder I grew up with; Bones' little device had a small hand-sized accessory that made a woo-woo-woo noise. I idolized Spock growing up; I often think how weird it is that I turned into a Bones instead. My bedside manner has a lot to do with DeForest Kelley, probably far more than is really appropriate.

We live in Seattle. My wife has a history of suffering from migraines. She takes some meds but doesnt do much follow up with her Neurologist to see if there is anything new she should consider trying. Her passive attitude frustrates me since I want her to find a "cure" that works for her. I notice a pattern of her having more headaches when the weather turns from sunny to rain here which is really only around now throught summer. Has any research made a connection with weather and headaches? Are there advancements made in the migraine area on a regular basis or is it still and will it always be a grey area in terms of effective treatment?

Weather changes and allergens are both common migraine triggers that are often seasonal.

Here is a little anecdote that I like: it costs about a billion dollars to get a new drug to market. Most of this has to do with jumping through the FDA's hoops regarding safety and effectiveness, so that the FDA will grant the drug a 'label' for a certain indication. Drug companies have gone through this process and brought eleven -triptan class drugs to market, even though they do nothing to prevent headaches; they are FDA-approved to abort a headache already in progress. There is not much difference among these agents in terms of efficacy and their mechanisms of action are identical.

There has never been a drug with an FDA-approved label to prevent migraines from starting, although many drugs are used off-label for this purpose with varying degrees of efficacy.

Honestly, I believe if NINDS threw eleven billion dollars at migraine researchers, we'd have a cure in 5 years. I love big pharma as much as the next doc but I think that the way the current system is structured causes our priorities to be out of whack.

I recommended Robert Cowan, MD's migraine book above; it is available on Amazon.

Let's see if I can stump you with a really difficult question... Which nootropics would you consider safe or moderately safe to use? Let's define "moderately safe" as the equivalent health effect of smoking a pack a day as an adult. And let's leave out any possible concern for effects that these substances may have on the developing brain. Let's just look at adults.

Would you prescribe a person one of these nootropics if they signed a waiver saying that they understand the risks and do not hold you responsible?

Smoking a pack a day 'moderately safe'? I cannot think of any single human behavior that has been shown to have more catastrophic health effects, other than things that are instantly fatal.

The idea of a nootropic (which incidentally I think is a silly word because it's the kind of thing that Penelope's suitor Antinoos would have wanted) is that a drug could be taken to enhance or improve mental functioning. Amphetamines clearly improve performance on all sorts of cognitive and functional tests; and have all kinds of deleterious side effects; it's not clear why people who don't mind harming themselves look further, and indeed many do not.

I don't think that the data is there to support the use of things like piracetam, selegiline, modafinil and its analogs, and a lot of other stuff that people use off label because they wish their brains worked differently than they do. It's not so much about safety for me; it's that I think the quest for brain enhancement in a pill may be fundamentally misguided.

I do not prescribe nootropics or anything like them. First of all, waivers like that are not legally enforceable. Secondly, if you presume that I know more about the topic than the guy signing the waiver (which may not be true, but if it is), then it's not ethically acceptable.

Finally, and most important to me: I took an oath that was very clearly phrased: First, do no harm. It didn't say: do no more harm than a pack-a-day of smokes. The oath says, quite clearly, "First, do no harm." I try to stick by that oath because I think it contains the wisest set of guidelines ever established for the practice of medicine. The part about doing no harm is clearly the most important part of the oath and I think that if more docs paid attention to that principle, a lot of good would result.

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Yes; yes.

From my perspective, the fascination of the neurology process seems to blind me to the fact that the patients suffer terribly and often find little relief. I found oncology incredibly depressing for the reasons you mention; neurology is another field that bothers a lot of medical people because there are few cures. I happen to be someone who isn't all that bothered by it, and that's a good thing because otherwise we'd be short on neurologists.

Adderall. Have you seen any negative outcomes from people using it who are not prescribed.

And what do you think of DTi as a diagnostic tool? What's your favorite imaging technique?

There are all kinds of well documented ill effects from misuse of amphetamines. I have seen them all, but don't take my word for it.

Diffusion tensor imaging is neat stuff. The experimental DTI that I have seen is among my favorites, mapping white matter tracts in intact and damaged human brains. Functional mapping with physiological radioligands - such as the PET DATscan - is also fascinating to me and I wish I had access to the technology for all the diseases I treat.

All brain imaging is fascinating to me and it seems to advance every year. I often wonder what the neurologists of old would make of it. They would spend weeks doing their intake neurological exam and then perform a careful autopsy on the patient's death; it is an incredible luxury to be able to have the MRI minutes after examining a patient, there has never been a better or more exciting time to be a neurologist.

Hi Doc, I was wondering if you would mind telling me what you know about Pick's disease?

I would! It would take hours! What do you want to know about it?

You must be busy! Im just wondering how the social life of a doctor is. It is my dream to become a pediatric cardiologist, but it is so much schooling. I want to live my life. Im no the best when it comes to math and my grades arnt the best. One thing i can tell you is that i love medical books. I could read symptoms and scenerios endlessly. Im in high school by the way TL;DR: hows the social life? Not the brighest student, can i still be a doctor.

Most doctors are introverts and would prefer an hour curled up with a good book to an hour out with friends. There are exceptions and well-disciplined people can overcome this with extra hard work and still make time for their social lives.

But really, would you go to a doctor if he told you he wasn't good at math and his grades weren't the best? Would you want him picking a drug for you to take, or calculating the proper dose? (Would you want to be that doctor - the one who was pretty confident that other docs who were smarter would do a better job taking care of his own patients?)

Everywhere I've been, if medicine wasn't the #1 thing in your life, you were told that you belonged elsewhere.

Doctors have among the highest job dissatisfaction ratings and the highest levels of suicide of any career path. In my experience those are the docs who went into it for the wrong reasons - they don't get a kick out of doing medicine, they want something else - money, status, approval, a sexy spouse, being just like the doc who cured them or their brother or father. Whatever. They get to the middle of their lives and realize they're not satisfied, and wasted their youth on something that didn't give back what they were expecting.

My guess from what you have said is that you are among the 99% of people who will not become doctors. If you chose to prove me wrong, you would make an excellent start by boosting your high school grades - in all the classes - and then going on to college to do well in a major you truly enjoyed.

What are your thoughts on chronic headaches?

Most headaches are migraines; migraineurs tend to have a lot of rebound headaches, which result from taking too many analgesics. I recommend Robert Cowan MD's headache book to everyone who wants to learn more; it's available on Amazon. (I don't get a kickback.)

Hi, I feel I would like to become a doctor today, specifically a neurologist too. Were there any other medical fields that interested you? How are your working hours as a neurologist? Ever see anything gruesome in your career? What is the whole deal with 'scopes' of someone's specialty, say if someone broke their leg, would you not be able to fix it or not be the most qualified to fix it? How do you remember all the big names of diseases and stuff, isn't it hard?

Also, I must ask, how is your handwriting?

Thanks for doing the AMA

My handwriting is not terrible, although it used to be beautiful. When I need to be legible I print draftsman's block capitals.

I seriously considered trauma surgery; I later realized they are the only other docs who really depend on their physical exam to do their daily work, which was what I really liked about that field. I also considered neurosurgery, and I was surprised by developing a real love for ENT (head and neck surgery) during my rotation. These decisions were made much easier by the fact that I have terrible hands - using my hands to do fine work every day was always going to be an uphill battle and I am so, so glad I decided against it. There's nothing wrong with my manual skills medically; they're just a little below average, my art projects always were misshapen and drippy, my model airplanes fell apart, et cetera. Not the guy you want operating on you, right?

As far as the nonsurgical specialties, I liked endocrine and nephrology - they are both very analytical, cerebral specialties. Most of the endocrine and kidney docs I know also like neurology. It's a personality thing, I think.

I only practice neurology today. I just don't bother doing anything else, when I know there's someone who trained many years and is so much better at it than I am, and they're right down the hall.

You're welcome! I'm enjoying it.

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Neuropathy in HIV is actually a rather complicated topic and I am not up to date on it; the area where I practice doesn't have a very large HIV prevalence and I send all the nerve cases to my partner anyway. So I'm going to beg off your very reasonable question. Nearly any big city university will have a neurologist with a special interest in questions like these and I think you might benefit from a visit to that doc.

Also, if someone has used blood products from donors who had CJD... should they be worried?

Hell yes.

What is the possibility that a human brain could create its own reality?

100% man, haven't you ever gotten high?

As the parent of an mid-to-high functioning autistic daughter, age 5, what do I need to ensure I do to help her maximize her trajectory? We currently do OT, speech and ABA therapy. Secondly, from your experieance should we try cranial sacral therapy?

I'm not comfortable answering this question, but I wish you and her the very best.

Is asking for a range in which your salary resides out of question?

Salary.com has figures for neurologists. On years that I work extra hard I can hit their median figure for my area; last couple years I've been dialing it back a little and am closer to the 25th percentile. I do not have a "money practice" - never cared to run my affairs with that as the #1 priority - and I guess I could probably hit their top of range figure if I cared to try that way; but I would not respect myself in the morning.

Another way of looking at my compensation is this: I have never felt that I wanted for a single material thing in my entire life. That may actually be a better way of looking at it, I think; and I count myself among the most fortunate people now alive because I can sustain that lifestyle doing important work I love to do every day.

I actually don't have very expensive tastes, though. Yesterday I spent a few hours building a clock for my railroad station in Minecraft. That was free.

How often do you deal with spinal cord injured patients and what are some of the best/most remarkable/surprising recoveries you've seen?

I see a handful; neurosurgeons see more. I have definitely seen a few people who I told flat out "You will never walk again" get up and surprise me a few months later. All of those patients took my statement as a challenge.

Stubborn, strong-willed people do well after spinal cord injury. Anxious fussbudgets like me often curl up and die. I hope I never get a spinal cord injury!