Editors' Note: Sethi suggests that neurology is mainly a clinical discipline. Dhand et al. explain that while many neurologic diagnoses are made clinically, some need additional laboratory, imaging, and electrophysiologic testing. The role of cortical cholinergic function on gait in patients with Parkinson disease is further elaborated by Mehanna. The role of acetylcholinesterase inhibitor drugs is, however, modest. Bohnen et al. suggest that drugs that selectively stimulate α4β2(*) nicotinic receptors may be more beneficial. —Chafic Karam, MD, and Robert C. Griggs, MD
Dhand et al.1 studied the diagnostic practices of community neurologists. Experienced neurologists require little more than patient history supplemented by a general physical and neurologic examination to diagnose disease. They may confirm their diagnosis with the aid of various tests. Ideally, the model for the majority of neurologic diagnoses should be clinical (C) 4, laboratory (L) 1, and neuroimaging (N) 1. A shift to more testing (L4 N4) is due to many factors: the experience level of the neurologist, physician conflict of interest, fear of malpractice liability, and practice setting (academic center vs small community hospital). It would be interesting to replicate this study in different clinical settings in various countries.
Author Response
We appreciate Dr. Sethi's comments. Many diagnoses in neurology, like Parkinson disease, are dependent on the clinical domain. However, other conditions are only suggested by clinical findings but require neuroimaging (e.g., multiple sclerosis) or laboratory analysis (e.g., meningitis) to make the diagnosis. As we observed in these disorders, the imaging and laboratory components were equally as important as the information elicited by the history and examination. Therefore, we caution against advancing an overly classical view of neurologic diagnosis; one of the important findings from our study was the variance among disease types. We agree with Dr. Sethi that similar studies in other settings would be valuable.
References
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