A Brief Defense of Neurology by Prof. Andrew Lees
The notion that non-motor symptoms were ignored by practising neurologists until recently is a myth. Although it is true that the scales used to evaluate potential new treatments in Parkinson’s disease focused predominantly on motor handicap and its impact on everyday activities like dressing, feeding and bathing, James Parkinson mentioned all the important non-motor symptoms in his 1817 monograph with the exception of cognitive impairment, anosmia and sleep disturbances. Dysregulation of the sympathetic and parasympathetic autonomic nervous systems (gut, bladder, cardiovascular and sexual function) was emphasised by the great masters of neurology like Charcot, Erb and Gowers in their lectures and writings. Good neurologists listen without interruption to the history and then carry out an examination. If constipation or pain seems to be the most damaging and prevailing symptom then they treat this as best they can as they have always done. In many cases these symptoms respond to dopaminergic drug modification rather than separate symptomatic treatment.
In recent years the drug companies have realised that launching another ‘me too’ drug for Parkinson’s disease with similar properties to an existing medication is unlikely to make profit or even obtain a licence. If they can show, however, that their new drug enhances cognition or lessens constipation as well as improving bradykinesia then they are on to a winner – ‘a multimodal drug for a multisystem degeneration’.
This has cynically led to the infiltration of international congresses with symposia dedicated to ‘non motor symptoms’ and the development of an armamentarium of scales and tick box questionnaires which have crossed from academic research into some Parkinson’s clinic. A patient who I saw three weeks ago for a second opinion told me that she had been to a Parkinson’s centre of excellence a few months earlier where she had been asked to fill out forms which took at least twenty minutes about symptoms she felt had no relevance to her presenting complaint. Only then was she seen by a doctor for ten minutes who spent much of the time gazing at a computer and writing down the scores. At no time was she asked about her difficulties in doing up buttons or her problems in getting coins from her purse, which were her main concern, and no examination was carried out.
This has been our experience. Doctors are no longer allowed to be Doctors but are now reporters. At first I was incredulous over the lack of time given the patient..4 minutes by one Urologist..until I realized that the bottom line dictates! Money is their God!
This is very important context. Indeed the classical neurologists like James Parkinson are a fantastic resource and their detailed clinical phenotypical descriptions are still relevant today, and better than most standard textbooks. But I think the criticism of the pharmaceutical industry is somewhat unfair. Both doctors and private pharmaceutical companies are motivated by personal success including income (just like everyone else) and also by making a positive impact on patients’ lives. Personal disclosure – I recently made a move from hospital medicine to the pharmaceutical industry but still treat patients part-time.