My experience of working in neurology as a SHO
Neurology is a fascinating field. Partly because I have no idea about neurological conditions and I find it extremely difficult. And partly because the consultants are extremely friendly- as they do not have a lot of inpatients and do not do acute medical on calls ( unless they are part of acute stroke rota)- They teach their juniors and encourage them to learn.
As a SHO, I found it incredibly helpful for my PACES exam. I honestly had no idea about neurology other than the differences between upper and lower motor neuron lesions. I still think I have not learnt a lot but I got the opportunity of seeing rare "PACES cases".
PS: This is my experience and management plans differ from trust to trust. This blog post is only to give you an idea of what I have experienced as a SHO in neurology.
A WEEK IN THE LIFE OF A NEUROLOGY SHO:
This is how my week in neurology usually goes:
1. I come at 9 AM everyday and my consultant, registrar, a physician associate and the nurses go through the patients admitted to the neurology ward which is shared with cardiology and endocrinology. We usually have 4 to 5 inpatients and the rest are referrals. We discuss events overnight, discharge plans and any outstanding investigations.
2. We see the patients in an hour or 2 and then go through jobs.
3. We then go for lunch. The consultant/registrar see the referrals and sometimes ask the juniors to come.
4. I usually get bleeped from the medical day unit to prescribe the following infusions:
Natalizumab - usually given to multiple sclerosis.
Intravenous immunoglobulins for patients with CIDP.
I have to go through letters by the neurology consultants which usually mention a plan. Sometimes the letters may mention that we need to contact the neurology consultant before their next intravenous infusion or may mention that if the patient is pregnant, to stop the infusion.
Sometimes, we have to examine patients who have had a reaction to that infusion.
This unit helped me a lot to understand complex neurology and allowed me to examine stable patients who are 'ideal PACES patients'.
5. We have O/P lumbar puncture days on Tuesdays and Thursdays. These patients are relatively well and need lumbar punctures to check CSF pressure, fancy tests like oligoclonal bands, cytology, HMDS, etc.
Again, we have to go through the consultants last letters to make sure we are not missing anything they have suggested.
6. The physician associate and I then meet and go through any outstanding jobs.
7. We also get to attend clinics where most of the neurology patients are dealt with.
8. We leave on time most of the days.
9. We have a MDT every Wednesday morning which is attended by all neurology consultants, neuro-OT, neuro-PT, neuro-dieticians, ward nurse in charge, neuro-psychologist and mental health team. We discuss all the admitted patients and on going referrals and a clear plan is typed up in the MDT document which is later printed out and put in the patients notes.
10. We have a neuro-radiology meeting every Wednesday afternoon in which interesting cases, doubtful scans are discussed.
THE NEUROLOGY MDT:
1. Consultants
2. Registrars
3. Neuro- OT/PT
4. Neuro-psychiatrists
5. Neuro- dieticians
6. Specialist nurses - MS, MND, epilepsy
7. Palliative team
8. SLT - speech and language team
9. Neurophysiologists
10. Discharge coordinator
11. Rehabilitation consultant
INVESTIGATIONS DONE IN NEUROLOGY
1. EEG - This is done by neurophysiologists. This is explained here:https://www.nhs.uk/conditions/electroencephalogram/
2. Nerve conduction studies (NCS)
3. Electromyography (EMG)
Explained here: https://www.nhs.uk/conditions/peripheral-neuropathy/diagnosis/
4. Video telemetry - To check for seizure activity.
5. Lumbar punctures.
6. Radiological imaging - CT head, CT angio, CT venograms
- MRI head, MR angio, MR venograms
WARD CASES
As a junior doctor, we need to ensure all investigations are done, they have regular bloods, monitor for complications, do procedures like lumbar punctures, liaise with other teams ( neurosurgery) for management of patients.
Acute myasthenia.
These patients are quite interesting. This is also a common case in PACES. These patients come in with general fatigue and on examination, fatigability and complications ( like low FVC, swallow problems) are demonstrated.
The investigations and management is mentioned here:https://patient.info/doctor/myasthenia-gravis-pro
From a SHO point of view, I have to make sure all the necessary investigations are requested. The link above clearly mentions what is required.
Specific tests like Serum anti-acetylcholine receptor (ACh-R) antibody may take some time to come back.
Also, we ensure that the FVC ( this is small digital spirometer in which a patient into and it gives a reading which the nurses usually document in a spirometry chart. Spirometers can be found in the neurology, respiratory, AMU wards or in ITU) is monitored regularly and if there is any change, they may be considered for ITU. Therefore these are high risk patients.
Also, it is important to check the patients OBS and bloods on a regular basis.
Steroids can cause infections ( hence CRP is more reliable. WCC will be elevated with steroids, ensure temperature and heart rate is normal)
Pyridostigmine can cause bradycardia and unmask unknown conduction abnormalities. It is reasonable to start such patients on telemetry and consider reducing/withholding it ( This is always a consultant decision as there is risk of the myasthenia getting worse).
These patients are always followed up by neurology team as an outpatient on discharge.
Gullain Barre Syndrome:
This is another potentially fatal condition.
This can present in different ways: ascending paralysis or the Miller Fisher variant ( descending paralysis).
There is sometimes no clear cause, or sometimes there is a bout of diarrhoea a few days/weeks before the symptoms start.
The investigations and management is mentioned here:https://patient.info/doctor/guillain-barre-syndrome-pro
From a SHO point of view, I have to make sure all the necessary investigations are requested. The link above clearly mentions what is required.
Usually, these patients need an urgent LP to send for the usual ( WCC, C+S, protein, glucose) PLUS anti-GQ1b antibodies, sometimes tests for Creutzfeldt-Jakob disease ( as the treatment -IVIG is contraindicated in CJD patients) which may take some time to come back.
They also need FVC monitoring on a regular basis.
EEG may show some specific patterns.
These patients are usually started on intravenous immunoglobulins ( brand name: Privigen) which is quite expensive and hence is a neurology consultant decision. It is stocked in the emergency drug cupboard if it is needed out of hours otherwise the pharmacists usually authorize it if in hours.
This drugs details are mentioned here:https://www.privigen.com/
Please remember that a neurology consultant must go through the risks of this and potential side effects.
Other complications may include vision problems hence the ophthalmology team can be quite helpful ( ie - assessing vision and considering prism glasses for patients with ophthalmoplegia secondary to Miller Fisher)
This is usually a 5 day course and then the patients are discharged and followed up as an outpatient.
Creutzfeldt-Jakob disease
This is a very unfortunate rare condition and always breaks the hearts of the neurology team. The details are mentioned here:https://www.nhs.uk/conditions/creutzfeldt-jakob-disease-cjd/
https://www.gov.uk/government/collections/creutzfeldt-jakob-disease-cjd-guidance-data-and-analysis
This is a rapidly progressive disease. These patients come in with rapidly progressive dementia, depression, poor mobility. However on neurological examination cerebellar ataxia, visual disturbance, as well as pyramidal and extrapyramidal tract signs may be present.
This condition is usually diagnosed clinically, radiologically and by doing an EEG and lumbar puncture.
This may be sporadic or genetic.
MRI head is the specific radiological investigation of choice:https://radiopaedia.org/articles/creutzfeldt-jakob-disease
A lumbar puncture is performed for the usual ( WCC, C+S, protein, glucose), tests for Creutzfeldt-Jakob disease- this may take a few weeks to come back.
These patients usually pass away in days to weeks. It is a very difficult conversation with families as they are usually absolutely normal before the symptoms started. The neurology consultants have this discussion with the family and patient ( who may have capacity and may be aphasic/dysphasic).
These points are discussed:
1. Rapidly progressive.
2. Incurable
3. The patient will die
4. Discussion about DNAR.
5. Genetic testing.
6. Discharge destination - This may be discussed in subsequent consultation a day or 2 after breaking this horrible news to the family.
7. Referral to the Creutzfeldt-Jakob disease team - a team of specialists who get the patients details, also do blood samples for research purposes ( if the patient/family allows) and provide support.
Genetic testing is very important. The patients family may be so shocked about this whole condition that may need time to think about this. However there is a worry that the patient may die before that. Therefore we always take samples from the patient for genetic testing.
These samples are usually sent to a specialist lab once the family CONSENTS to doing genetic tests. Otherwise they remain stored in the lab. Like the CSF result, this takes a few days to weeks to come back.
These patients are moved to a side room, the family is allowed open access to the ward and the palliative team is also involved. Some patients/families want them to come home and hence a FastTrack form is filled and then the hospital applies for funding from the local council to provide a hospital bed, portable commode, district nurses review re: administration of PRN anticipatory end of life medications. The community palliative nurses may also review the patients at home to ensure the family is managing and to consider transferring the patient to a hospice if it is becoming unmanageable.
HEADACHES
This is a very common reason for referring to neurology.
The acute on call team usually does a lumbar puncture if there is any question about :
1. Meningitis ( fever, neck stiffness, high WCC/CRP, pyrexia)
2. Subarachnoid haemorrhage ( sudden onset headache, worst headache ever, thunderclap headache).
3. Benign intracranial hypertension (high BMI)
The lumbar puncture is done for checking CSF pressure WCC, C+S, protein, glucose PLUS xanthochromia ( remember that you need to protect this from direct sunlight and the CSF bottle with this sample is always put in a black bag).
If these investigations come back to be negative and the patient has a persistent headache not responding to strong analgesia, then a neurology referral may be warranted.
The neurology team takes a very detailed history ( search for 'headache pathways' on Google - you will always know what questions to ask/conditions to rule out when you are clerking a patient with a headache), examine the patient ( including fundoscopy) and then makes a management plan - which is usually considering some other investigations or discharging them with O/P headache nurse/consultant follow up.
Multiple sclerosis
Sometimes, a young female may be admitted with weakness.
https://www.nhs.uk/conditions/multiple-sclerosis/diagnosis/
A MRI head and spine is performed. A lumbar puncture is done tocheck CSF pressure WCC, C+S, protein, glucose PLUS paired oligoclonal bands (which means sending a CSF sample PLUS a blood serum sample for oligoclonal bands).
These patients are usually started on steroids and then follow up in the neurology clinic.
Motor neuron disease
These cases are usually managed in the outpatient setting however may end up under care of the neurology team due to a different presenting complaint like aspiration pneumonia secondary to poor swallow and then have complex rehabilitation needs.
Sometimes, they may be admitted for day procedures like PEG tube insertions - usually coordinated with anaesthetic team as their airway is already compromised.
This is explained here:
https://www.nhs.uk/conditions/Motor-neurone-disease/
Functional neurological disease
Those who have not come across this may think that the patient is 'crazy', does not need any investigations or treatment as nothing is wrong with them and it is all 'in their head'. However these patients need the most care especially with regards to physio and occupational therapy and neuro-psychiatry.
This is an amazing website:
https://www.neurosymptoms.org/
Once the necessary tests ( bloods, confusion screen, HbA1C, nerve conduction studies, MRI brain and spine, lumbar puncture) are done, the neurology consultants print a leaflet similar to this and explain this condition to the patients.
They start understanding their underlying condition as there is finally a cause for it. This website gives a lot of information, referrals to groups and helps patients help us improve their weakness/palsy,etc.
EPILEPSY
This is usually managed as an outpatient however some cases, like status epilepticus who end in ITU are taken over by neurology. You can read more about this here:
https://www.nhs.uk/conditions/Epilepsy/
You may come across on your acute on call as well and usually, a CRASH call is put out. This is a helpful guideline:
https://www.nice.org.uk/guidance/cg137/chapter/appendix-f-protocols-for-treating-convulsive-status-epilepticus-in-adults-and-children-adults-published-in-2004-and-children-published-in-2011#treating-convulsive-status-epilepticus-in-adults-published-in-2004
These patients need very careful monitoring. Once stable, they are discharged with the necessary advice and outpatient follow up. This might be helpful to remind yourself on what to discuss with the patient:
https://www.epilepsy.org.uk/info
Other rare conditions I have seen:
1. Bleeds, tumors, post operative rehabilitation - usually managed by general medical team/stroke team
2. Friedreich's ataxia- the young patient had AF, then an ischemic stroke.
3. Central pontine myelinosis - thought to be secondary to hyponatermia due to a new medication which the patient may have subconsciously corrected rapidly.
My tips to SHOs starting in neurology:
1. Read about interesting neurological conditions on the ward you may never see again in your life
2. Use this chance to do as many lumbar punctures as possible.
3. Always read the previous neurology letters when prescribing an infusion to a neurology patient in the day unit.
4. Always review a patient ASAP if the day unit is worried about him/her.
5. Attend outpatient clinics and ask your consultants to supervise you examining patients - This is excellent practice for PACES.
6. Observe your consultants taking a history and examining a patient- You will always learn something new.
Overall, it is an amazing specialty with an incredible team of genius consultants who love to teach and dedicated, passionate therapists who can make a huge difference in the patients life.
As a SHO, I found it incredibly helpful for my PACES exam. I honestly had no idea about neurology other than the differences between upper and lower motor neuron lesions. I still think I have not learnt a lot but I got the opportunity of seeing rare "PACES cases".
PS: This is my experience and management plans differ from trust to trust. This blog post is only to give you an idea of what I have experienced as a SHO in neurology.
A WEEK IN THE LIFE OF A NEUROLOGY SHO:
This is how my week in neurology usually goes:
1. I come at 9 AM everyday and my consultant, registrar, a physician associate and the nurses go through the patients admitted to the neurology ward which is shared with cardiology and endocrinology. We usually have 4 to 5 inpatients and the rest are referrals. We discuss events overnight, discharge plans and any outstanding investigations.
2. We see the patients in an hour or 2 and then go through jobs.
3. We then go for lunch. The consultant/registrar see the referrals and sometimes ask the juniors to come.
4. I usually get bleeped from the medical day unit to prescribe the following infusions:
Natalizumab - usually given to multiple sclerosis.
Intravenous immunoglobulins for patients with CIDP.
I have to go through letters by the neurology consultants which usually mention a plan. Sometimes the letters may mention that we need to contact the neurology consultant before their next intravenous infusion or may mention that if the patient is pregnant, to stop the infusion.
Sometimes, we have to examine patients who have had a reaction to that infusion.
This unit helped me a lot to understand complex neurology and allowed me to examine stable patients who are 'ideal PACES patients'.
5. We have O/P lumbar puncture days on Tuesdays and Thursdays. These patients are relatively well and need lumbar punctures to check CSF pressure, fancy tests like oligoclonal bands, cytology, HMDS, etc.
Again, we have to go through the consultants last letters to make sure we are not missing anything they have suggested.
6. The physician associate and I then meet and go through any outstanding jobs.
7. We also get to attend clinics where most of the neurology patients are dealt with.
8. We leave on time most of the days.
9. We have a MDT every Wednesday morning which is attended by all neurology consultants, neuro-OT, neuro-PT, neuro-dieticians, ward nurse in charge, neuro-psychologist and mental health team. We discuss all the admitted patients and on going referrals and a clear plan is typed up in the MDT document which is later printed out and put in the patients notes.
10. We have a neuro-radiology meeting every Wednesday afternoon in which interesting cases, doubtful scans are discussed.
THE NEUROLOGY MDT:
1. Consultants
2. Registrars
3. Neuro- OT/PT
4. Neuro-psychiatrists
5. Neuro- dieticians
6. Specialist nurses - MS, MND, epilepsy
7. Palliative team
8. SLT - speech and language team
9. Neurophysiologists
10. Discharge coordinator
11. Rehabilitation consultant
INVESTIGATIONS DONE IN NEUROLOGY
1. EEG - This is done by neurophysiologists. This is explained here:https://www.nhs.uk/conditions/electroencephalogram/
2. Nerve conduction studies (NCS)
3. Electromyography (EMG)
Explained here: https://www.nhs.uk/conditions/peripheral-neuropathy/diagnosis/
4. Video telemetry - To check for seizure activity.
5. Lumbar punctures.
6. Radiological imaging - CT head, CT angio, CT venograms
- MRI head, MR angio, MR venograms
WARD CASES
As a junior doctor, we need to ensure all investigations are done, they have regular bloods, monitor for complications, do procedures like lumbar punctures, liaise with other teams ( neurosurgery) for management of patients.
Acute myasthenia.
These patients are quite interesting. This is also a common case in PACES. These patients come in with general fatigue and on examination, fatigability and complications ( like low FVC, swallow problems) are demonstrated.
The investigations and management is mentioned here:https://patient.info/doctor/myasthenia-gravis-pro
From a SHO point of view, I have to make sure all the necessary investigations are requested. The link above clearly mentions what is required.
Specific tests like Serum anti-acetylcholine receptor (ACh-R) antibody may take some time to come back.
Also, we ensure that the FVC ( this is small digital spirometer in which a patient into and it gives a reading which the nurses usually document in a spirometry chart. Spirometers can be found in the neurology, respiratory, AMU wards or in ITU) is monitored regularly and if there is any change, they may be considered for ITU. Therefore these are high risk patients.
Also, it is important to check the patients OBS and bloods on a regular basis.
Steroids can cause infections ( hence CRP is more reliable. WCC will be elevated with steroids, ensure temperature and heart rate is normal)
Pyridostigmine can cause bradycardia and unmask unknown conduction abnormalities. It is reasonable to start such patients on telemetry and consider reducing/withholding it ( This is always a consultant decision as there is risk of the myasthenia getting worse).
These patients are always followed up by neurology team as an outpatient on discharge.
Gullain Barre Syndrome:
This is another potentially fatal condition.
This can present in different ways: ascending paralysis or the Miller Fisher variant ( descending paralysis).
There is sometimes no clear cause, or sometimes there is a bout of diarrhoea a few days/weeks before the symptoms start.
The investigations and management is mentioned here:https://patient.info/doctor/guillain-barre-syndrome-pro
From a SHO point of view, I have to make sure all the necessary investigations are requested. The link above clearly mentions what is required.
Usually, these patients need an urgent LP to send for the usual ( WCC, C+S, protein, glucose) PLUS anti-GQ1b antibodies, sometimes tests for Creutzfeldt-Jakob disease ( as the treatment -IVIG is contraindicated in CJD patients) which may take some time to come back.
They also need FVC monitoring on a regular basis.
EEG may show some specific patterns.
These patients are usually started on intravenous immunoglobulins ( brand name: Privigen) which is quite expensive and hence is a neurology consultant decision. It is stocked in the emergency drug cupboard if it is needed out of hours otherwise the pharmacists usually authorize it if in hours.
This drugs details are mentioned here:https://www.privigen.com/
Please remember that a neurology consultant must go through the risks of this and potential side effects.
Other complications may include vision problems hence the ophthalmology team can be quite helpful ( ie - assessing vision and considering prism glasses for patients with ophthalmoplegia secondary to Miller Fisher)
This is usually a 5 day course and then the patients are discharged and followed up as an outpatient.
Creutzfeldt-Jakob disease
This is a very unfortunate rare condition and always breaks the hearts of the neurology team. The details are mentioned here:https://www.nhs.uk/conditions/creutzfeldt-jakob-disease-cjd/
https://www.gov.uk/government/collections/creutzfeldt-jakob-disease-cjd-guidance-data-and-analysis
This is a rapidly progressive disease. These patients come in with rapidly progressive dementia, depression, poor mobility. However on neurological examination cerebellar ataxia, visual disturbance, as well as pyramidal and extrapyramidal tract signs may be present.
This condition is usually diagnosed clinically, radiologically and by doing an EEG and lumbar puncture.
This may be sporadic or genetic.
MRI head is the specific radiological investigation of choice:https://radiopaedia.org/articles/creutzfeldt-jakob-disease
A lumbar puncture is performed for the usual ( WCC, C+S, protein, glucose), tests for Creutzfeldt-Jakob disease- this may take a few weeks to come back.
These patients usually pass away in days to weeks. It is a very difficult conversation with families as they are usually absolutely normal before the symptoms started. The neurology consultants have this discussion with the family and patient ( who may have capacity and may be aphasic/dysphasic).
These points are discussed:
1. Rapidly progressive.
2. Incurable
3. The patient will die
4. Discussion about DNAR.
5. Genetic testing.
6. Discharge destination - This may be discussed in subsequent consultation a day or 2 after breaking this horrible news to the family.
7. Referral to the Creutzfeldt-Jakob disease team - a team of specialists who get the patients details, also do blood samples for research purposes ( if the patient/family allows) and provide support.
Genetic testing is very important. The patients family may be so shocked about this whole condition that may need time to think about this. However there is a worry that the patient may die before that. Therefore we always take samples from the patient for genetic testing.
These samples are usually sent to a specialist lab once the family CONSENTS to doing genetic tests. Otherwise they remain stored in the lab. Like the CSF result, this takes a few days to weeks to come back.
These patients are moved to a side room, the family is allowed open access to the ward and the palliative team is also involved. Some patients/families want them to come home and hence a FastTrack form is filled and then the hospital applies for funding from the local council to provide a hospital bed, portable commode, district nurses review re: administration of PRN anticipatory end of life medications. The community palliative nurses may also review the patients at home to ensure the family is managing and to consider transferring the patient to a hospice if it is becoming unmanageable.
HEADACHES
This is a very common reason for referring to neurology.
The acute on call team usually does a lumbar puncture if there is any question about :
1. Meningitis ( fever, neck stiffness, high WCC/CRP, pyrexia)
2. Subarachnoid haemorrhage ( sudden onset headache, worst headache ever, thunderclap headache).
3. Benign intracranial hypertension (high BMI)
The lumbar puncture is done for checking CSF pressure WCC, C+S, protein, glucose PLUS xanthochromia ( remember that you need to protect this from direct sunlight and the CSF bottle with this sample is always put in a black bag).
If these investigations come back to be negative and the patient has a persistent headache not responding to strong analgesia, then a neurology referral may be warranted.
The neurology team takes a very detailed history ( search for 'headache pathways' on Google - you will always know what questions to ask/conditions to rule out when you are clerking a patient with a headache), examine the patient ( including fundoscopy) and then makes a management plan - which is usually considering some other investigations or discharging them with O/P headache nurse/consultant follow up.
Multiple sclerosis
Sometimes, a young female may be admitted with weakness.
https://www.nhs.uk/conditions/multiple-sclerosis/diagnosis/
A MRI head and spine is performed. A lumbar puncture is done tocheck CSF pressure WCC, C+S, protein, glucose PLUS paired oligoclonal bands (which means sending a CSF sample PLUS a blood serum sample for oligoclonal bands).
These patients are usually started on steroids and then follow up in the neurology clinic.
Motor neuron disease
These cases are usually managed in the outpatient setting however may end up under care of the neurology team due to a different presenting complaint like aspiration pneumonia secondary to poor swallow and then have complex rehabilitation needs.
Sometimes, they may be admitted for day procedures like PEG tube insertions - usually coordinated with anaesthetic team as their airway is already compromised.
This is explained here:
https://www.nhs.uk/conditions/Motor-neurone-disease/
Functional neurological disease
Those who have not come across this may think that the patient is 'crazy', does not need any investigations or treatment as nothing is wrong with them and it is all 'in their head'. However these patients need the most care especially with regards to physio and occupational therapy and neuro-psychiatry.
This is an amazing website:
https://www.neurosymptoms.org/
Once the necessary tests ( bloods, confusion screen, HbA1C, nerve conduction studies, MRI brain and spine, lumbar puncture) are done, the neurology consultants print a leaflet similar to this and explain this condition to the patients.
They start understanding their underlying condition as there is finally a cause for it. This website gives a lot of information, referrals to groups and helps patients help us improve their weakness/palsy,etc.
EPILEPSY
This is usually managed as an outpatient however some cases, like status epilepticus who end in ITU are taken over by neurology. You can read more about this here:
https://www.nhs.uk/conditions/Epilepsy/
You may come across on your acute on call as well and usually, a CRASH call is put out. This is a helpful guideline:
https://www.nice.org.uk/guidance/cg137/chapter/appendix-f-protocols-for-treating-convulsive-status-epilepticus-in-adults-and-children-adults-published-in-2004-and-children-published-in-2011#treating-convulsive-status-epilepticus-in-adults-published-in-2004
These patients need very careful monitoring. Once stable, they are discharged with the necessary advice and outpatient follow up. This might be helpful to remind yourself on what to discuss with the patient:
https://www.epilepsy.org.uk/info
Other rare conditions I have seen:
1. Bleeds, tumors, post operative rehabilitation - usually managed by general medical team/stroke team
2. Friedreich's ataxia- the young patient had AF, then an ischemic stroke.
3. Central pontine myelinosis - thought to be secondary to hyponatermia due to a new medication which the patient may have subconsciously corrected rapidly.
My tips to SHOs starting in neurology:
1. Read about interesting neurological conditions on the ward you may never see again in your life
2. Use this chance to do as many lumbar punctures as possible.
3. Always read the previous neurology letters when prescribing an infusion to a neurology patient in the day unit.
4. Always review a patient ASAP if the day unit is worried about him/her.
5. Attend outpatient clinics and ask your consultants to supervise you examining patients - This is excellent practice for PACES.
6. Observe your consultants taking a history and examining a patient- You will always learn something new.
Overall, it is an amazing specialty with an incredible team of genius consultants who love to teach and dedicated, passionate therapists who can make a huge difference in the patients life.
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