The Physicians’ Neurologist

You know you are about to enter the twilight zone, that’s of your career when your mentors start dying and your children take pictures of you, upload them to FaceApp to show what will become of you in a few years time. Scary?

Sadly, Professor Mike Harrison, one of my mentors, passed away on the 9th of July.

In 1997, the year he retired, I was lucky to work as his last senior registrar. I was very fortunate to have learnt from him even if it was for only one year. His fiefdom was the old Middlesex Hospital in central London; 1997 was one of those years when Middlesex Hospital was in limbo. The hospital had been earmarked for closure, sale and demolition, but had to remain functional with little or no money for repairs and general upkeep. This visibly upset Mike Harrison, who obviously loved the Institution.

Old Middlesex Hospital Chapel, image from Wikipedia

Although Mike Harrison retired that year he still had the time and energy to teach, enthuse and inspire. He taught me the value of why less is often more and why you need to maintain an interest in general medicine. As a result of Mike Harrison, I still read the BMJ and NEJM, cover-to-cover, every week. You can’t be a ‘good neurologist’ without being up-to-speed with what is happening in general practice and, more importantly, in general medicine. This is what Mike Harrison stood for. He epitomised the old-school neurologist.

What about the man? Mike Harrison was a man of few words, but when he uttered them they were to the point and ruthlessly accurate. He was not a raconteur. I recall us seeing a young man in his thirties who had been admitted to the medical ward with hemiparesis due to a stroke. He had had lymphoma in his twenties, which had been successfully treated and was considered cured of his tumour. On the weekly ward round the registrar took Mike Harrison to see the patient. Prof Harrison didn’t bother with the neurological examination apart from asking the patient to stretch out his arms so that he could see the subtle pronator drift. He used this simple manoeuvre to take the man’s hand and feel his pulse at the same time asking him how is lymphoma had been treated. The man mentioned that he had chemotherapy. With this information, Professor Harrison examined his heart. He concluded the consultation by simply saying to the man that we would need to check out his heart as it was the likely source of the blood clot that had caused his stroke. He said to the patient that in all likelihood he would need to start a blood thinner called warfarin to prevent further strokes. Mike Harrison then wrote a single line in the notes diagnosing him as having chemotherapy-related cardiomyopathy complicated by a cardiothromboemolic stroke. He had made a medical and not a neurological diagnosis. His diagnostic plan was simple and to the point; an ECG and cardiac echo. His treatment plan; query anticoagulation with warfarin. The whole consultation must have taken about three minutes. Needless to say, Mike Harrison was spot on. The patient had a chemotherapy-induced cardiomyopathy and was eventually discharged on warfarin.

Neurology for Mike Harrison was simple and to the point. I recall him telling me that if you get to the sensory part of the neurological examination and you had not yet made a syndromic neurological diagnosis you were in trouble. How true this aphorism has proved to be. Another time I recall him saying to the juniors on the team that in his experience 70% of diagnoses are made on history, 10% on the physical examination, 10% with investigations with the remaining 10% remaining undiagnosed. This ratio is not too far off from what happens today; this is 20-plus years after he retired.

I have many examples like these of Professor Harrison’s clinical acumen. It was clear to me that he was first a physician and only secondly a neurologist. This explains why he always attended the medical grand rounds, had an interest in stroke, which is really a medical speciality, and became de facto the first HIV neurologist in the UK and possibly the world. Mike Harrison loved general medicine and was at his best on the general medical wards at the old Middlesex Hospital. I got a sense that he was not at home on the neurology wards at Queen Square. Queen Square was quite sterile with neurological fascinomas rather than being filled with the hustle and bustle of activity and energy you get on a general medical ward.

I have always been of the opinion that the best neurologists happen to be physicians. I mean this in the pure sense in that these neurologists often have had dual training as both a physician and then a neurologist and tend to see the world from a medical rather than a neurological perspective. Physician neurologists are not only better diagnosticians and lateral thinkers, but they have a pragmatic approach to both the workup and management of patients with neurological problems. Having trained in South Africa I may be biased to this way of thinking. In South Africa, you simply couldn’t get a neurology training position without doing at least a year, and sometimes more, of general medicine. I only later found out that Michael Harrison had taken this career path as well. He is the only neurologist of his generation that I have witnessed doing dynamic auscultation to work out a cardiac murmur in a patient with a neurological problem. In the modern era, most neurologists don’t own or even use a stethoscope.

In short, Mike Harrison had a reputation for being an outstanding and dependable diagnostician. He would spend more time on his Queen Square rounds seeing other consultants patients for opinions, i.e. being the neurologists’ neurologist, than seeing his own patients. He was also continually being asked by other senior Middlesex physicians to see their patients on the medical wards. These tended to be personal referrals that would come directly to him from his colleagues, bypassing the usual junior hierarchy. He would often call me to clerk these patients for him so that I could present them to him on the ward rounds. This direct consultant to consultant referral system rarely happens nowadays and is one of the symptoms of what is wrong with how medicine is practised in the modern era.

If Professor Harrison was a football team he would be in the Premiership, certainly a top-four team and more often than not at the top of the league. Mike Harrison was more than a neurologist or the neurologists’ neurologist, he was the physicians’ neurologist an exalted position. I will cherish my memories of working for Mike Harrison, who I suspect was the last great physician neurologists.

RIP

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Gavin Giovannoni

Neurologist, researcher, avid reader, ms & preventive neurology thinker, blogger, runner, gardener, husband, father, dog-owner, cook and wine & food lover.