What is the value of a neurologist?

I openmy e-mails, only to see yet another admonishment from the hospital administration. I have not checked enough boxes on the electronic health record, and therefore have not met criteria for meaningful use. I wonder: is this what taking care of my patients boils down to? It was Friday morning, and I awoke anxious, reluctant to confront the day. Facing me was the usual busy schedule of EMGs and clinic patients. Nothing out of the ordinary, yet I was anxious because I knew that I would have to break the news to Ms. S.A., a 50-yearold woman, that she had amyotrophic lateral sclerosis (ALS). I had worked her in urgently a week prior at a colleague’s request. As I listened to her history and examined her, automatic thoughts, the product of years of training and experience, ran through my mind and crystallized into a diagnosis: clinically probable ALS. I sifted through her history and examination and perused her cervical spine MRI for anything that would tell me otherwise. Zebra diagnoses danced through my mind: could she have polyglucosan body disease, hexosaminidase deficiency, or a pure motor variant of syringomyelia? Was she Ashkenazi Jew? I ordered bloodwork and a brain MRI and worked her into my EMG schedule the following Friday. Today was that Friday, and she was the last patient of the day. As expected, bloodwork results were unremarkable and brain MRI showed no abnormalities to explain her clinical picture. She came in, anxious, hoping that she had a treatable condition. The EMG provided no alternative diagnosis. I discussed all her results and showed her theMRI. I gave her the scientific explanation: that her symptoms pointed towards an affliction of her motor neurons. Her husband had researched her symptoms on the Internet and asked if she could have multifocal motor neuropathy. I spent some time explaining why her symptoms were not consistent with that diagnosis. She was devastated when she realized that I was indeed telling her that she most likely has ALS. She asked me what she should tell her children, ages 13 and 17; what her life expectancy was; and how the disease would progress. She cried. The discussion changed from the scientific to the emotional. I reassured her, as much as one can reassure when delivering a diagnosis of ALS. I held her hand. Her husband asked about riluzole. The scientific discussion again: dose, side effects, monitoring. She asked when the disease would spread to her legs. And affect her swallowing. She cried again and said she was hoping for an alternative diagnosis. I urged a second opinion so she would not have any doubts. She said she would prove me wrong. Then the practical discussion: what next? Occupational therapy, prescriptions, follow-up appointments. I hugged her, and told her I would walk through this with her. Her husband cried. He requested that I call every so often to check on her. I was emotionally drained. I made a note on my calendar to call her every week, and billed a level 5 evaluation and management (E and M) visit code. And wondered what code covered the time and the emotions I had spent soothing, comforting, consoling. Is it the one that states “over 50% of this 40-minute visit was spent in counseling and coordination of care?” Is there a code for telephone calls to ask how she is doing and help her feel less alone and afraid? Mr. S.L. was in his mid-40s when I diagnosed him with ALS. His wife accompanied him to the visits, and I saw him go from being ambulatory to wheelchairbound; from conversant to barely comprehensible because of dysarthria. His wife called me, guilt-ridden about placing him in a care facility. She had to work to sustain the family, and help was not available. I just listened, let her talk, and reassured her that she knew what was best for her husband and her family. They brought their 3 sons in to talk to me. The oldest was 16 and deeply involved with his father’s care. The youngest boy was 7, scared and not quite understanding the situation. The middle child, about 12, shut himself off, would not talk about his father or spend time with him. I spent an hour and a half explaining, letting them talk, probing their fears, and answering questions. I gave them my cell phone number to call or text me any time they were scared or had a question. I did not bill for that visit, nor do I know of a code for comforting the children of a patient with ALS. Mr. E.N. was in his mid-50s, very active, and a physical fitness freak, but he smoked. He had dermatomyositis, and I was worried about an underlying cancer. Indeed, he had lung cancer, stage III at diagnosis. He was one of the most positive people I have had