Q&A-42: to do a neurological examination or not

A counterfactual could be a delayed diagnosis, a lower efficacy platform DMT, several breakthrough relapses, disability with significant end-organ damage...

Question: I just spent over £100 on a train journey and several hours travelling to see you. Is this all you have to offer? Surely, an annual assessment needs more to be done than this? Next time, can we please do the visit remotely?  

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Prof G’s reflections

Earlier this week, I saw a patient who had been treated with alemtuzumab in 2015 and 2016 and has been stable and fully functional since then. He works full-time, exercises 3-4 times a week, and says he is in a "good place” after moving from London to the Dorset coast during lockdown. He has no bladder, bowel or sexual dysfunction and says his mood is good. Sleep could be better because his three-year-old son still wakes up at night, occasionally leaving him tired. He didn’t think MS fatigue was a persistent problem underlying the fatigue associated with sleep deprivation. 

His latest brain MRI showed no new lesions, and his brain volume looked well preserved according to the neuroradiologist's naked eye. Please note we don’t do regular BVL measurements in routine clinical practice. His online webEDSS score was 1.0, his self-timed 25-foot walk was 4.6 seconds, and his dominant and non-dominant self-administered 9-hole peg test times were 15.9 and 16.7 seconds. His online SDMT (symbol digital modality test) was 54 (normal >40). His body weight was normal, and his blood pressure was low. Apart from vitamin D3 supplements (4,000U per day), he was on no other medications. He was up-to-date with his flu and COVID-19 vaccines. His diet was good, and his weight was 73kg. He is a non-smoker and consumes about 10-14U of alcohol per week. He had developed autoimmune thyroid disease after alemtuzumab, but this had resolved itself. 

This assessment took 5 minutes, so I chatted with him about his wife’s new job, said goodbye, and said we hope to see him next year. I also told him that a colleague would take over his care as I was partially retiring to work on MS prevention.  

This is when he said, “I just spent over £100 on a train journey and several hours travelling to see you. Is this all you have to offer?”. I sensed he was disappointed with the brevity of the consultation…..