2022/Jun/27 Monologue of a First Year Neurologist by Dr Minali Nigam

Dr Minali Nigam


Minali Nigam is a neurology resident at Mass General Brigham. She's a proud graduate from UNC School of Medicine and UNC Hussman School of Media and Journalism. As a physician-journalist, she hopes to share stories that raise public health awareness and make medicine (especially neurology!) easier to understand. Here we present her prose poem reflecting on her recently completed first year of neurology residency.


Monologue of a First Year Neurologist


I started my first day as a neurologist armed with a reflex hammer, ophthalmoscope and safety pins, ready to localize lesions and perfect physical exam maneuvers.

Brisk reflexes are different from hyperreflexia. Neck flexion and extension correlate with diaphragmatic strength. It’s possible to sing but not speak. I learned in awe.

The first year neurologist is the first responder, cross-covering patients at night and thinking about new patients when they come to the hospital. Why did they lose vision, memory or ability to walk? What caused the convulsions, unbearable headache or asymmetric face?

Alone at night, patients are seen in the emergency room, hospital wards and ICU. Twelve to twenty-eight hour shifts of non-stop decision making.

Quick triage takes place. Transient symptoms? Think stroke, seizure or migraine. Low NIHSS? DAPT or no DAPT. Is it functional or not? Do I just not know the answer?

The pager goes off, sometimes I run. And call for help.

The shaking isn’t stopping. Ativan, Ativan, Keppra load, Intubate.

Right pupil blown, unresponsive. Head of bed up, CT head, Hyperosmolars, Hemicrani.

Images show ischemia that’s turned into blood, complete occlusion, dissection, heterogeneous mass, vasogenic edema or herniation.

Panic. Exhaustion. Can’t do it. Should I just quit?

There are more worldly matters than the inner workings of the hospital. Headlines I read on my commute. A building in Miami collapses, Simone Biles withdraws from the Olympics, soldiers leave Afghanistan, the FDA authorizes the first antiviral pill to treat Covid, another surge of Covid, masks come off at airports, baby formula shortages, children shot in schools, abortion rights lost. The stories never end.

A purpose outside of neurology. I think of stepping away, but then I’m reminded why I keep going…

When her EVD reads an ICP of 60 and her hemorrhage leaves her with no reflexes and CO2 retention. Brain dead. But her son comes to me and thanks me for the care and compassion. He blesses my hands to save and treat as many lives as possible.

A man with multiple cranial nerve palsies who couldn’t walk or recognize his family members. We called it a viral encephalitis likely from the tick in his backyard. He returns to clinic two months later and shares good news with his wife – their first baby is on the way!

Another’s headaches so crippling, she spent most of her days in a dark room, unable to work or socialize with friends. Tried amitriptyline, propranolol, topamax, sumatriptan, rizatriptan with no progress. We turn to Botox. Headache is better and she returns to work. I switch clinic locations, but she messaged to say she would make the long commute to continue her care from me.

Phone calls with families who express utmost gratitude. My loved one is in your hands and we trust you, they tell me.

Within one year, bloody lumbar punctures become champagne taps. Family meetings don’t seem as daunting. Medical students learn and turn to me for questions.

What I do matters. The neurologist in me matures. Still tough days and nights when I’d rather cozy under my blankets at home than walk the cold hallways of the hospital. Sometimes patients left without answers.

A single neuron can send a signal to a larger neural network that enables change in learning or behavior.  My single observation of an abnormal eye movement or spot on a brain MRI can enable a medical team to better a patient’s life. Just like a neuron, the first year neurologist has the capability to make change.

Surprisingly fast, I reach a synapse and pass through another year.



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