Interview with Neurology Resident Dr. Bokhari
Members of our Editorial Team met Dr. Bokhari at the Brain Health Fair organized by the American Academy of Neurology in Philadelphia. Dr. Bokhari was kind enough to agree to be interviewed for an exclusive article on MultipleSclerosis.net answering some of the most frequently asked questions we see in the community. Learn more about him below and see his thoughtful answers to our team's questions!
About Dr. Bokhari
My name is Dr. Matthew Bokhari and I am a graduating resident in neurology at Thomas Jefferson University Hospital in Philadelphia, PA. I completed medical school at Upstate Medical University in Syracuse, NY in 2015. This summer I will start my first job as an attending neurologist at NYU Winthrop Hospital in Mineola, NY. My position is a neuro-hospitalist, meaning I work exclusively in the inpatient setting seeing patients in the hospital.
Why does it take so long to confirm MS?
Q: Getting a diagnosis can be a really frustrating experience for many in the community. Can you explain why it can take so long to confirm MS?
A: This is a great question and for a long time, neurologists have debated what the exact criteria should be to make the diagnosis. Fortunately, we have a standard set of criteria, the McDonald criteria, which was recently revised in 2017 that is the standard we use to make the diagnosis.
Evidence of lesions must be separated by space and time
To make the diagnosis of MS we have to see characteristic brain lesions on MRI separated in space and time. What this means is that there needs to be multiple lesions (not just a single lesion) in different parts of the brain and/or spinal cord AND the lesions have to be separated in time. In other words, if I see a patient with some concerning lesions on a brain MRI at one point in time, I also need to see evidence of new lesions at a separate time in the future (for example, at a follow-up visit a few months later) OR old lesions from a prior MRI. One of the great updates to the McDonald criteria is that we no longer need to wait a few months between MRI scans to be sure there are lesions separated in space and time. With the use of IV contrast, we can make the diagnosis in a single visit if there are both enhancing lesions (indicating new or active inflammation) and non-enhancing lesions (indicating old lesions).
The diagnostic challenge comes when lesions look atypical or when we compare scans we do not see evidence of old and new lesions. Moreover, patients may have abnormal scans but have never had any MS symptoms. Conversely, patients may have symptoms but the imaging may be unrevealing. For these reasons and many others, we sometimes cannot make the diagnosis easily and we either need to wait for another scan to show progression of disease or use other testing methods, such as lumbar puncture.
Why can't people start treatment anyway?
Q:Watching and waiting can be really stressful for some people. Why can’t people start treatment for MS if their neurologist suspects MS but is waiting for more clinical evidence?
A: Like all medical decisions we make as doctors, we have to weigh the risks and benefits. The treatment for MS involves suppressing or modifying the immune system in some way to reduce inflammation in the brain. All of the medications can have side effects, ranging from mild injection site discomfort to a potentially irreversible or even fatal type of brain infection called PML. Until we are absolutely sure of the diagnosis, in most cases, the benefit of treatment does not outweigh the risks.
What about MS symptoms?
Q: We know that stable disease doesn’t necessarily mean symptom-free. What do you recommend for patients who aren’t experiencing progression but still struggle with various symptoms?
A: Patients with MS suffer from many symptoms related to their disease even when their scans are stable. These include bowel/bladder issues, walking difficulty, spasticity in their muscles, erectile dysfunction, neuropathic pain, generalized fatigue, and mood disorders such as depression and anxiety. As neurologists, we manage both the disease itself and these myriad complications. I recommend that patients be honest with their doctors about all of their symptoms. Fortunately, we have many treatment options available for addressing these issues which encompass both medications (e.g. for controlling bladder function) and other approaches (physical therapy for spasticity, acupuncture, mindfulness for stress reduction).
What makes MS different?
Q: Many people think MS is actually Lyme disease, lupus, or something else. What makes MS different from other conditions?
A: Part of the diagnostic challenge with MS is that there are many conditions which can mimic MS. The key difference is that these other conditions present in other ways. Lyme disease is a common bacterial infection transmitted by ticks which can cause lots of different symptoms in the nervous system from nerve pain to facial droop to meningitis. Lupus is also a systemic illness which has many effects on other organ systems especially the skin and joints. As clinicians, we need to take a careful history (asking about exposure to ticks especially in the summer) and perform a careful physical exam (for example, looking at the characteristic skin rashes of lupus or evidence of tick bites) to be sure there is not an alternative diagnosis. Most of the time we can distinguish an MS mimic from true MS on the basis of the history and physical exam. However, there are times when we cannot make this distinction; in those cases, we have to follow the patients carefully over time to see if there is progression of disease before we can definitively make the diagnosis.
What have you learned from people with MS?
Q: What is one thing you have learned from people living with MS about the condition and how does it affect your work or your perspective?
A: I have been very fortunate to have taken care of a number of MS patients during my training. The most important thing I learned is to listen carefully to my patients especially if they are reporting new or worsening symptoms. Sometimes my patients will notice a little blurry vision or trouble going to the bathroom or some new numbness. These symptoms may ultimately represent a flare-up of their disease, requiring a brief hospitalization with IV steroids to quell the inflammation. I also learned that it is important to factor in patients’ personal preferences regarding treatment. Some patients hate needles; some are fearful of getting infusions; still others may decline treatment altogether. It is crucial to work together with patients and find areas of compromise.
Have you ever heard someone say the following: