More in Defense of the MSE
I was very glad to see the letter from Richard Jacobson in the latest issue of Practical Neurology, in which he rebuts the article written by Dr. Hoffman in the previous issue. I myself was taken aback by what Dr. Hoffman said, and decided he must not be a neurologist at all, but perhaps a neuroradiologist, or allied with some other ancillary field. I still cannot believe that a clinical neurologist, practicing or retired, could state that the MSE was obsolete.

It's unfortunate the article by Doctor Hoffman was published, but I'm very glad you gave equal time to Doctor Jacobson. I'm concerned though that many neurology residents (who comprise a large part of your readership), might have seen the article by Doctor Hoffman, and been misled by it.

May I suggest you poll your readers, to see the spectrum of opinions on this topic? I would certainly be interested in the results. It could be accomplished online, with a link given in the next issue, along with a description of the controversy.

David W. Tesar, MD
Pittsburgh, PA

Dr. Hoffman Responds
—In response to the January 2009 (vol. 8, no. 1) Letter to the Editor, p. 12.
I realize that pro-and con haggling over an issue can quickly make a "Letters to the Editor" column tedious, but a clearly ad hominem criticism of a position needs some defense. Dr. Jacobson's exclamatory (Wow!) response to my earlier letter in Practical Neurology (Dec. 2008, vol. 7, no. 12) about the so-called mental status exam leads me to wonder how he can be such a rapid scanner of a message and grasp so little of it. He certainly deserves recognition for inventive inferences.

My appeal ("rant") has never been to eliminate ("throw out") any neurologically sound or useful method to assess the function of any part of the central nervous system in any patient.

Instead, my message was that common sense should prevail in clinical problem-solving. Nowhere does that concept threaten to "eliminate" the MSE. The purpose of my message was to replace nonsensical, offensive ritual probes, such as serial seven subtractions or the request to draw a clock face, with gentle, polite, non-threatening but meaningful verbal testing as the initial step in the complete evaluation of someone whose behavior or thinking (or both) may have changed. Such cautious invasion of a patient's inner life is particularly important in the examination of children.

In over 50 years of helping to teach students and residents in neurology, I have learned that testing the highest functions of the human brain without civility and without full consideration of the patient's background, education, his work, his fears, his prejudices, or his reaction to illness is neither productive nor accurate.

To Prof. Jacobson's request that I offer a replacement for what I would "tear down," I list only the attitudes above plus some empathy for the patent's family, and judicious use of modern imaging and laboratory investigations. None of these will make him or any sensible clinician as "obsolete" as the ugly techniques of the past.

W. W. Hofmann, MD