Inside the Mind of an Academic Child Neurologist


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SS 153: Inside the Mind of an Academic Child Neurologist

Session 153

Dr. Nelson is the Director of Child Neurology Residency Training at NYU Langone Health. We talk lifestyle, residency, pathway, and more. Dr. Aaron Nelson is an academic child neurologist who’s been in practice for about seven years now. If you want to find some more information about this specialty, check out Child Neurology Society.

For more podcast resources to help you along your journey to medical school and beyond, check out Meded Media.

Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:08] Interest in Child Neurology

Aaron was interested in the brain from an early age. He took a class in the biology of the brain at the University of Iowa. So he got exposed very early on to the intricacies of the brain and neuroscience. That’s what he first fell in love with.

He went into undergraduate, not necessarily planning to be a doctor, but just to study zoological neuroscience. But the more he learned, the more he was interested in higher cognitive processes and things that happened in brain development. 

It was then a natural evolution for him to decide to go into medical school. He originally planned on taking MD/Ph.D. As soon as he got into clinical care, he realized his love for working with children and treating patients. So he gravitated away from the basic neuroscience research and towards clinical care.

Then he just had to decide between Child Neurology, Child Psychiatry, and then Developmental and Behavioral Pediatrics. The hardest decision in his trajectory was deciding between those three. He had ultimately chosen Child Neurology, and haven’t regretted it.

In choosing between Child Neurology and Adult Neurology, Aaron was always pediatric-focused, which is not the case for everyone. Students have to decide by the end of medical school because it’s a very different pathway for one than the other. That being said, jumping from adult neurology to child neurology involves extra work and extra years of training.

“A lot of people are trying to weigh adult neurology versus child neurology when they're in medical school.”Click To Tweet

[03:18] The Biggest Misconceptions or Myths Around Child Neurology

The biggest myth that follows neurology in general, but particularly child neurology, is the notion that there’s a lot of things that you diagnose that you can’t treat. When you have a child diagnosed with an untreatable or irrevocably progressing disease, you may not be able to arrest that disease process. There’s still a lot you can do to improve the quality of life to help the family as a whole. 

They deal with epilepsy, and there’s a huge difference in terms of treating someone’s seizures versus if you don’t.

Aaron adds that there’s a lot of historical bias because that’s a lot of how it used to be. They had to figure out the problem, whether it be a stroke, or ALS on the adult side, or other genetic disorders you see in children.

With the recent innovations and advances in genetics and therapeutics, a lot of targets are now being treated. Unfortunately, people in training are seeing people that have been out of training anywhere from 30 to 40 years. Hence, you may have a different frame of reference when you’re counseling medical students.

[06:03] Traits that Lead to Being a Good Child Neurologist

Aaron emphasizes empathy and the ability to care for patients. Most importantly, you have to be patient with children. More than 90% of their exam is spent on observation and seeing the child playing, interacting with their families, those sorts of things. Those things are the hardest to teach. You can teach someone to memorize anything, but a lot of those fundamental humanistic qualities are baked in at that point.

“You need to be patient with children. You have to enjoy working with them and enjoy working with children across the developmental spectrum.”Click To Tweet

In the private settings, there’s a huge rush on time. You may only be given a certain amount of time to see a certain number of patients. Unfortunately, not all patients will fit within that time window. You have to be willing to pause and take that extra time and realize that it is exceedingly important. 

There are also other times when brutal efficiency is the most important thing you can do for your patient to improve their outcome. Mostly in the ICU, in the setting of stroke or seizures, you want to take advantage of any amount of observation and parse out fine details of the exam and the history.

[08:05] Types of Patients

Aaron says they see a mixture of patient types. They see a lot of developmental delay, which can be a developmental arrest, or developmental regression. They see a lot of headaches, whether it be pediatric migraine, other headache disorders, as well as a lot of epilepsy. Aaron first got exposed to epilepsy and became interested in epilepsy because he hadn’t decided to go into it until midway through his child neurology training. So those are the first big things they see.

There’s a lot of multi-organ syndrome, IQ disorders, genetic diseases, just because of how much expressed protein you see in the brain. When you have a very diffused process, it’s common for the brain to be affected. 

There are a lot of rare diseases, unusual presentations of either more common or rare diseases. And patients will often come to them with a diagnosis that is not correct. 

“You can do a giant disservice to a patient to just take their diagnosis at face value.”Click To Tweet

It’s common to have a patient come with a diagnosis of cerebral palsy, for example, or developmental delay. But what you find are specific features that point to a specific condition, some of which are treatable. So it’s common for them to pick up things that have gone undiagnosed for years. These conditions may include subtle or subclinical seizures and progressive neuromuscular problems that can be treated.

[10:21] Typical Day or Week

Aaron considers himself a jack of all trades, and he goes all over. His typical days when on service which makes up a large chunk out of the year is he’ll meet up with a team of residents, usually child neurologists. But he also sees adult neurologists, occasionally pediatric residents, and a handful of medical students.

They’ll start at the north end of the medical complex in southeast Manhattan then move south through a neonatal ICU. And then they’ll go from there to Bellevue Hospital.

During that time, they’re seeing patients in the emergency department, in a general pediatric floor, and a pediatric ICU, neonatal ICU. Some of them are high acuity and a lot of them are low.

Then he will settle in Bellevue where he runs pediatric epilepsy. He’ll read ECGs while teaching how to read EKGs to usually a subset of those residents. Once they’ve rounded on those pediatric epilepsy patients, all join one other attending who is staffing their child’s neurology clinics.

Aaron gets to see a whole variety of different patients anywhere from infants up through young adults for their follow-up continuity of care. That will usually go into the early afternoon. Then the later part of the afternoon if he’s on service will be family meetings. Whether it be with other specialists, parents of patients, or with patients, they’re discussing new concepts that have come in during the day.

[12:19] Kid Patients with COVID-19

Aaron says that they have a whole database of interesting cases. He has mainly seen a host of an acute encephalopathy, particularly with seizures where the main cause identified is COVID-19. 

They’ve picked up a number of cases where there were no outward clinical seizures, but they weren’t waking up upon activation. They found that they were actually having seizures that with treatment, they would turn to their baseline.

It’s, therefore, essential for them to be involved when patients were not waking up or getting back to their baseline after sometimes prolonged intubation.

[13:28] Are Procedures Involved in Child Neurology?

“You can be involved in procedures depending on which area you want to go into.”Click To Tweet

If someone wants to do mostly outpatient child neurology, but mainly wants to do procedures, then they can do pediatric neuromuscular medicine. They can specifically learn to focus on doing EMG and nerve conduction studies. The bulk of which is doing procedures and laying of hands on patients.

The main procedures that they do in patients are lumbar punctures. Anyone in any aspect of training for child neurology can get good at it.

Another is pediatric neurocritical care, which is a very new field and there are fellowships in it. Those are specifically high-level acuity patients working much more closely with pediatric neurosurgery. So there’s a lot more hands-on care and procedures for those patients as well.

[14:26] Taking Calls

Calls for child neurology emergencies vary a lot from program to program and region to region. It’s usually dictated on how big the program is, along with the number of trainees present.

At their program, for example, for the trainees in house, there’s an “adult neurology night float system.” It consists of an in-house junior neurology resident and senior neurology resident. Their child neurology trainees do that over the course of their training.

Fortunately, with advances in technology, they can review imaging and labs with ease. They can do pretty much anything and everything that you would want to do aside from the laying of hands on patients. So they’ll have to decide whether they can work with the in house Junior neurology residents with regards to what the exam is or whether or not they need to come in.

Aaron is on another layer above that. So even though he’s on-call pretty regularly, he doesn’t have to come in as an attending.

[15:36] Life Outside of the Hospital

For Aaron, the field affords good work-life balance as long as you’re careful enough to set both goals and limits. It’s a situation where some people are able to work part-time, only three or four days a week, primarily outpatient.

If you want to do clinical neurophysiology epilepsy or neurocritical care, you can do shift work. It’s similar to what you’d imagine for an ER type C. You can do everything – outpatient, inpatient shift work, or continuity of care.

“It's just a matter of negotiating what it is that you want.”Click To Tweet

In academics, it’s very common to have either a half or a full-day devoted to academic productivity. You may be doing clinical work four days out of the week, and then have the fifth day to be able to work on whatever scholarly activity you’re doing longitudinally.

[16:34] The Training Path

The training path for child neurology has changed a lot over the last decade or so. It’s very different now from even when he was going through training. Currently, there are three main ways to become a child neurologist.

But there is one way that he would recommend people go, which is the categorical child neurology positions. Those are positions that you apply to through the regular match during your last year of medical school similar to the vast majority of training programs. You have to apply to a single program for their categorical position.

In most places like NYU, you’ll get the opportunity to interview not just with the child neurology program, but with the pediatric program, the adult neurology program, etc. But then you’re there for five years. You do two years of pediatric training, a condensed schedule. Then you do about a year of adult neurology and two years of child neurology.

When all is said and done, at the end of those five years, you are board-eligible to become a general pediatrician. You can sit for the general pediatric boards, as well as adult neurology boards with special qualifications in child neurology. If you want, you can be double-boarded at the end of those five years.”

“You can essentially be double-boarded if you want to be at the end of those five years.”Click To Tweet

Some people choose to go on and do additional fellowships which may add on time but the core training experience is five years.

There are other pathways available. People can do a full pediatric residency, and then apply to what are called reserved child neurology positions. Here, you’re only matching three years, just the adult neurology and two child neurology years.

For advanced positions, you match to just those three years, but several years in advance. That would be for someone who knows where they want to go separately for pediatrics. But again, that’s a pretty convoluted pathway.

Some people have done adult neurology residency and then jumped over to child neurology residency. But then that requires additional years of training as well.

Aaron recommends exploring early on and pursuing a categorical pathway of training because then it’s one match and five years of training at one program and then you’re done.

Child neurology matching is not particularly competitive. You don’t have to worry about whether or not you will get into a program. However, most of the programs are very small and have a handful of positions.

Because of that, it is highly competitive at the few clearly top programs, where it’s the top candidates vying for a very small number of spots. So it is competitive at that highest level. But in terms of whether or not people have to worry about board scores to be able to match in the residency,   it’s not an issue.

[19:50] Thoughts on Pass/Fail System

Aaron doesn’t think it’s going to hurt students nor will it be helpful. It’s just going to shift what people look at.

“With Step 1 going pass/fail, it's going to be that much more important to make yourself stand out outside of just having completed medical school with good clinical rotations.”Click To Tweet

Aaron thinks it becomes that much more important to find a good mentor. They also have to have research projects to show some degree of academic productivity, because that is something that is looked for quite heavily for child neurology applicants.

He advises students to shift the focus to things that make themselves stand out in some fashion. It’s possible that people will then look more at Step 2 CK (clinical knowledge). Clinical Skills is currently suspended. In the past, he used to discuss the benefits of visiting rotations and institutions. Unfortunately, it’s not something a lot of places are doing currently in the setting of Coronavirus.

Aaron says it’s good to be forced to reinvent things. Despite the pandemic, they were able to continue their didactics throughout. They’ve found that they even have more participation in things like protected didactic lectures, grand rounds, and speakers. There’s more involvement throughout their whole network and individuals can make sure they’re consistently getting that education.

[22:08] Opportunities for Fellowships and Subspecialization

There are a lot of opportunities in most child neurology training programs. He would estimate a majority of the trainees go on into fellowship, but it’s not required.

“You can get jobs in child neurology without fellowship training.”Click To Tweet

Child neurologists are heavily in demand throughout large chunks of the country where there’s a severe shortage of child neurologists. So you don’t need to do fellowship training in order to be able to get a job.

That said, a lot of people do choose to do subspecialty training. The most common ones are clinical neurophysiology or epilepsy or pediatric neuromuscular fellowship. But nowadays, you can do nearly anything that you would do in adult neurology.

For pediatric neurology, for example, you can do pediatric headaches, pediatric movement disorders, or developmental and behavioral child neurology. But the only thing you can’t do is dementia.

[23:10] Negative Bias Against Osteopathic Physicians

Aaron admits seeing the bias which is not a good thing. In some situations, there may still be a bias. He routinely gets requests for information along those lines from applicants at NYU. But he always tells them that it doesn’t make a difference.

Aaron believes that it’s a situation more about what their pathway has been. It’s about what their background experience is, what their interests are, their long term career pathway, and goals. 

“It's important to have that dialogue for DO candidates if they're applying so that they know before they are trying to take the leap of faith at a particular institution.”Click To Tweet

During his training, Aaron has worked with multiple DOs, both co-residents, and co-fellows. He has also been working side by side with DO candidates throughout the department. But if you’re talking nationwide and as you’re applying and casting your net, Aaron thinks it would be foolish to not at least think about that. So try and have a dialogue about it with wherever you’re interested in going.

[25:23] Message to Future Primary Care Physicians

The biggest thing Aaron wishes pediatricians to know is that they exist and that they’re a resource. Most of the time, they would rather that children were referred sooner rather than later.

“One of the most common things that we see that I wish we could avoid are late referrals for developmental delay or late referrals for episodes that they're worried could be seizures.”Click To Tweet

There’s a concern for head growth and it turns out to be okay, but Aaron would still rather see those patients.

As to those pediatricians pushing back from referring early on because they default some diagnosis to developmental delay, Aaron thinks this can be resolved through education.

He regularly gives lectures not just to child neurologists or adult neurologists, but to the general pediatric residents and training at NYU, specifically on these sorts of aspects. He talks about the things they need to look for, things they need to refer to so they can try and catch people early.

They want to make it an ingrained part of the physician’s identity to know that they exist and to utilize them as technology changes.

Now, with telemedicine, it’s that much easier to have a physician-to-physician consultation. If you’re in a location where there’s not as ready access to child neurology nowadays, you may be able to get that access. The patient no longer has to travel as far as they might otherwise need to travel.

They’re also trying things like a consultation where if you’re referring someone to child neurology, you can have a discussion in advance of that referral to avoid any unnecessary delays and treatment and in testing.

Aaron thinks it’s important to just get it normalized within the culture. That when there’s a question or an issue or concern, they shouldn’t err on the side of statistics saying that most children who have very mild developmental delay will be fine. Instead, they have to be erring on the side of maximum intervention, which is picking up everyone as early as possible, because that makes a huge difference.

[18:23] Specialties They Work Closely With

Aaron works closely with developmental and behavioral pediatricians. They share a continuity clinic with them along with their genetic specialists one day a week. They see patients with genetic developmental disorders who often have comorbid neurologic issues beyond just the development.

They do quarterly multidisciplinary conferences with them and their fellows as well on topics of shared interest.

They also work with child psychiatrists where they will often have case presentations and case conferences. They’ll often see interesting cases and figure out the best approach. If a patient presents with a psychological issue, they need to figure out if it’s due to an underlying separate organic neurologic disease that needs to be treated. Or should it just be left primarily to pharmacologic treatment and therapy in the hands of the child psychiatrist?

[29:53] Advice to His Younger Self

Aaron would have advised himself to not be as stressed as most of the time?

“A lot of people who go into medicine now, relatively type A personalities, are prone to stressing out about things.”Click To Tweet

It’s a situation where medicine is very stressful. But as Aaron has gone through the pathway of training, he realized more and more, at least on the pediatric side, that people are very friendly and nice. Everyone is looking for everyone else to succeed.

Early on, Aaron stressed out about every little thing that goes into trying to develop an academic career. And if he had lived the life with a little bit less of that anxiety, everything would have still turned out probably just as well and then maybe a little bit more pleasant.

[30:50] Most and Least Liked Things About Child Neurology

The thing he likes the most is the opportunity to treat and see children who are across the developmental spectrum. Aaron fell in love with clinical care. When you’re evaluating a baby, three-quarters of the exam is essentially playing with an adorable baby and observing their reactions. So it’s a very fun and very pleasant thing to do. Aaron also likes teaching and he enjoys his role in residency and education. 

“Look for something that you feel the same about because it makes life much better when you're enjoying large chunks of your day.”Click To Tweet

The things Aaron likes the least in the field are charting and dealing with insurance companies.

Aaron works both at the height of private medicine and public medicine because he sees patients both at NYU and Bellevue. There is a vast chasm in terms of what patients are afforded access to in this country. And so that’s the biggest thing that bothers him day-to-day.

[33:07] Changes in the Healthcare System

In the face of COVID-19 and racial disparities, Aaron hopes to see some changes in the healthcare system.

There are giant disparities from community-to-community as well as differences in mortality in New York from zip code to zip code. There are marked differences in terms of pediatric and adult mortality. And that should not be the case.

Children are going through a lot right now, not only because of racial disparities but because of trying to deal with homeschooling in the setting of Coronavirus. In New York, some families can adapt much better to distance learning than other families. It’s not just because of money and access to electronic equipment, but also due to cultural differences, language barriers, etc. These things are not necessarily being dealt with as evenly across the board to help everyone as it should be.

But with any good that can come out of an incredibly tragic and unnecessary act, Aaron hopes that the changes would be enacted. Because this would be helpful for children in those communities as well.

[34:42] Final Words of Wisdom

If he had to do it all over again, Aaron still would have chosen Child Neurology. He feels very fortunate and happy to be doing his work every day.

As for those students who might be interested in Child Neurology, Aaron’s advice to them is to try and get a sense of the different approaches. Get exposure early. Not all institutions have great rotations in child neurology. And so if you’re in a place that you don’t have access to, seek it out.

Most places that do child neurology will accept visiting students, maybe not in the next six months due to Coronavirus. But it’s an excellent way to get exposure because you have to make up your mind by the time you’re entering into the midway part of the third year. Because in your fourth year, you have to do the electives, get the letters of recommendation, and have a competitive application.

So if you don’t have those steps in place, you could suddenly find yourself with not enough time to get where you need to be.

If you want to find some more information, check out Child Neurology Society.

Links:

Meded Media

Child Neurology Society

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