Focusing in on Parkinson’s and Movement Disorder Medicine


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SS 169: Focusing in on Parkinson's and Movement Disorder Medicine

Session 169

Dr. Justin Martello is a community-based Neurologist who focuses on movement disorders and Parkinson’s Disease. Come learn about this specialty! If you are interested in this specialty, check out The International Parkinson and Movement Disorder 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.

[01:15] Interest in Neurology and Movement Disorder

Justin’s interest in neurology started in his third grade. He was amazed by the biography and stories written by Dr. Ben Carson, who was a very famous pediatric neurosurgeon before he entered political life. And even though he was a surgeon, he wrote a lot about cool neurology cases.

Justin was interested in the inner workings of the brain and the connections between the rest of your body and the power of the brain.

So that just led him into eventually doing a high school internship in his junior year. He randomly did it with a neurologist that specializes in movement disorders. And that got him into that interest of the whole movement world. After a year working with the specialist, he just skyrocketed into his specialty from there.

[02:33] Diagnosis and Pathologies

For movement disorders, the majority of it is going to be Parkinson’s disease as well as essential tremor, which is the kind of tremor that involves your hands shaking when you’re using them, or holding something, or writing.

“Essential tremor is the most common new movement disorder that exists. But a lot of people don't necessarily seek medical attention for that all the time.”Click To Tweet

They also deal with Huntington’s disease, which is within the movement world. They see anything that has some kind of abnormal movement to the body, with the exception of seizures.

People with balance issues can fall under this specialty as well as people with abnormal muscle contractions or spasms, sometimes called dystonia.

[03:38] Traits That Lead to Becoming a Great Movement Disorder Specialist

The specialty is very visual and very interactive with the patient. As a movement disorder specialist, you have to be able to eye them up the minute they come in. Be able to look for any kind of abnormal movements they may have.

The exam is really important so you can feel if there are any stiffness and rigidity. Have them do certain things in the clinic. This is helpful to diagnose them and then go along with that. The diagnosis and the treatment are very much consistent with this whole idea of the art of medicine.

'There's not a cookie-cutter way to approach these patients, whether you're talking from diagnosis to treatment.'Click To Tweet

They follow guidelines and certain structures when treating these patients but treatments and the diagnoses are dependent on patients. So much of the test is very clinical. As patients walk into the office, Justin can give the diagnosis right there which is quite unique for a lot of different specialties in medicine.

[05:23] The Biggest Myths or Misconceptions Around Movement Disorder

There’s this saying in neurology which is “diagnose and adios” where they diagnose things but when it comes to doing anything about it, there’s nothing you can do. Just tell them what they have, and then send them on their way.

And what Justin loves about the specialty is that even though they don’t have any cures for the diseases they treat, the impact of the medication is dramatic. They offer different therapies from surgery to other procedures like Botox procedures and other medications. And these can have a dramatic impact on their life and their quality of life. This is the kind of impact that patients will want to hug you the next time they see you and they feel that much better.

They also do things you can see in real-time like Deep Brain Stimulation Programming. Using a device or an iPad, he can program the settings for their electrode in their brain and cause them to have physical symptoms right in front of him, or benefits.

'With the power of technology with this subspecialty, you can see real-time effects and just make people feel so much better.'Click To Tweet

[07:42] Diagnosis vs. Treatment

They don’t have any real testing to rely on to help us with this so they have to be able to take a good history and a good exam. They are sometimes getting clues from their caregivers, and things like that.

'We're learning so much of Neurology even over the past 10-20 years, and it's even growing exponentially going forward.'Click To Tweet

As with other specialties, we know everything there is to know about the heart, the lungs, kidneys. With the brain, we know a lot but there’s so much more that we still don’t know and we’re still learning. So if you really want to be on the cutting edge of medicine and things that we don’t know about and learning about and discovering then this is it.

[09:31] Typical Day or Week

Justin sees patients day in and day out, four and a half days of clinic per week, which is a little bit more than what you would necessarily get in the academic world. Then he breaks down his days into different types of clinics.

He has a whole half-day where he just does Botox injections and another half day where he does deep brain stimulation programming. Then they block out time for new patients and follow-up patients.

He also has time built in to do some research, and it’s important to have that to offer patients although it’s not necessarily required for his position. And if in the event, you want to enter academia and do more of that kind of work such as clinical trials then it’s something you could also pursue.

There are not too many of them, in fact, Justin is the only movement disorder specialist in his state. Hence, patient demand is quite high.

[11:01] Life Outside of the Hospital

Justin has four and a half days so he frees up my Friday afternoons. Whenever you join a private hospital institution, a lot of times, they’ll require a call from you. For Justin, it’s once every couple of months on a weekend, so it’s not too often. So it is a nice work-life balance.

'There's no emergency within the movement disorder specialty.'Click To Tweet

If there is an emergency, they just tell them to go to the hospital and get seen and be admitted. So there’s no urgency and this is something Justin likes about this specialty.

[11:54] The Training Path

You do a neurology residency, which requires a year of medical internship. Justin finds this very helpful for his specialty. Then three years of Neurology residency and a year or two of Movement Disorder Fellowship. If you’re interested in research and academia, that may require a second year. But Justin was able to do research within his first year.

During your medical internship, when you’re taking care of these patients, especially Parkinson’s patients, Justin explains that you also get to put back your internal medicine cap on.

Parkinson’s disease affects the whole body and all of the different organ systems. So instead of really listening to their symptoms and saying it’s a cardiology issue or a pulmonary issue, Justin just takes it upon himself to learn and manage different things that Parkinson’s affects – whether that’s blood pressure regulation, sleeping issues, depression, constipation issues, etc.

Instead of referring them out, he addresses them all by himself, making him a one-stop-shop for them. It makes him feel like he can help them in all these different ways and he’s not just referring them to a million different specialists. Again, you get to put on that internal medicine cap.

[13:29] Other Specialties They Work the Closest With

They work the closest with cardiology with a lot of blood pressure and heart rate fluctuations. A lot of times, you want to rule out other kinds of causes to these things besides Parkinson’s. 

Justin also works a lot with primary care doctors as they come up with all the questions related to symptoms of Parkinson’s.

“A lot of times, primary care doctors don't know, and being their quick resource is the key.”Click To Tweet

[14:24] Message to Future Primary Care Physicians

'Because there are not too many movement disorder specialists out there, many people are still managed by primary care doctors for their Parkinson's.'Click To Tweet

If you have that resource within your community and have access to a movement disorder specialist, it is recommended to be seen by them at least once a year. Because there are so many things that come up with Parkinson’s.

Over the past five years, there have been two or three new medications for Parkinson’s released every year. So there are new things that they’re learning about the disease. It’s fun yet it’s also hard to keep up with which is why there’s a subspecialty for this.

It’s good to be aware of the new medications and it’s okay to start your patients on medications that improve their quality of life. Because you don’t need to wait for them to see a movement disorder specialist.

Sometimes, they also use the medications as a test to see if they have Parkinson’s. If they improve, and they should improve in a dramatic way, then it’s a clincher that they have Parkinson’s disease. So why wait to start your patients on that when you can start it, see how well they do, and then eventually get them plugged in with the movement disorder specialist.

[16:27] Community vs. Clinical Setting

Justin personally appreciates seeing patients clinically more than focusing on grants. In academia, you’re only going to be doing two or three half days of clinic a week. So you don’t see that many patients.

There’s also this misconception that these experts who go to academia know the most. They probably do know the most about what they research. But as far as patient numbers, Justin has probably seen more patients in the last year than some of his mentors have in five years.

'To become really an expert clinician and an expert in your field is that you've seen so many patients.'Click To Tweet

Justin also likes being in a community setting where he’s the only one there so everyone refers to him and he’s able to be the expert in his community. He can do outreach in the community and he has more time to do things like volunteer and support groups, and things like that.

Whereas you’re left in the “ivory tower of academia” because you’re set apart from the community. Academic centers tend to be close to each other. So you get to talk to your colleagues about hard cases. But Justin feels he can also do that with his old mentors as he could still connect with them. And he still gets involved with dinner programs that he can share cases with. So you can still get that but still be in a community setting.

[18:14] What He Wished He Knew Before That He Knows Now

Because movement disorders have so many new medications out there, a lot of them are brand name medicines. So a lot of them require a lot of paperwork, insurance denials, appeals. You hear this throughout medicine and a little bit more so in his subspecialty. They have all these branded medicines and a lot of generic ones.

“The mainstay of therapy is still generic, but it's a little bit harder to fight for your patients to get a lot of these great medicines covered.”Click To Tweet

You hear about it but you don’t really get to experience it until you’re out there doing it. So you get all this paperwork at the end of the day to fill out. It’s a game that the insurance companies play to try not to cover all this stuff. And it’s just a bad game you have to play with them.

[19:22] Tau Buildup in the Brain in Parkinson’s Disease

Parkinson’s involves tau build up in the brain. People used to think Parkinson’s was all environmental, which the majority of it still is. But now we’re learning about this interplay of genes and why a lot of pesticides can lead to Parkinson’s. To clarify, not all farmers get Parkinson’s but just a few of them.

'There are 30 or 40 genes that have some connection with Parkinson's. So it's an ever-growing field.'Click To Tweet

It’s an interesting kind of field that we’re again learning more about why do people get Parkinson’s to begin with?

[20:39] Is There a Cure for Huntington’s Disease and Parkinson’s Disease?

“Huntington's disease is probably the top two of the worst neurological diseases you can get, second to ALS.”Click To Tweet

As far as all the symptoms involved, and how it affects your body, only one gene is involved in Huntington’s disease. And everyone with Huntington’s disease has an error in that gene. They know where the error is. It’s a simple “error” that’s easily fixable and definitely curable with CRISPR in the future.

For things like Parkinson’s, it’s a little bit more complex, unfortunately. There are certain types of Parkinson’s disease where it’s clearly genetically related. Everyone within the family line has a risk of it if they get this gene. And this is where CRISPR will play a role.

But it’s very complex with the interplay of environmental risk factors. We don’t know all of the environmental risk factors that play a role in influencing Parkinson’s. And even within the genes, it’s not as simple as this same repeat, or this similar area in the gene is always affected. It could be different parts of the gene.

[22:21] Most and Least Liked Things

Justin thinks it all goes back to the impact that you can have on patients again. When you understand there’s no cure for this disease, it can be depressing at times. You’re giving these patients diagnoses of a degenerative condition where they can’t do much about it, with the exception of exercise that can slow it down. But you get to tell them you’re going to be there with them on their journey and connect with them.

'You get to give them therapies that are really impactful to their quality of life so they can live great lives.'Click To Tweet

The procedures involved are everything from deep brain stimulation programming to  Botox injection. You get to do the procedural end of things and you get to also do the clinical end of things. 

In some circumstances, you also get to be their primary doctor where you treat other aspects of their condition and of their body.

Ultimately, this patient population is a good group. And the reason for that is that they’ve lived full lives because you get Parkinson’s, usually late in the 50s, early 60s, and sometimes late 60s. And so, they have lived a majority of their life.

These are the patients that want to be motivated. They want to keep going, they want to work with you, and they want to take their medicines. And when they get worse, it’s sad that you’re there to hold their hand, to be supportive to their caregivers and their loved ones. And being a part of their family is a great feeling as a clinician to do that.

On the flip side of things, what Justin likes least about his specialty is that when they get worse, there are fewer things to offer them.

At this point, they have over 20 different medications for Parkinson’s and more advanced therapies to offer. And they have a lot of great things down the road and research trials.

But they get to a certain part where they can’t walk. Their balance is awful. They have issues swallowing. They can have issues with psychosis or hallucinations. Sometimes, they only have a certain amount of medications to help with those things and therapies to help. And then it starts impacting caregivers and there’s not much they can always do to support them.

It’s just frustrating to know that towards the end of their life, that can be sad to go through with them.

[25:45] Message to Students Who Might Be Interested in This Field

In a lot of med schools, you may get the basic science of neurology, but you don’t really need to get the clinical stuff until later in med school. Movement disorder is largely outpatient. You’re not spending a lot of time in the in-patient team. You don’t get a lot of that outpatient experience until later in a neurology residency. So by then, you’ve already picked a fellowship. 

That being said, they definitely highly welcome and encourage students to come through their clinic, see what they do.

'I doubt you'll ever find a movement disorder specialist that does not want to accept a student into their clinic.'Click To Tweet

If you’ve met one person with Parkinson’s, you have to understand that it is a spectrum of disease. You can read about it, you can watch videos, and those things are great. But seeing patient after patient, if you go to one day of a movement disorder specialist, you’ll say that every patient was interesting and different. And that somehow defends against burnout because you’re seeing something different all the time. So get connected with a movement disorder specialist and just reach out.

Movement Disorder is a newer subspecialty. There’s this new generation of neurologists moving through. There are actually breaking away from the typical old kind medications and looking into other alternative medical therapies. Whether it’s acupuncture or a boxing class, they’re all for it.

'When you deal with Parkinson's, you're open to those things because you want anything you can offer to these patients to make them feel better.'Click To Tweet

Links:

Meded Media

The International Parkinson and Movement Disorder Society

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