Treating Life-Changing Diseases as a Neurologist

Session 193

Dr. Brandon Beaber is a Fellowship Director and Neurologist. We got to talk about his favorite things about neurology and treating patients with diseases such as MS. Brandon is a community-based neurologist specializing in neuroimmunology, which we often think of as MS specialist. He works in Southern California at Kaiser, and we talk all about his journey to neurology, why he liked neuro immunology, and so much more.

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[01:50] Interest in Neurology

Brandon initially didn’t have any idea what specialty he wanted going into medical school until his third year when he did a neurology rotation. And he didn’t decide between MS and immunology until the end of his second year of fellowship.

'You don't have to plan your whole life out, you can just sort of stay one step ahead. Know what you want to do next.'Click To Tweet

He specifically liked the diagnostic challenge of neurology and the innovation happening. Brandon adds how residency is very inpatient-heavy. They were overwhelmingly with emergency diseases like stroke, brain hemorrhages, spinal cord compression, and epileptic status and things like that. They didn’t get a lot of multiple sclerosis, which is mostly an outpatient disease, or with Parkinson’s disease. And you don’t necessarily get a ton of experience with that early on.

But Brandon was lucky enough to have a mentor who is known in multiple sclerosis research. He then started doing research with her and shadowing her in clinics.

One thing that differentiates different types of neurologists is some people have that cowboy mentality. They’re almost like emergency medicine doctors. They’re treating acute stroke and responding to emergencies.

But Brandon prefers having relationships with people over time and getting to know people. He has some patients I’ve seen for 10 years, and teenagers who have blossomed into adults. He likes how he gets to see the changes people have in their lives. He likes to talk to people about their profession and their interests and helping them over time.

Brandon also likes how MS is a chronic disease. The immunology behind it is so interesting, and there are so many new things coming out all the time. Things have changed so much that they’re now able to stop a large number of relapses and new lesions with MS. People are much more stable and they’re really able to keep a lot of people out of the hospital and be higher functioning, going on to more advanced ages.

[05:14] The Biggest Myths or Misconceptions Around The MS Field

In general, people tend to think of Neurology as a field that’s more diagnosis-based and less treatment-based. Historically, that was true. They didn’t have any FDA-approved treatments for multiple sclerosis until 1993 and those drugs weren’t all that effective. And so historically, there was less they could do for people.

But now, they’re making a big difference. Certainly, there are neurological diseases where their treatment is less effective. And there are people with MS where their treatment is less effective.

[06:08] Traits That Make Someone Good MS Specialist

Brandon describes MS as very academic. Therefore, you would have to be someone who’s really interested in research and good at interpreting clinical trials. You have to have knowledge of clinical trials, methodology and statistics.

“MS is very academic so you would have to be someone who's really interested in research and good at interpreting clinical trials.”Click To Tweet

And while MS is very academic, Brandon is the exception to that as he’s working for Kaiser Permanente Southern California. He is entirely a clinician. He has done some research like epidemiologic research and participated in clinical trials. But he’s not really doing that right now.

All that being said, you need a little bit of an academic mind. You have to be very patient with people. People with MS have a lot of problems. You have to be willing to listen to people and have good interpersonal skills. And you have to be willing to do a lot of dirty work.

[08:35] Typical Day

Most of his work is in the clinic. He works from 8 to 530 or 6pm on a typical day. He’s on call once every seven weeks, and they’re on call a week at a time. They do their regular clinic during the day, and do phone calls in the evenings. Over the weekend, they go round in the hospital. Occasionally, they have to cover for an entire week because the neuro hospitalist is out.

But during a typical day, he gets in early and starts reviewing the charts of his patients he’s going to see. He reviews their history and their MRI scans. He could also be answering patient messages. He’s also getting paged from infusion centers because a lot of his patients are receiving medications so there’s some coordination and care involved. He eats lunch while charting. And then he’ll do the same thing in the afternoon.

[10:05] Percentage of Pre-Diagnosed vs. Undiagnosed Patients

Brandon says that a lot of the people he sees are already diagnosed, probably around 75% already have a diagnosis.

'One thing about MS is that it's very commonly misdiagnosed.'Click To Tweet

There was a study done at Cedars Sinai and UCLA in Los Angeles, where they looked at every single patient with a diagnosis of MS. They found that 18% were actually misdiagnosed.

One clinical tip Brandon wants to give to anyone in any specialty is that never 100% accept the diagnosis from another provider. Even if it’s someone who is experienced and well-qualified because it’s easy to make mistakes.

The most common disease in the United States is multiple sclerosis. About 1 in 350 people have it. But they also see people who have optic neuritis or just transverse myelitis, or neuromyelitis optica, or neurological manifestations of other rheumatologic diseases like sarcoidosis and Sjogren’s syndrome. So they see a diverse collection of patients although the most common is MS.

“The field of MS isn't just MS. It's neuro immunology.” Click To Tweet

The other thing that happens is overdiagnosis. Sometimes, the patient has another neurological disease, like another autoimmune disease of the nervous system. Sometimes, it’s something else entirely, like a stroke. Or sometimes, people just get carried away. A lot of people can have white matter lesions on MRI scan that are benign and not really caused by a specific neurological disease. So that can cause a lot of confusion too.

I’ve shared my story openly before but I have a diagnosis of MS in my chart from several years ago. But at this point, after lots of MRI follow-ups and clinical presentations, I’m not progressing like an MS patient typically would. I’m not on medications. And so, we think it’s just a transverse myelitis that happened in my past that was misdiagnosed at one point as MS.

[13:26] Types of Procedures

Aside from Botox that they’re doing for patients, another procedure specific to neuroimmunology would be a spinal tap, but any neurologist can do that.

Brandon does some other little procedures like occipital nerve blocks or trigger point injections for other diseases. But the most common thing he does is Botox both for spasticity and MS.

[13:58] Taking Calls and Life Outside of the Hospital

Where he is now at Kaiser Permanente in Downey, Southern California, they have a neuro hospitalist. And so normally they’re not covering the hospital during the week, but they’re on call just once a week. They don’t have a residency program so they’re fielding the pages themselves. Generally speaking during the week, you’re just fielding phone calls.

Sometimes, he would log on for a view of the film remotely, but usually he doesn’t have to go into the hospital on a typical random night. During the weekend, he has to go to the hospital, but usually for a limited amount of time because they’re not the primary team.

That being said, Brandon wouldn’t say there’s one particular call schedule typical of this field. There are definitely some neurologists out there in this field who don’t take calls because it’s an outpatient specialty. Although he heard if you’re in private practice, that in order to build up your practice, you may have to do some hospital work realistically.

Brandons says he’s been able to exercise and stay in shape. He has hobbies, like writing and various things. He has two young children and everything. At the end of the day, if you’re able to balance life, it works out pretty well. So it’s a good thing that he hasn’t had to give up too much in his personal life.

[16:32] The Training Path

Basically, you do four years of medical school, one year of Internal Medicine internship, and then three years of Neurology residency. And then you do a one-year or two-year fellowship in Multiple Sclerosis/Neuroimmunology.

If you want to be more of a clinician, like Brandon, you typically do one year. And if you want to go into academics, you typically do two years.

Brandon was supposed to do two years, but his organization desperately needed someone. And so he ended up quitting after a year and a half to be hired by the same organization.

'Right now, multiple sclerosis is actually not an ACGME-accredited fellowship.'Click To Tweet

If you want to be a neurocritical care specialist, you’ve got to take a board exam to be certified in that. And all Brandon has is a certificate because there is no board in multiple sclerosis. The neurology program is categorical where you automatically got the internship. But when he applied, he had to apply separately for internal medicine.

[19:29] How to Be a Competitive Residency Applicant

Brandon reiterates that you want to do some research being an academic field. He did a decent amount of epidemiologic research, and he was able to get involved in that early. If you can present at conferences, even if it’s just a case report, anything helps.

It’s a small field so a lot of positions are obtained just by word of mouth. You meet someone at a conference and you impress them. And so, being social with people at conferences and meeting people and collaborating with people in research could help. It’s not generally speaking, like a super competitive fellowship. This could have changed now. But during his time, there weren’t a lot of people who were interested in it.

These days, it tends to be pretty female-dominated. For whatever reason, not a lot of men want to go into this field, although he thinks it’s a great field for anyone.

[21:29] Message to Future Primary Care Physicians

Brandon explains it’s really hard for primary care doctors to diagnose MS because a lot of people have numbness and tingling that’s benign. But you have to recognize clinical histories that are a little bit more suspicious.

If you have tingling in the hand with activity, that could easily be carpal tunnel syndrome, or something else benign or some peripheral nerve syndrome. But if you have numbness in the trunk, for example, like numbness from the waist down, that’s a little bit more suspicious. So you just have to be familiar with the clinical histories that are more suspicious for MS.

'Every primary care doctor should be able to do a basic neurological exam and you'll pick up things.'Click To Tweet

Brandon says the best diagnostic test for detecting MS from an economic perspective, it’s reasonable to just use your best judgment. Just like with headaches, if you think the headaches are migraines, then don’t order an MRI. And if you think something else could be going on, and there’s a 10-20% chance, you probably should order the MRI.

[24:30] Other Specialties They Work Closely With

Sometimes, they work with rheumatologists for patients who also have autoimmune diseases with neurological manifestations, like Bechet to C’s or Sjogren’s syndrome. Because they may be getting medications from one of them that are treating both conditions.

For example, for someone with rheumatoid arthritis and multiple sclerosis, the class of drugs, TNF alpha inhibitors, such as Humira can actually make multiple sclerosis worse. So he would tell the rheumatologist not to give them that class of medications.

Another specialty they work closely with is Radiology. When you’re an MS doctor, whenever there’s a mysterious condition with a weird looking lesion in the nervous system on MRI, they become the doctors of choice, even though it may not actually be immunological. It could be something rare, such as an adult onset leukodystrophy. But they end up getting those consults.

[25:45] What He Wished He Knew Before Getting into the Field

Brandon says he would have liked to know more about everything that’s going with social media and communicating with other people. He learned a ton just from the Multiple Sclerosis blogger Gavin Giovannoni, who has a really good MS research blog.

'Regardless of what specialty you're in, you don't have to get all of your information from your mentors. You can learn a lot online these days.”Click To Tweet

Brandon advises following people on Twitter who are experts on the field and they help you keep up with the research. He also wished he knew a little bit more about interpreting clinical research. He feels like they weren’t taught very well in medical school, and he just learned it during residency.

[26:37] The Most and Least Liked Things

Brandon likes having patients that he follows over a long period of time and having conversations with them and getting to know them over the years. He adds it’s also rewarding to see patients improve.

People with MS have pain and other nagging symptoms. And so, part of his job is fielding a lot of emails and dealing with problems as they come up, which is something he likes the least.

[28:35] Major Changes Coming Into the Field

One type of stem cell therapy for MS is hematopoietic stem cell transplant. And this is a proven treatment in relapsing Ms. It’s been used for over 40 years. But this is a treatment where chemotherapy is given to wipe out the immune system. And the transplant is to reboot the immune system. And it can be very effective and even create long term remission.

This is the treatment that Selma Blair had, for example. Some people have a spectacular response to it and an indefinite remission. Although for that treatment, the effective part of the treatment is the chemotherapy, not the stem cells. The stem cells are really just to prevent complications. And so, that treatment definitely can work. It has risks, but it can definitely work.

Now, in terms of stem cells to regenerate the nervous system, there are a lot of disappointed people who have been victims of this medical tourism. There is some research on this.

One person who does it is Dr. Saud Sadiq at the Tisch MS Center in New York. He published an non randomized trial showing that it could be beneficial. There’s a center in Israel called Hadassah that has done this. And so there’s some preliminary data but it still needs further research.

[30:08] Final Words of Wisdom

If he had to do it all over again, Brandon says he still would. Survey says 60% of neurologists are burned out, but he’s not burned out yet which is a good thing. He is young and he’s happy with his career.

Finally, he wishes to tell students listening to this thinking about going into neuro immunology to try to get a good mentor. And if you could do a little bit of research early on because if you’re interested in the science of it, it will probably keep you excited about it for years to come.

You only have to stay one step ahead. If you’re a medical student, just figure out if you want to go to neurology residency. You don’t have to plan your whole life.