Clinical Neurophysiology & Epilepsy with a Program Director

Session 201

Dr. Ann Hyslop is a pediatric neurologist who specializes in clinical neurophysiology and epilepsy. Find out what inspired her to choose this unique field. If this is something you’re interested in, visit the American Epilepsy Society for more information.

For more podcast resources to help you with your medical school journey 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 Pediatric Neurology and Epilepsy

Ann explains she has a brother with severe Tourette’s who self-diagnosed himself when he started reading some books. And only later when Ann was in college, that she realized it was a true diagnosis. And so, Ann had seen her brother grow through the different stages of trying to deal with Tourette and manage that.

Then in college, she kept being attracted to neurology, whether it was through just a combination of different types of neuroscience classes, chemistry and biology, and psychology. Ann ended up doing a major in neuroscience and in biology with a minor in psych.

When she went to medical school, she noticed all her projects and papers going into rotations had something to do with neurology. And when the match came around, she knew she wanted to do neurology and ended up matching into pediatric neurology.

By the time she finished her pediatric neurology residency at Seattle Children’s, she wanted to do a fellowship in epilepsy surgery training. Her primary interest is in epilepsy surgery evaluations for kids with medically intractable epilepsy.

'There's just not enough time in medical school to get all the exposure that there is that that exists.' Click To Tweet

[08:49] The Biggest Myths or Misconceptions Around Epilepsy

One of the biggest misconceptions around epilepsy is that it’s not curable. Ann clarifies that it’s actualy curable in a subset of patients. It’s not for everybody. And she finds being able to cure epilepsy through epilepsy surgery as the most satisfying she has ever done.

Ann adds that epilepsy is far more frequent and far more common than you would think. It doesn’t just occur in people that have developmental delays or have a brain injury or have a brain malformation.

'There are so many different etiologies, some of which we never understand and identify, that cause epilepsy, and later in life, there are some of us who may go on to develop epilepsy.'Click To Tweet

Ann also thinks there are a lot of misconceptions about the care of seizures although we all get to straighten out in medical school. But for people that aren’t in medicine, one of the biggest challenges is how to help people through seizures.

[10:36] Percentage of New Patients vs. Diagnosed Cases

Ann estimates that 80% of the new patients she sees have had just a first seizure or they had some febrile seizures when they were younger. And they had their first unprovoked seizure. Then more than 20% of the new patients she sees are second opinions. They have a diagnosis of epilepsy and have become medically intractable. Meaning they’ve tried seizure meds that are appropriately chosen and didn’t have side effects. They went to the optimal dose and continued to have seizures. So they’re considered medically intractable.

And so, it’s a fairly good mix but she sees a lot of patients that are still undiagnosed, or have abnormal movements, even not necessarily known to have had a seizure.

[11:35] What Epilepsy Surgery Looks Like

Once somebody has tried their second medication, they appear to have a focal onset or looks generalized. Until they get them into the hospital for a full 360-degree evaluation, they realize there is some physicality to their generalized appearing seizures.

Then they do a functional MRI to do some mapping and check the motor cortices are where they expect them to be. They also need to identify which side the Broca (the expressive speech center) is on and identify their receptive speech areas and their visual cortices.

The patients then come on to the seizure units since hospitals usually have their Epilepsy Monitoring Unit. They put EEG electrodes on and record them. They may reduce their medicines, or stop them completely so they could capture seizures while they’re there yet in a safe place.

The following week, they have a conference where they present and walk through the patient’s data. And all of the epileptologists and the neurosurgeons sit down and evaluate whether the patient is a good surgical candidate.

Sometimes, they offer palliative measures when surgery isn’t an option and those can really help patients reduce the number of the severity of their seizures.

[18:14] The Training Path

After either pediatric or adult neurology residency, you can do one or two fellowship years. There are two ACGME-accredited fellowships. One is Clinical Neurophysiology (CNP), which is a one-year fellowship that has been established for decades now. And the second one was just established a few years ago, called Epilepsy. And you take either one or the other.

Right now, there are about 91 CNP programs and about 81 epilepsy programs in the U.S.

CNP is more concentrated on neurophysiology. It is widely variable, but there are kind of different tracks that certain institutions will offer.

For Adult Neurology, you do five years of training. For pediatric neurology, you do two years of pediatrics and then three years of neurology, plus one year of CNP or Epilepsy.

In many institutions, you have to do a CNP year first, and then you do an Epilepsy year. During the CNP year, you get exposed to different ways to monitor the peripheral and central nervous systems. And then your second year, you’re really concentrating on epilepsy and the management of epilepsy.

[22:25] Taking Calls

Ann says taking calls varies in the institution. As Program Director, they consider their no call policy. So when people come out of residency, and they’re tired, and they’re studying for their neurology boards, they want them to be on point and learning during the day. And they want the night to be there for them to get good rest.

And so, what call amounts to is really just coming in every few weekends on a Saturday or Sunday for two or three hours.

[24:09] How to Be Competitive for Matching

Ann says they’re looking for people who want to be intellectually challenged, detail-oriented, and are going to keep pushing until they understand. They don’t expect people to have come in with a long list of publications or projects.

They’re not expecting people to come in and start publishing as it’s hard to get a proper project from start to finish and publish it in one year. They have some ongoing projects that people can take to take part in and to get some publications.

[26:33] A Day in the Life of a Fellow

Ann illustrates how their fellows will usually come into the hospital between 530 and 7 am, depending on how many EEGs there are. They’ll read on their own until 830 am.

At 830, they sit down with Ann for about an hour, and go through all of the EEG’s and raise whatever questions they have. They sit down and work on their reports. Every second that they’re doing a report, there’s another second of EEG coming in.

They usually have a conference almost once a day where they sit and review EEGs a team along with neurologists and epileptologists. By the end of the day, they sign some reports and go home.

[29:00] Overcoming Bias Against DO Students

Ann explains she has worked with several DOs in their program and it’s not something that she ever heard anybody mentioned or identify. And so, she actually found this question odd since she never even thought this was ever an issue.

[29:56] Message to Future Primary Care Physicians

Ann wishes to tell future primary care doctors to just get those notes and have them go through those. Unfortunately, they don’t always get the notes but this is part of the medical system issues.

[31:07] Keto Diet and CBD for Epilepsy Treatment

A lot of people don’t actually know that the keto diet was created for epilepsy. And there’s been a renewed interest in it since it became a bit of a fad a few years ago.

Ann says the keto diet is very helpful for children with medically intractable epilepsy. They don’t use it typically as a first-line option because it’s pretty extreme when you do it right. That being said, it can be a very effective diet. They could use it for about two years. In some cases, they’ll use it longer, especially in certain gene defects.

CBD is another medication option. It’s cannabidiol that’s extracted. The THC is extracted out of the plant. Then it’s crystallized and placed in sesame oil with strawberry flavor and given twice a day.

Although some kids struggle with some side effects like sleepiness, or drug interactions, Ann says it’s easy to use. In fact, it has become increasingly accessible even for those without those two syndromes.

[34:20] What She Wished She Knew Before

Ann says she used to always have lengthy differentials. And she realized a lot of these patients she has had for 10 years. So she’s reading her notes.

But after a while, she became more succinct and started to use an AI-driven software that can listen to a conversation, distill it down, and put it into a note without you having to take notes.

[35:57] What She Likes Most About the Job

What Ann likes most about her job is being able to cure epilepsy. She has patients that will never outgrow their epilepsy or they’ll never have surgery. The devices are implanted, and they don’t work. And when their caregivers and sometimes the patients themselves are still grateful that she has walked them through every step, this gives Ann a certain sense of fulfillment.

[37:18] Major Changes Coming Into the Field of Epilepsy

Ann says they work closely with pharma companies and there are so many different opportunities and things that could change.

'EEG is here to stay, I don't think any computer algorithm is going to replace that and the need to look over it as a human anytime soon.'Click To Tweet

Ann says the field is leaning into deep learning to come up with methods by which they can predict how successful something like epilepsy surgery or a certain implant will be in controlling someone’s seizures. Targeting of genetic diseases has already started.

[39:03] Finals Words of Wisdom

If she had to do it all over again, Ann says she wouldn’t do anything different in terms of choosing a specialty.

Finally, to those students who might be interested in clinical neurophysiology or epilepsy, Ann’s advice is to spend time with somebody who has done a CMP fellowship or has done training EEG or EMG or nerve conduction. See what they do as it’s such a great mix of procedures.

She’d like to urge anybody even thinking about it to spend some time with somebody who does this type of mix of reading procedures as well as clinical care. It’s very rewarding and it’s a pace that can be very sustainable for decades.