An Academic Pediatric Neurologist – Headache Doc

Session 33

A lot medical students go through the process end up at a time where they have to submit their rank list and they have no clue what they want to do. And this is a lot of unneeded stress. In this podcast, I talk to a specialist that you can’t get hold of so you can understand what is out there for you.

Today’s guest is Dr. Lauren Strauss, an academic Pediatric Neurologist who specializes in headaches. She is a DO at a large academic medical center for an allopathic residency program. She is currently the Residency Program Director at Wake Forest Baptist Medical Center for Pediatric Neurology. Listen to her thoughts on the field and what you should be looking into. Also check out our other podcasts at MedEd Media.

[01:50] Interest in Pediatric Neurology

Lauren has an interesting background having started in engineering. She did her major at UPenn in bio-engineering. She has always loved science and math. Her grandfather being an engineer and not having any doctors in the family, Lauren decided to do engineering. She thought bio-engineering would be offering her a big variety. What she found she loved the most was being able to do projects that brought them over to the hospital and allowed them to interact with clinicians.

When she decided to do her senior engineering project, she ended up in the Neurology lab where they did research related to vertigo. At that time, she didn’t know she wanted Neurology but she knew she liked other things outside of engineering.

After graduating in engineering, she decided to take a year off while looking into medicine as an option. She worked at a pediatric practice for her pediatrician. She worked there for a summer which later turned into a whole year. Then she realized she wanted to go to medical school to be a pediatrician.

It was during their pediatric subspecialty month that she could rotate through a lot of different specialties and neurology was one of them. It still didn’t hit her at that point that it was what she was going to. When she picked a full month in a pediatric specialty, some subspecialties she signed up for were already filled except for pediatric neurology. She did the rotation anyway.

Then she decided to apply to Pediatric Neurology. Lauren describes it as a hard decision to do.  Nowadays, most programs are categorical where you do your pediatrics and neuro in the same location. But at that time, there were still some where you could train at two separate places. Hence, it was a difficult process. When she talked to her medical school at New York College of Osteopathic Medicine, they never had anyone else who had done Pediatric Neurology.

She is very happy she did take the plunge though. Where she ended up doing her training was pediatrics at a larger children’s hospital at Long Island Jewish Medical Center. Then she did her child neuro training at Boston Children’s Hospital.

She then found out that a lot of people will pick an interest within Neurology and academics and go on and subspecialize with fellowship. She initially considered epilepsy since majority of the practice in pediatric neurology is developmental delay epilepsy and headache. Since she had an engineering background, she felt it was best for her to go into epilepsy. The reading of EEG’s relies on physics. She soon discovered her love for patient interaction and taking a history from a patient and solving a puzzle. But she didn’t love reading an EEG as much and sitting by herself.

[06:18] Becoming a Pediatric Headache Specialist

Lauren says a lot of people don’t know you can subspecialize in headache. As a new emerging specialty, Headache Medicine is part of a UCNS (United Council for Neurologic Subspecialties) fellowship. A lot of people going into the field are adult headache specialists being the paved route. It’s much easier from the adult side.

Lauren notices that headaches in kids can be as young as age two but majority of them are in the pre-teen or teenager years. She loves the challenge of convincing the patient to give her that history. She also loves the overlap with some of the social dynamics and healthy living. She loves how to coach them back towards a better life. She also likes the fact that a lot of headache patients tend to get better if you have the right tools in place. She finds this very satisfying.

So when she looked into Headache Medicine, she explored her other options including a pediatric pain fellowship as well as an adult pain fellowship. She likes procedures but realized she didn’t like it to the extent that majority of her practice was going to be procedures. So she ultimately settled in doing a headache fellowship. She ended up doing an adult headache fellowship at the Brigham and Women’s Hospital, one of the first headache centers established in the country. Their adult headache fellows were very interested that she was doing her child neurology training locally. So they got interested in collaborating with and training a future pediatric headache specialist.

Lauren is actually one of the pioneers of the said field. She knew that when she graduated fellowship, she wanted to have all of the necessary tools. If she left the programs in Boston, then she would want to be at a center where there is no other pediatric headache specialist. She is currently at Wake Forest being one of the few fellowship-trained pediatric headache specialists in a several-state-region.

Moreover, she is heavily involved, not only in patient interaction, but also in education and community efforts. She is streamlining protocols for the emergency room and educational materials for patients. It’s very common but there is also a lot of need in headache since not everyone has gone onto this subspecialty level.

[09:07] Traits that Make a Good Pediatric Headache Specialist

Lauren illustrates that anyone interested in going to pediatrics has to be a little bit more patient and creative.

When you’re examining children or taking a history from a child or family, you have to be willing to go out of order. The child might not let you examine at the beginning of the visit until the end of the visit. So you have to be able to charm people. You have to use your communication skills to warm up the child or the parents to what you’re trying to ask and what the plan is going to be. In headache, those skills are taken into the extremes. The patients and their families are dealing with a situation where their child is very much in pain. They don’t initially know other families are dealing with the same condition. So it can be very isolating and very anxiety-producing. It can be a huge struggle.

Moreover, a lot of these patients can be very disabled by their condition. They can look like other children but they’re dealing with special issues. They could miss school and have many other challenges. As a specialist, they have to be able to coach them and be firm at times on helping them get back. Hence, communication is very helpful.

Lauren adds that you want to be a little bit of a problem-solver. You may want to ask a few more questions to make sure it’s migraine and not something else. You have to be able to understand the exam and how that fits into the history.

[11:15] Patient Types and Procedures

In general neurology, they see all ages up to eighteen in pediatric neurology. In the outpatient setting, they will usually do evaluation for young children who are delayed in walking or talking. They try to understand if it’s something they’re going to catch up on. Or is it something related to a genetic condition or a metabolic condition? You need to assess if you need to do another workup. How do you help them get the right services they need so they can catch up on their milestones.

Additionally, they see first time seizure patients or refractory seizure patients. They try to see how they can help diagnose the right epilepsy condition. They have a lot of patients that get better. They can make a diagnosis of a seizure disorder that they know by the time they’re teenager, it may go away or in a few years. So they have to make not only a diagnosis but also be able know whether it fits into an epilepsy syndrome. This way you can help the family understand what the true prognosis is.

So epilepsy is a big bulk as well as headache. Since her passion is headache, most of her outpatient practice over time has become headache. Headache patients come in various types. You can see someone with their first headache that may be had some interesting features to it. They can have a visual aura. Children, just like adults, can have very interesting aura symptoms for their migraines. They can see a cracked glass, speckled colors, sparkles, shooting stars and a whole gamut of things. And this can be very scary for the first time it happens.

Part of Lauren’s expertise is sorting out how consistent it is with migraine or if there’s any workup needed. She also sees patients with repeated headaches or those that never go away everyday. Some of the typical medicines they would use over the counter won’t seem to stop it. So it’s also part of her practice to sort out which medicines they can use to help the patient. Or if there are certain things in your lifestyle that contribute to this such as overuse of caffeine found in local soda or sweet tea.

They also focus on avoiding skipped meals, hydration, exercise, and addressing other concerns like bullying or other things going on at a school setting.

Moreover, Lauren is also trained in procedures to help manage pain. They can do  a nerve block. The patient takes a numbing medicine and the specialist injects on the scalp to numb it and give it temporary or long-lasting pain relief. They also do Botox which is a muscle paralyzer which you can use in managing chronic migraine. You inject in 31 places on the scalp and the neck. It affects the nerves locally to prevent them from spreading neuropeptides and inflammatory markers to perpetuate pain. Lauren explains there are a lot of interesting ways to treat headache including coaching and procedure. This keeps her practice very interesting.

[15:10] Choosing Academics versus Private Practice

Lauren initially thought really long and hard about what she wanted her career to look like. She thought private practice was very attractive because you have more control over your schedule. You might see consistent types of patient population You might have more consistent hours. The reason she ultimately chose academics is she wanted a job where it could grow with her as her interests change.

As a young faculty, she knows she loves education but she doesn’t really know if that’s her path. If she went into private practice, she thinks she would have missed a lot of things – being with the residents and medical students and seeing the collaboration and the discussing of interesting patients. Since she has been at Wake Forest, she started up a Headache Case Conference. They host it once a month where they get together and talk about their most fascinating headache patients. Because of this, they can get back up on patients they need more guidance on as well as be able to hear from other providers. She loves this kind of collaboration and learning all the time.

Lauren is glad she chose academics. She has gotten so passionate about education that she is now the Residency Director for their Pediatric Neurology Program. She now helps design curriculum and make sure block schedules look nice. She looks into ways to improve the education for their residents at all stages.

Another thing she likes about academics is that it allows you to be part of both the inpatient and outpatient sides of it. She loves being in clinic and it’s the majority of what she does in headache managements. But she also loves being occasionally on inpatient service. You see so many different things there that by the time you see them on clinic, they’ve already been stabilized and they no longer have ongoing concerns. Academic allows you to be varied and depending on where you get hired, you can have all different types of job descriptions.

[18:00] Work/Life Balance

Lauren stresses this is something very important to look at when choosing a field not only for women, but for anyone when choosing their career. You never know what your home life is going to look like when you’re making these big decisions.

Lauren knew she was going to likely possibly leave the area where her family lived. She would be in an area without initial extended support and friends. She wanted to be in a place where she didn’t have to work nights and weekends all the time. Lauren loves the balance in pediatric neurology. She generally works Mondays through Fridays and works one weekend every six weeks. She’s not in-house for those calls and works from 9-11 doing patient rounds and then she goes home. She also answers pages from home on the weekends she’s on.

For Lauren, it’s manageable because it ends up being an 8-5 job with lunch breaks. Then she can also squeeze the meetings. But in general, her practice is very manageable for having a family.

[19:35] Residency Path and Fellowship Training

Lauren explains that a lot of programs have moved towards combining your match into being able to apply once into both pediatrics and child neurology at the same hospital. At Wake Forest, you come for a two-day interview. You will be interviewed by the pediatrics group and then by the child neurology group. But when they make a decision and you get your match result, it’s at one program. Lauren did her training at two separate places. It does have its benefits like being able to know all these different hospital systems. But she reckons it’s nice to spend all five years (two in pediatrics and three in child neurology) in one place. It allows you to build connections much easier and you spend less time worrying about computer systems. Then you can focus more time on learning as you transition from pediatrics to child neurology.

What’s different in their field is you spend two years purely in pediatrics. Then when you transition over to child neurology, you will spend a bulk of that first year in adult neurology training. You’re treated just like another adult neurology resident. Lauren describes this as a hard transition to go from general pediatrics to dealing with adult patients who may have internal medicine problems. Some of those conditions may have overlaps in pediatrics in ways.

Moreover, programs approach problems differently. At their program, their pediatric neurology residents don’t do in-house call on the adult neuro side.

How competitive Pediatric Neurology is depends on where you want to practice. Some of the top five programs tend to be larger programs but they’re biggest hits in the major cities. So several of those programs can be very competitive if you had your heart set on one of those programs. But in general, pediatric neurology every year will have a few spots that are unmatched across the country. Relative to some other specialty fields, Pediatric Neurology is less competitive. Compared to adult neurology, it’s also less competitive.

The fellowship training is a one-year program. There are programs that offer a two-year program depending on what your research interests are. But usually, it’s a one-year clinical fellowship. Then you may add on a second year if you have plans to complete a certain type of research project by the end.

[22:50] DOs, Primary Care, and Other Specialties

As a DO, Lauren was very worried in some of the programs she was interviewed at being it could be something that was mentioned or asked about. At the program she settled at Boston Children’s Hospital, she was worried about it being a Harvard-based program. She was afraid being an osteopath would be seen negatively. But it was a positive to them as their prior residents and chief residents have also been DO’s.

You would be sometimes be worried that it’s going to be a problem in a program. But there are programs that you’re unexpectedly amazed that they see that as a strength. She interviewed at a place in New York and she was asked why she didn’t go to a real medical school. She thought it was a joke until she realized it was actually happening in real-time.

Everyone will have things in their CV that they’re very proud about or other people are going to question. If someone says something negative, Lauren says you just have to rise above and say you’re proud of where you come from. Explain to them why they should be excited about what you’ve done in the past. Other than that on interview though, she has never experienced any negativity towards being a DO. She finds this as a huge strength in her clinical practice because she practices an OMM (Osteopathic Manipulative Medicine) or OMT (Osteopathic Manipulative Treatment). She tends to use it on the head and neck in some of her headache patients. And they really appreciate the hands-on approach. Lauren admits she’s blessed and happy she chose the training she did. It has opened some doors that would have been opened for someone else.

Working with primary care, Lauren says it’s helpful that as you’re going through training, seek out as many opportunities that might be out of your comfort zone. She recommends gaining as much information as you can during rotations. You never know when that knowledge is going to come back into play and be helpful for that one particular patient. She thinks that if you decide to  only do pediatrics, you may have opportunities where you’re able to interact with a neurology patient during training. Lauren recommends taking the opportunity to do neurology month or take things you may not always deal with. You never know when you have that one patient in your practice and you feel very uncomfortable with. Moreover, Lauren says it would be helpful to say why you’re worried and what you’ve already discussed to the patient. Other specialties she works the closest with include general pediatrics, neurosurgery, and neuroradiology.

[28:33] What She Wished She Knew And What She Likes Best and Least

Going into pediatric neurology and headache, what she wished she knew that she knows now is that they have a great work-life balance but their pay is less compared to other pediatric subspecialties or adult colleagues. Nevertheless, she is very happy with her work-life balance and her salary but she just didn’t realize this was something in play. She thought that if you treated the same complicated type of cases that you’d be compensated the same. Lauren points out how resources account for this. You’re very lucky in academics if you’re at a children’s hospital that is layered with different administrative support and fund raises.

Lauren’s favorite thing is when patients get better. She loves it when a patient comes back and they’re doing really well. You can’t cure everyone but she says it’s very rewarding when you hear that someone’s life was upside-down and now they’re back on course. On the flip side, what she likes the least is the frustration of trying to help your patients but they can’t see a path out. They’re not willing to improve their lifestyle like cut caffeine or sleep better.

If she had to do it all over again, Lauren says couldn’t imagine what else that other career would be or what else would she be so excited about. She simply loves her job.There are times that anyone and any job can feel that have a frustrating day or interaction with someone. But in the end, she finds what she does as really fascinating and the opportunities are very rewarding. She says you don’t get to have that kind of rewarding and intense job as much. But she would choose the same specialty all over again.

[34:30] Lauren’s Final Words of Wisdom

No matter field you’re looking at, Lauren says it’s always about reaching out to areas you’re thinking about and finding out what opportunities are available. It could be spending time with someone in clinics or in the operating room. It could be spending time on the inpatient side or in a research project.

Especially in academics, Lauren says everyone is excited when they have someone reaching out to them. When you see someone young and enthusiastic and looking at what you’re doing, it can be contagious. So it’s very important to be involved in that process and don’t be afraid to reach out. Introduce yourself or maybe attach your resume so they can also understand your background. Be honest to say you don’t know if neurology is for you. Then ask if you could schedule a time to be able to spend time with them in the clinic just to see how you’re going to love that experience.

[36:30] Breaking the DO/MD Stigma

It seems that the DO and MD stigma is going away. Lauren is a DO at a large academic medical center for an allopathic residency program. Hopefully, you understand that being a DO is not holding you back. If you’re listening to this as a DO student, there are some self-limiting beliefs that you don’t actually need.

If you are in the Wake Forest area and that triad of medical hospitals and universities looking at pediatric neurology, go reach out. See if there’s an opportunity to shadow her or somebody else in the program in that department.

[37:31] Compare and Contrast

Two weeks ago, we did adult headache medicine and this week we did pediatric headache medicine. Now you’re seeing some differences if you’re thinking about headache and you’re thinking about adults versus kids. Listen to these two episodes. Compare and contrast.

If you have a specialist you would like for me to talk to, shoot me an email at [email protected].

Links:

UCNS (United Council for Neurologic Subspecialties)

Wake Forest Baptist Medical Center

adult headache fellowship at the Brigham and Women’s Hospital

Specialty Stories Episode 31: What Does a Headache Specialist’s Job Look Like?

Brigham and Women’s Hospital

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