SS 42: Academic Neuromuscular Neurologist Talks About Her Specialty

Session 42

Dr. Vanessa Baute is a Neuromuscular Neurologist. She has been in the academic setting for the last five years out of her fellowship training. We discuss what drew her towards it, what she likes and what she doesn’t, and much more.

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[01:16] Her Interest in Neurology and Neuromuscular Medicine, Patient Types, and Procedures

As a medical student, Vanessa was completely blown away by cranial nerves and their complex, visual system. She would read about it and study it and it didn't feel like work. The neuromuscular part evolved from having good mentors in the area for neuromuscular medicine. She enjoys doing procedures as well as the patient population. Not to mention, there was a fellowship spot available.

She still sees general neurology patients as with her inpatient work. She considers 75% of her practice as neuromuscular, which is a good chunk. Although she also sees patients having issues of neuropathic pain, different forms of neuropathy, and other neuromuscular diseases. She likes the variety of cases as well as the teaching part of it.

Some of the procedures she does to patients include occipital nerve blocks with ultrasound guidance, carpal tunnel injections with steroids, EMGs (which are a big part of her practice), skin biopsies, lumbar punctures, BOTOX for migraine and facial spasms.

“A big part of my practice is procedural.”

[04:34] Traits that Lead to Becoming a Good Neuromuscular Neurologist

Vanessa cites some traits that lead to becoming a good neuromuscular physician would be the ability to stay with the patient through the journey and explain every step of the way. Every patient is going to be different so you have to be able to tailor your approach. It's not always black and white.

[06:20] The Misconception about Localizing and Being Able to Do Anything About It

Vanessa gives her take on the concept of localizing the problem but not being able to do anything about it once you localize it. She thinks of this as a misconception considering the number of genetic therapies coming out as well as a whole slew of medications used to treat disease.

When you think of neuropathic pain and other forms of pain in neurology like headache or disc diseases, this brings on a whole holistic, integrated approach they can offer patients. This involves lifestyle medicine.

“There aren't many times in my career where I feel I can't do anything for a patient.”

By this, Vanessa means doings things like walking with them in trying to figure out their diagnosis. For her, the ultimate goal depends on the person. Some people don't want to take a pill to have everything fixed. For other people, their healing journey is figuring out what's going on and how it's affecting their family. How can they live with it? Is their doctor going to be with them? Are their doctors listening to them? So she sees a lot of these in her practice just counseling patients.

“Even if I can't figure it all out in one visit and fix everything, that's not really a lot of people's goal.”

Nevertheless, Vanessa assures there are cures for epilepsy as well as medications and treatments for MS. They have a lot of good treatments apparently. So she feels that her patients could be empowered. And maintaining their neurologic health, it's not always a big neurologic disorder they're coming with.

[08:40] Other Specialties She Considered

Vanessa describes herself as a happy person, so she likes everything. She knew the complexity of neurology but she also loved her prelim medicine year, in almost everything she rotated through. She knew that surgery wasn't for her even, if she likes procedures. As funny as it may sound, she actually broke the sterile field on her first day of surgery rotation when her pants fell off!

She likes hematology oncology and found it's similar to neurology in some ways, in terms of its complexity and the diversity of diseases. She loved the nephrology rotation, but not the acuity part of it. She is not a neuro-intensivist, but more of looking for bread and butter ways to look at preventive medicine.

Nevertheless, there was nothing strong enough to pull her away from her chosen field.

“There cannot be anything in this life other than a neurologist.”

[10:52] Types of Diseases, and Followup Care

Vanessa considers her bread and butter neurology practice as a lot of peripheral neuropathy, neuromuscular junction disorders (ex.myasthenia gravis), cervical disc disease, lumbar disc disease, weakness, or a referral for motor neuron disease, ALS or an ALS variant.

Being an adult neurologist, she doesn't see children with muscular dystrophies. But they do have patients with adult muscular dystrophies, such as myotonic dystrophy and imb-girdle disease.

In some of her general neurology practice she deals with headaches and migraines, which she gets lots of referrals for. She also noticed how this has recently increased with the levels of stress as well as dietary influence. But she finds this exciting because of good treatment and good counseling options available.

According to Vanessa, in most days, even if it's difficult news and diagnosis, she's still able to instill hope in patients and offer them all the different treatments. She walks with them in the path which she finds very rewarding.

There are several instances where she does followup care, when the patient comes to her already with diagnosis of ALS for example. About 80% of her patients come in having seen somebody, whether another neurologist or primary care doctor. Somebody has already labeled them and thought they had a certain diagnosis.

This is something she always harps on, with education about a patient, is not going blind. It doesn't matter what somebody else had said, because today is today and they're clearly here in our office. They always question the whether the diagnosis is right or wrong. We don't know what was happening when that person was in that doctor's office. They look at how the patient was diagnosed, the workup, the labs, the CK and the ENG report. They think from a critical standpoint if those were the things they would have measured. She always teaches her students to take a critical look at how these diagnoses are made.

“Some of the treatments are heavy-hitters and even just the labeling of the diagnosis. So we want to make sure.”

And sometimes, they're able to take that diagnosis away and label away. And a lot of times, for a better one. For instance, Vanessa explains how ALS can be difficult to diagnose initially. So it's a big thing to tell somebody they have ALS if they don't or vice versa. So they take their time with all the information. Oftentimes, they repeat some of the tests until they both the physician and patient would feel good.

[15:27] Typical Day

As a neuromuscular surgeon, every single day is different. But she does this on purpose since she likes to be doing different things at different times. But a typical day for her would be a neruomuscular clinic. She works with neuromuscular fellows. Her favorite part of the job is being able to watch the process done by the fellow or the trainee.

Vanessa also enjoys catching up with the patients. She sees from five to eight patients in a half day. And the rest of the day is spent giving lectures to students or practicing integrative neurology. She does a lot of work in education, specifically, curriculum design, and nutrition counseling. She also does a little bit of research.

[17:05] Academic versus Community Setting

Vanessa chose academic versus community-based setting for the primary reason that she loves the educational aspect of it, which involves a lot of teaching. She also likes the mentorship. Medical training is challenging. And her personal experience with that stayed with her. It's almost traumatizing and hard.

“The educational standpoint is so redeeming. I can be there with the student or whoever it is I'm talking to.”

She just can't imagine not having this part of it. Another thing about academics that she loves is being able to see a complicated neuromuscular patient and she can talk about it for two hours. She can talk about it with whoever – patients, doctors, nurses, or colleagues. They can conference about the case and talk about it forever.

[19:03] Percentage of Patients She Does Procedures On

Vanessa mentions having a few sessions of EMG lab in procedures. Apart from her clinic, she has sessions devoted solely for procedures. So she separates her procedure clinic and her patient clinic. In her patient clinic, about 40% of them have a procedure ordered – something with a needle. Then she will put them in her either procedure or EMG lab clinic, which is comprised of a half clinic and half procedure ratio.

A lot of her patients in the procedure clinic are those who are people she met in the community. Not everybody likes procedures, but since she loves them, she is known for it. So her colleagues will refer the different patients who need procedures to her.

“The referral base is good and I like being the person that is known for doing these procedures.”

[20:49] Taking Calls and Clinical Coaching

Vanessa hardly takes any calls other than those calls she takes voluntarily. She still does a bit of inpatient service and that where she takes a call. She does this primarily because of the teaching aspect. Their calls are a mandatory process. She does four weeks per year of general inpatient neurology. A lot of this is neuromuscular cases like myasthenic crisis, Guillain-Barre, or transverse myelitis, etc. She sees this as an opportunity for her to get exposed to the residents and do a lot of bedside teaching, physical exam review, and clinical coaching. With clinical coaching, she partners with a third year medical student and kind of takes them under her wing. She goes and sees patients and watch them do history interviews. Then they'will have a feedback session afterwards. The calls she takes are home calls, which she took as a junior faculty. So likes to keep it fresh and keep up with the educational part of things.

[22:22] Work-Life Balance

Vanessa admits she tries to have a good work-life balance. Her goal is to show up at work and do something so fun that it doesn't feel like work.

“My goal is to show up at work and so something that's so fun that it doesn't feel like work; and then go home and be at home.”

Her goal is to use her training and what she's passionate about and what she loves, feel good about it, and then go home and be able to have that part of her life just as important. This is another thing she thinks a lot of people struggle with because you're not going to be an MD all the time. Your other roles are important too. She stresses the importance of focusing on those roles too as much as we're in the MD role. Nevertheless, the transition is challenging as we try to just sweep in. Know that you don't have to fix everything.

“You're not an MD all the time. It's important to be whatever other roles you play in your life.”

[24:22] Neuromuscular Fellowship, Bias Against DOs, Subspecialty Opportunities

Vanessa describes neuromuscular fellowship as not being very competitive in the sense that a lot of programs are looking for neuromuscular fellows. They're trying to recruit good fellows. There have been changes in the reimbursement in the last five years, specifically with EMG reimbursements. She's not sure if this motivates people to not go into neuromuscular medicine. Although it shouldn't, because Vanessa stresses that if you're not loving what you do, it doesn't matter all – getting reimbursement or how much you're getting paid – if you're not into it. But this may have some influence in it. Again, she wouldn't consider it as a very competitive fellowship.

In terms of bias against DOs in the field, she doesn't really see this. Many of the fellows she has trained are DOs. Vanessa says DOs have a lot to offer and a lot to bring to neuromuscular medicine. She finds that it is a unique background, even if she's not DO. But she's heard a lot about it from the people she works with and she acknowledges how beneficial DOs are.

“DOs bring a lot to the table, especially with the manipulation, the musculoskeletal component, and anatomical component.”

In terms of subspecialty opportunities, many will do a neuromuscular fellowship with research. Most would do neuromuscular fellowship in one year. Some people will do a clinical neuro-physiology fellowship with several varying months of neuromuscular EMG training.

If you're interested in something specific after that, it's normally within that fellowship that you're going to get that training. In many cases, she knows people who went back and did something specific within neuromuscular medicine. Some people spend more time doing EMG while others spend more time looking at neuromuscular junction disorders.

Neuromuscular ultrasound is an emerging field, which is something she teaches at workshops and meetings. She noticed that more people want the training. There are different courses available for this – muscular dystrophy for instance.

[28:00] The Path to Neuromuscular Fellowship

From graduating medical school to being a neuromuscular neurologist, you do your first year or transition year as your first year of residency. You look at all the specialties and then you have three years of neurology. Most programs are front-loaded. Your PGY2 year may involve taking a lot of inpatient calls or seeing acute stroke – things like high-acuity neurology. Then it tends to get more clinical in most programs. You may also be exposed to EMG. It's rare to have EMG exposure early on in neurology residency, although there are definitely programs able to do that. EMGs are mostly outpatient and most residency training is patient.

After your three-year neurology, you go into your one-year fellowship. Sometimes, this can extend to two years especially if you're interested in research opportunity.

[29:35] Working with Primary Care and Other Specialties

When Vanessa sees referrals from primary doctors, she wished they knew the neurologic exams. Sometimes she takes a referral over the phone asking about a neurologic questions. They would describe a neuromuscular disease to her and she would as how the patient's reflexes are doing. And then they say they didn't check the patient's reflexes. She considers this a travesty.

This is where Vanessa thinks clinical coaching is very helpful for students. Getting down how to perform a neurologic exam, no matter what specialty you're going into. And basic things are important such as checking reflexes.

A great resource for learning this is the book Neuroanatomy Through Clinical Cases by Hal Blumenfeld. And practice this with your friends and family. Then have your neurology rotation. Do neurologic exams and have a neurologist watch you do it and coach you through it at least once. Record that. Take notes on that. And a neurology resident would be happy to do that too.

“Everybody needs to have some form of neurology exposure and medical training.”

So one of Vanessa's biggest pet peeves is people not knowing if the patient has reflexes or Guillain-Barre. She would want them to at least know the level of sensory loss, especially if it's a spinal cord lesion. It's not that complicated, but just a matter of education. It's a matter of learning that and practicing. Vanessa again stresses the importance of knowing how to perform the neurologic exam early in your training.

Aside from primary care physicians, other specialties she often works with include neurosurgery, orthopedics, hand surgeons, physiatry, PM&R, and rheumatology.

[34:18] Special Opportunities Outside of Clinical Medicine and What She Wished She Knew

There are also special opportunities outside of clinical medicine in terms of advocacy and administration within the hospital. It's a general personality trait, as she describes it, so it's not only unique to neurology. There is also a big split between a clinical role and a research role.

What she knows now, that she wished she knew about her specialty, is reassurance. If she had seen this practice she has, going on where she unites neuromuscular medicine with integrative medicine with education and mentorship, she would have been relieved.

“Everything feels very intimidating when you're in training and you don't see how it can be.”

They've also had some surprises in the field with genetic therapies, spinrasa (nusinersen) and intrathecal administration for SMA. These are new things on the horizon. Looking at herself as a fellow looking at her now, she'd probably be surprised how fulfilling neurology can be as well as neuromuscular medicine. She'd be surprised in how far you can really go. Just keep going one day at a time. Keep going. Keep working. And you're going to be landing your dream job.

[37:05] The Most and Least Liked Things About Her Specialty

What she likes the most about being a neuromuscular neurologist is her colleagues and the chance to be able to work with the neuromuscular fellows. They have two fellows for a year, so they get to be intimate in their learning which she finds very rewarding. She loves how she's able to make a difference in the patient's lives while educating.

What she likes the least is paperwork. Again, not unique to neuromuscular medicine. She finds it challenging to implement and get people in the room, coordinating the referrals, and scheduling. Unfortunately, medicine has pitfalls in terms of bureaucratic processes which aren't what you want to be doing. So she tries to minimize this by building a good team and having meetings with everyone.

“Every person is essential. I'm only as good as my support staff… we all have to work intricately as a team.”

[39:37] Major Changes in Neuromuscular Neurology

Vanessa notices that for muscle diseases, they have traditionally done their muscle testing and muscle biopsies in certain cases. Now, with genetic testing, they're able to talk to a patient and send off a gene test. Then you may no longer need a muscle biopsy. They're not exactly there right now but hopefully, more innovations and drug therapies are coming out soon.

If she had to do it all over again, she still would have chosen neuromuscular medicine with integrative medicine. For Vanessa, the two have to go hand in hand. She loves the patient population, her trainees, and her colleagues. She adds it's something you can tailor to what you're interested in. And if you know what that is in your own life then you can ask for that. Go for that. And you can make your practice really rewarding.

[41:25] Final Words of Wisdom to Students

Vanessa encourages students who like neuroanatomy and have done neuro rotation, or even if you're just curious if you're going to like it – go shadow a neuromuscular neurologist. And if you think it's challenging, it is! They're not easy. But don't get discouraged by that. As long as you like it and you're dedicated to it, know yourself and know what you're interested in and just go for it.

[42:42] Last Thoughts

One of the biggest takeaways for me during this interview was how much she loves procedures. As a neurologist, it's finding the ability to do procedures. Typically, neurology isn't considered to be a very procedure-heavy field. But she has found a niche for herself in doing these procedures because that's what she loves to do.

If you're thinking about something and disappointed because it's not very procedure-heavy, think again. You might be able to find a niche for yourself. And do the procedures you want while also seeing the pathologies and treating the patients that you want.

If you know somebody who would be a great guest here on the show, please shoot me an email at ryan@medicalschoolhq.net and we'll try to get them on the podcast.

Links:

MedEd Media Network

Neuroanatomy Through Clinical Cases by Hal Blumenfeld

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