An Academic MS Specialist Discusses The Specialty

Session 53

Dr. Jacqueline Bernard is an academic Neurologist who specializes in treating patients with multiple sclerosis. She is a physician at OHSU (Oregon Health and Science University). We talk about the specialty and so much more.

Tune in every week to hear different stories of specialists even if you’re interested in going into primary care. One of the questions I ask them is what they wish primary care doctors knew about their specialty. Also, check out all our other podcasts on MedEd Media.

This week, I interview Jacqueline who has been in practice now and out of her training for many years now. She has been in the community-based setting and is now back in an academic setting.

I was diagnosed with MS about three and a half years ago so this episode hits home for me. So we chat about her career as an MS specialist, what drew her to it, what keeps her happy, things she didn’t like about it, and her advice to you if this is something you’re interested in.

[02:04] What Do Her to Becoming an MS Specialist

Jacqueline says her interest grew in her. As a woman, her practice was getting referred a lot of female patients with neurological disease. And a large percentage of them were patients with MS. She realized very early on how this was a very compelling group of people. They were trying to educate themselves as much as they could about this disease process and what treatments are out there. This grabbed her pretty quickly once she was in the region of the country where it was disproportionately highly prevalent compared to other places.

Minnesota for instance, has a lot of MS cases. So it was the volume of patients she was seeing that grew quickly. Within a couple of years from moving to the state, this impacted her.

Jacqueline explains how MS is a tricky disease and you would have to be able to detect it to figure out what’s going on because it can relapse and remits. So you’d have to look at the circumstantial evidence. It might ¬†involve various parts of the nervous system such as optic nerve, spinal cord, or the brain. So you get to see the impact of the inflammation in a lot of different ways.

The most compelling part for her is how people are able to manage it and how they bounce back and continue to really live with the disease. Another piece about it is that people with MS can have really severe attacks. Jacqueline says you can help them get through that and bounce back. Ans this is something that inspires her to help patients.

[05:45] Traits that Lead to Being a Good MS Specialist

Jacqueline says you have to be curious about the path of MS and having interest in all the different ways you can suppress inflammation. If you’re interested in neuro immunology, Jacqueline things it’s one of them most interesting parts of clinical medicine today.

Jacqueline was initially drawn to Epilepsy seeing how it has interesting science and mechanisms. In fact, it’s more interesting now that there are certain antibodies found to be associated with refractory epilepsy.

She was also interested in moving disorders, having had some of the country’s best moving disorder specialties in their school. They actively engaged them into going rounds and invited them to hang out. They taught all the perils along with their fascination and passion about moving disorders. She specifically cited one of the editors of Handbook of Neurology who was their teacher – a big supporter of medical students. In fact, 10% of each class went into Neurology because of his teaching. Teachers have a huge impact in the way they bring the top of the live and how that inspires students. Anyway, she ended up doing MS which for her was workable for someone trying to raise a family.

[09:23] Patient Types and Over Diagnosis of MS

Classic patient demographics are those between the ages of 20 and 40, women to men ratio of 3:1. However, they’re now seeing much more pediatric MS. These are cases of children down to age 10. They’re also seeing first time diagnosis for people in their 50’s and even in their 70’s going to their clinic.

That said, they have a huge age range of patients at the MS clinic across the country. And by ascertainment, we’re not just getting better at testing and finding MS. Instead, there’s more people developing MS. And now that we have an MRI machine in every corner, it’s much easier. In fact, people are over diagnosing MS. This was at a recent meetings at European Clinical Trials MS Meeting in October saying this. Spots on an MRI does not equal MS. So it’s important we make sure we’re following criteria and that we’re able to sit with a little bit of ambiguity until we collect all the appropriate data before we tell people they definitely have MS.

Three years ago, I was diagnosed with MS and it was a question of whether I have MS or was it something else. It’s interesting to hear that there’s a lot of over diagnosis. It seems pretty simple. It’s not a test but a clinical diagnosis through the McDonald Criteria for MS.

Jacqueline explains that the good thing about this criteria is we could now incorporate MRI neurological information into out decision-making. Then use that to help us proof of dissemination and space and time. Those criteria are actually being decided upon for possible revision. She adds the need to be able to have clear evidence of dissemination in space and time. Otherwise, we’re going to see more people having lumbar punctures to try to find evidence of abnormalities to help substantiate this. This being said, more corroboration will be needed.

There are the clinically isolated syndrome but even before that, people talk about radiologically isolated syndrome, which are spots on the MRI obtained for other reasons. And this is probably the most common reason people are having an MRI.

[13:55] Percentage of Patients Already Having a Diagnosis of MS and Typical Day

Jacqueline sees patients in the MS clinic as well as some general neurology patients. Most of the patients in the MS clinic have been given a diagnosis. They’re asking for second opinion on the diagnosis or regarding some new treatments that may be out.

In the general neurology clinic, they get a lot of questions about numbness and abnormal MRIs. Some of them turn out to be MS but not all numbness equals MS and not all abnormal MRIs equal MS.

A typical MS day for Jacqueline may include having a medical assistant in the clinic with them. They have an MS-certified nurse and three fellows and several MS faculty. They get people roomed. They also have two city coordinators in the clinic, who see who could be patients appropriate for studies. They have 12-14 desktops in their workroom so they can pull the MRI results there and get a lot of discussions.

So Jacqueline sees 50-50 percentage of her time spent on MS versus general neurology. She also has another administrative role being the Vice Chair for Clinical Operations in her Department. She does a lot of work around access in the state of Oregon. She sees patients and learns about how they get referred in.So she’s still trying to understand referral patterns, access, and improving it in every way they can.

[18:06] Taking Calls in an Academic Setting vs. Private Practice

In academic medicine, Jacqueline their calls to be a little different. A couple of weeks may be spent on the teaching service. Their residents are taking the call for the general neurology ward as well as the stroke service. When they’re covering the neurology ward, they’re not covering the stroke service. But for at least the first week of their two-week stint, they’re covering the transfer service.

Any doctor in the state of Oregon, and sometimes the state of Washington, Idaho, or Montana can call into HSU if they have a neurology question. Or if they have a potential transfer. They take those calls. She describes the transfer center as very organized and data-driven that they call it command control. They monitor all calls that come in. Everything’s recorded. They give advice and they may follow the patient. Or if it’s a critical patient, they suggest they transfer the patient and their transfer center makes it happen if there’s a bed available.

Moreover, they partner with other community hospitals. Some of the less acute neurology transfers might go to one of their community partners rather than all the way into the university hospital. Her calls are intermittent during the day and at night for the first week of her two weeks. They also cover 24/7.

Jacqueline differentiates this from taking calls in private practice, which she did for a number of years. That would be you’re on call 24/7 for a full week and you’re taking primary call, mostly people you see in consultation on the same day or next. Or you get call from the ER for acute stroke or a huge hemorrhage.

As a neurologist, they’re consultative when they’re working in private practice. At academic institutions, they typically have a neurology ward where they do their teaching. So it’s a little bit different. Typically, when neurologists go out of private practice, they’re strictly consultative. They’re not running a ward.

[21:44] Work-Life Balance

Her decision to leave private practice and go back into academics was that because her kids were getting bigger, she can spend more time running papers and grants.

Jacqueline thinks there is a demand of time that is difficult to balance with having a family. It takes resources to raise a family. So it made more sense for her to cut back when her children were younger and then when they’re older, she’s now able to dedicate more bandwidth to her work.

At this point in her life, she considers herself busier than most people by choice considering the opportunity to take her leadership position. But she believes it’s hard to achieve a balance when your children are younger.

[23:55] The Training Path

Typically, you can take a one-year or two-year fellowship after four years of general neurology. These are not yet funded in the same way a stroke fellowship would be funded for instance. So it’s not ACGME-funded at this time. Most of their MS fellows find their funding either through pharma and other national MS society funders. They often go out and write their own application to entities that do fund. Jacqueline advises to plan this ahead of time.

Talk to some people and places and so some electives. See if that’s really what you want to do. Start to get your applications going.

The training is pretty popular as Jacqueline would describe. They would receive plenty of applications for their one or two spots they take each year. She thinks the MS prevalence has increased and the number of things they can do has increased. MS was also the place where they talk about neuro immunology which has grown so much. In fact, at the American Academy of Neurology, there’s not just an MS section but they now have an neuro immunology section. They call their fellowship MS under immunology but it may by at some be split off and it will be either/or. A lot of these disorders are associated with unusual antibodies. So there are different ways to think about your fellowship.

[26:42] How to Be Competitive for Fellowship

If you’re a resident interested in MS fellowship, during your PGY-2 when you’re trying to get exposed to everything, set up some electives. This way, you can spend more time to expose yourself. Second reasons is to get people to know you and like you and write letters for you.

If you have a research interest which is hard to do in your PGY-2 year, but if you can think of something where you can do over your residency in that field, go ahead. Have at least some project you can submit as a poster or write a paper, a review or part of the chapter with your MS faculty. Inquire early as to what they’re working on and where can you fit in.

Another important thing is to try to present at meetings to help you get to see what other people are doing. Get inspired by them and that will help you determine whether you want to do the fellowship.

[28:27] Bias Towards DO and Working with Primary Care and Other Specialties and Special Opportunities Outside of Clinical Medicine

Jacqueline has not seen any bias towards DOs. She has worked with fellow who had osteopath training. They fit in absolutely with the other fellows.

What she wished primary care providers knew is that not everything that is white spots equals MS and that not everything that is none is MS. It’s important to look for other entities and exclude other entities who are writing out e-consult guidelines to help our primary care doctors. At least, they do something to work up before sending patients over to them so they can help them know and also become more efficient and appropriate with their time and who they see in clinic.

That’s why neurology is so important in medical student education so people can start to put together all this random cranial nerves and motor reflexes. Learn that so that you can do these exams. Maybe it’s a peripheral neuropathy and it’s not MS. Or maybe it’s a migraine and not MS. So try to get a good neuro exam to get good history if you can.

Other specialties she works the closest with include ophthalmology, rheumatology, and hematology oncology.

Special opportunities outside of Clinical Medicine for MS specialists include pharma aspects. People can work in the lab and direct a drug development or in clinical trial design for potential drug candidates. Then those people putting drugs to the FDA. There are people who zoomed into pharma early in the career and they get an intensive experience getting a drug through the FDA. It’s a 24/7 stuff where you have your SWAT team.

Others who have worked in the MS centers for many years can get scooped up and get offers to go to different pharma companies to run their different clinical development program.

[33:55] What She Knew Now, Women in Neurology, and Major Changes in the Field

Jacqueline says there are no guidelines being a woman and having kids. But if she had known it’s going to work out then it would have been good. But she had no choice otherwise.

It’s common to see women in neurology now that more than 50% of medical school classes are women. Interestingly, they have a disproportionate number of women applying to neurology in their region. This reflects that more women are in medical school.

What she likes most being an MS specialist is the patients being so compelling as well as the science. MS has really led a lot of interesting science. The neuro immunology has exploded over the last 20 years. It’s a perfect mix of clinical with really interesting science. On the flip side, what she likes the least is generic to neurology, which is all the time they have spend on the computer. There are other people in the room with them that are from insurance companies. So it’s a whole different field now. Still good, but a lot more has changed.

In terms of the major changes in the MS field, she thinks patient continue to be very educated about what they choose to take. She just hopes people can maintain their healthcare coverage so they can continue to get the access to important medications.

If she had to do it all over again, she would still have chosen the same filed. She thinks it’s the most interesting filed, not to mention having great colleagues across the world. They’re working hard to improve treatments and assessments. All the aspects of it is interesting.

[38:01] Final Words of Wisdom

Jacqueline says that by 2025, they are predicting neurology desserts in at least five states because of the graying of the population. So there are more neurodegenerative disorders. So there’s job security in MS.

And if you’re in general neurology, you can see MS and other things too. Parkinson’s, Dementia, migraines, etc. You get to see a variety of people and lots of different kinds of diseases that help affect the nervous system and impact families hugely. Neurologists impact patients everyday.

Links:

MedEd Media

European Clinical Trials MS Meeting in October

McDonald Criteria for MS

OHSU (Oregon Health and Science University)

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