What Does a Movement Disorder Specialist Do?

Session 58

Dr. Kathrin LaFaver is an academic neurologist who specializes in movement disorders. We talk all about her job and what you need to know if you’re interested.

Dr. LaFaver is now four years out of training. She talks about why she chose to become a movement disorder specialist, what it takes to become one, and so much more!

Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:54] Her Interest in Movement Disorders

When Kathrin was a neurology resident, she got to do an elective in movement disorders. She found a great mentor and she was just fascinated by it, including the personal connections they formed. So from day one, she knew it’s what she wanted to do.

The great thing about movement disorders, Kathrin says, is that you see the problem in front of you. So you can often make a diagnosis as the patient comes into the room.

Movement disorder is a really interesting specialty with a lot of treatments available and the opportunity to follow people long term.Click To Tweet

Ultimately, she enjoys the connection with movement disorder patients. Treatment-wise, the medication for Parkinson’s disease that was discovered way back in the 1960s still remains as the mainstay treatment for Parkinson’s disease.

[05:15] Traits of a Good Movement Disorder Specialist

You have to have good observation skills—seeing the patient, finding the pattern, and fitting them into the right category. Over time, once you’ve done it for a while, it becomes natural to see those specific disorders, which may not be so obvious for someone who’s not specifically trained in it.

Other favorable traits include being able to enjoy logical thinking and fitting clues together, which is actually common to all neurologists.

[06:40] Types of Patients and Cases Seen by a Movement Disorder Specialist

Parkinson’s Disease is the mainstay for most people in this practice. Unfortunately, this disease has been on the rise. In fact, one in 37 patients is expected to have Parkinson’s Disease.

One in 37 patients is expected to have Parkinson's disease, so it's actually a very common disease. Whether you do neurology or not, you're going to see people with Parkinson's disease.Click To Tweet

Parkinson’s disease affects many people, young and old, and there are different treatments, both medication and non-medical treatments. Parkinson’s affects not only the motor system but also sleep, mood, and other symptoms. So this is an interesting area to study. There are a lot of things to be researched and discovered.

More Cases Regularly Seen by a Movement Disorder Specialist

Most common movement disorders span the whole spectrum of ages. They see dystonia. They see Tourette’s syndrome, which often affects children and teenagers. Tremor can also be present in younger adults. Others would be genetic forms of movement disorders often presented in midlife.

Tremor and Parkinson’s disease are especially common. It’s generally easy to tell them apart, but not everyone behaves like a textbook example of the disorder—so it’s not always black and white.

Patients with movement disorders are misdiagnosed quite often, either by primary care physicians or by neurologists who aren't very well-trained in movement disorders.Click To Tweet

Being at a tertiary academic center, Kathrin says they do get patients where they have to dig deeper to look for the missing clues and get the diagnosis. She has challenging cases every week where they have to be thorough with their history and examination to get to the diagnosis.

[10:55] Academic versus Community versus Private Practice

Kathrin has always been interested in human psychology, and movement disorders were just so interesting for her. Although they’re called movement disorders, they are so much more than that.

All these disorders like Parkinson’s disease and Huntington’s disease have behavioral manifestations, as well. Depression and anxiety, for example, are common in Parkinson’s disease. Anger and depression are very common in Huntington’s disease.

We're still just at the beginning of understanding all these movement disorders and finding better treatments and cures for them.Click To Tweet

Kathrin knew she wanted to be in a place where she can continue exploring and help contribute to gaining new knowledge about these diseases.

[12:40] A Typical Day: The Parkinson Buddy Program

Being the director of the Parkinson’s Disease and Movement Disorders Clinic at the University of Louisville, Kathrin spends 50% of her time on research. She’s involved in several medication studies for Parkinson’s and Huntington’s. These are studies run in multiple sites across the U.S. and Europe. This gives patients an opportunity to try new treatments or be involved in new treatment efforts.

They’re currently looking for treatment for anxiety affected by Parkinson’s. So Kathrin doesn’t see clinic patients. Rather, she’s involved in teaching medical students and doing community outreach.

Three years ago, they started the Parkinson’s Buddy Program where they team up first-year medical students with Parkinson’s patients in the community. This is an opportunity for these students to experience how someone with Parkinson’s lives and what challenges they face in their lives.

Three years ago, they started the Parkinson's Buddy Program where they team up first-year medical students with Parkinson's patients in the community.Click To Tweet

So when they get paired with a patient, they do some mentoring sessions with her. But the goal of the program is to let them meet with the patient in social settings, so they can explore and experience how Parkinson’s affects her daily life. Kathrin is involved in other community activities, teaching, and fundraising efforts, as well.

Typical Day for a Movement Disorder Specialist in an Outpatient Setting

The other half of her time, Kathrin does see patients in the office. Kathrin sees 100% movement disorder patients in the outpatient setting.

All neurologists in their group alternate on taking call, as well. For one week every 2-3 months, she spends a week in the inpatient general neurology service. On those weeks, she supervises residents and sees patients with general neurology conditions like epilepsy, multiple sclerosis, and so on. This is in contrast to all of her outpatient time being spent with movement disorder patients.

[15:50] Work-Life Balance and Lifestyle as a Neurologist

Kathrin is married with two kids, ages 2 and 4. Her work is fairly busy, but her time outside of the hospital is spent with her family.

What Is Residency Like for a Movement Disorder Specialist?

In terms of the path to becoming a movement disorder specialist, Kathrin outlines the process. First, you do a neurology residency, which is usually a year of internship in internal medicine, then three years of neurology. There are fellowships that are one year, mostly clinical. And many are two years—one clinical year and one research year.

Movement disorder is actually not an accredited fellowship, so the pathways are a little bit more flexible.Click To Tweet

There are also some opportunities to get intensive training in deep brain stimulation surgery. This is a surgical treatment mostly for Parkinson’s disease and essential tremors. It’s a team effort where the neurosurgeon does the procedure and then the neurologist or movement specialist does the programming and follow-up care for the patient.

Kathrin did one year of clinical fellowship in Boston, then spent two years on a research fellowship.

Is Movement Disorder a Competitive Specialty?

In terms of competitiveness, there is actually a shortage of neurologists. Some programs are more competitive than others. If you’re flexible with your location, it’s not extremely competitive to get into a movement disorder fellowship.

One of the challenges in the movement disorder sphere right now is the epidemic of Parkinson’s disease coming upon us in the next 20-30 years. The trends Kathrin sees coming in the future include more telemedicine, especially in rural areas, to hopefully help meet the demand for movement disorder specialists.

[19:36] Negative Bias Against DOs and Special Opportunities

Kathrin doesn’t really see any bias going on against DOs among movement disorder specialists.

[20:38] How Deep Brain Stimulation Surgery Works

In deep brain stimulation surgery, the patient essentially gets a pacemaker for their brain. Electrodes get placed in targeted areas, and in order to make sure this is done correctly, the procedure is done while the patient is just on anesthesia.

Then the electrode is advanced, and the patient is awake while mapping is being done. They actually listen to the cells as the electrode is advanced. And this is where the special training comes in.

Cells in the different parts of the basal ganglia have different characteristic sounds.Click To Tweet

Imaging plays an important role, but most centers still do the microelectrode recording as an additional means of finding the right location for these electrodes. Doing this procedure is a team effort with a neurologist, neurosurgeon, and neuro electrode physiologist.

Once they believe they’ve found the right spot, they turn the stimulation briefly on. Then they look at whether the tremor gets better. So they’re able to see an immediate effect in the O.R. as they confirm the correct placement of the electrode. Although results are not guaranteed, there have been many cases where the tremor has really stopped. For many patients, it’s really a miracle surgery.

[23:58] Working with Primary Care Physicians

Kathrin’s message to primary care physicians is to not be afraid of referring a patient to a neurologist or movement specialist. Because Parkinson’s and essential tremor are so common, sometimes the internist or the primary care physicians become the main providers treating patients. And often, it works out just fine. But it’s important for people without special training to realize their limitations. So if the patient continues to experience the tremor, they should not hesitate to refer them.

In many cases, movement disorder specialists really have very effective treatments which can make a huge difference. Even for people in more advanced stages, treatments like deep brain stimulation surgery may be an option.

Kathrin's message to primary care physicians is to not be afraid of referring a patient to a neurologist or movement specialist.Click To Tweet

Working with Other Specialties as a Movement Disorder Specialist

Other specialties they work the closest with are psychology, physical therapy, speech therapy, and occupational therapy. Many centers, in fact, run special multidisciplinary clinics where they have a monthly clinic for Parkinson’s or Huntington’s disease. People can see multiple specialists at the same time.

This is very helpful in facilitating and streamlining care for the patient. It also helps to get input from multiple specialties on how to serve the patient best and work together.

Movement disorder specialists also work with social workers. Kathrin stresses the importance of understanding how movement disorders affect someone’s work or social life, especially in the more advanced stages.

Opportunities Outside of Clinical Medicine as a Movement Disorder Specialist

Special opportunities outside of clinical medicine include different kinds of research. Some have actually pursued a full-time research career. Other options are private practice or working in academia. Your career can change multiple times throughout your life.

Just being in medicine in general and being a physician, building your expertise in a particular area, you can really forge your own path and find your niche.Click To Tweet

[27:55] What She Wished She Knew About Being a Physician

There are many changes happening in medicine right now. Some of these changes can really be a burden on physicians and other providers. In the real world, you spend a lot of time on the phone as you try to get your patient’s medication approved due to insurance issues.

That's a hidden truth right now that our physicians are maybe not as autonomous as we would like to be... oftentimes, insurances mandate which medications we can prescribe.Click To Tweet

The Best and Worst Parts of Being a Movement Disorder Specialist

What she likes most about her job is working in a setting where she gets to see patients, do interactive trainings, and do research. There are challenging times, but in the end, it’s all worth it. Having success in one area can sometimes compensate for another disappointment, so it balances things out.

What she likes the least about her job is dealing with insurance companies. She’s hopeful, though, that this will get resolved in the coming years and physicians will gain a little bit more autonomy.

The Future of Neurology and Movement Disorders

Major changes that Kathrin sees in the field include deep brain stimulation surgery becoming more individualized soon. Another interesting area is genetics. They can now do whole-genome sequencing for $5,000, which was unthinkable years ago. So there are more discoveries and insights to come in the future.

They can now do whole-genome sequencing for $5,000, which was unthinkable years ago.Click To Tweet

The interplay of environmental and genetic factors is crucial for complex disorders like Parkinson’s disease and other movement disorders. Hopefully, we can learn more about how to intervene and really make a difference for patients.

Kathrin says that if she had to do it all over again, she would still choose to become a movement disorder specialist.

[33:55] Words of Wisdom for Students Interested in Movement Disorders

Kathrin encourages students to do an elective rotation in neurology. There are also a lot of opportunities to get involved in research. Kathrin has students working with her during summer break. And this is a good opportunity to have a good hands-on experience. Do a research project or get some patient contact to see if this is something that interests you.