58: 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.

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Going back to today's discussion is a movement disorder specialist who has now been four years out of training. She talks about why she chose her career, what it takes to become one, and so much more!

[01:54] Her Interest in Movement Disorder

Kathrin was a neurology resident and she got to shadow or 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 they come into the room. On the other hand, there are people with too much movements and you can describe and see what's wrong. Then you can make your own conclusions from just observing the patient.

"It's a really interesting specialty, a lot of treatments available, and the opportunity to follow people long term."

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

[05:15] Traits that Lead to Being a Good Movement Disorder Specialist

Kathrin says you have to have good observation skills - seeing them, finding the pattern, and fitting them into the right category. Over time that 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 skills include being able to enjoy logic thinking and fitting clues together, which are actually things common to neurologists.

[06:40] Types of Patients and Cases

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."

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

Most common disorders spans the whole spectrum from age ranges such as dystonia, tourette's syndrome that 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. They also encounter other forms of dystonia as well as tremors.

Kathrin explains that many are still diagnosed although essential tremor and Parkinson's disease are so common. She says it's easy to tell them apart, but not everyone behaves like a textbook. So it's not always as easy.

"Surprisingly often, they're misdiagnosed either by a primary care physician or a neurologist who might not be very well-trained in movement disorders per se."

Being at a tertiary academic center, Kathrin says they do get patients where they have to dig deeper to look for the missing clues to get to the diagnosis. That said, 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 disorder was just so interesting for her. Although they're called movement disorders, they are so much more. 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, too.

"We're still just at the beginning of understanding all these diseases and finding better treatments and cure for them."

This said, Kathrin knew she wanted to be in a place where she can continue exploring and help contribute to gaining new knowledge about 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, she spends 50% of her time in research. She's involved in several medication studies for Parkinson's and Huntington's. These are studies run in multiple sites across the US 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 she doesn't see clinic patients. Rather, she's involved in teaching medical students as well as 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.

So when they get paired with a patient, they get 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 it. Kathrin is involved in other teaching community activities, fundraising, etc.

And the other half of her time, she does patients in the office.

Kathrin sees 100% movement disorder patients in the outpatient setting. All neurologists in their group the alternate call as well. One week every 2-3 months, she spends a week in the inpatient general neurology service. At this time, she'd supervise residents and see all patients with general neurology conditions like epilepsy, multiple sclerosis, etc. While all of his outpatient time is spent with movement disorder patients.

[15:50] Work-Life Balance and the Residency Path

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

In terms of the path to being a movement disorder specialist, Kathrin outlines the process. First, you do the neurology residency which is usually a year of internships, one year of internal medicine, and three years of neurology.

"Movement disorder fellowship is actually not an accredited fellowship so the pathways are a little bit more flexible."

There are also fellowships that are one year, mostly clinical. And many are two years - one clinical and one research year. As well, there are some additional opportunities to get intensive training in deep brain stimulation surgery. This is a surgical treatment for mostly Parkinson's disease and essential tremors. Kathrin describes it as a teamwork where the neurosurgeon does the procedure and then the neurologist or movement specialist would do the programing and follow-up care for the patient. For Kathrin, she did one year of clinical fellowship in Boston. Then spent two years of research fellowship.

In terms of the competitiveness, Kathrin points out the shortage of neurologists. Some programs are more competitive than others. But if you're flexible with your location or willing to go, it's not really extremely competitive to get into a 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 she sees coming in the future is telemedicine, especially in rural areas, in the hope of meeting the demand for movement specialists.

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

Kathrin doesn't really see any bias going on against DOs. Moreover, if you're interested in surgical treatment options like deep brain stimulation surgery, it requires special training.

[20:38] How Deep Brain Stimulation Surgery Works

The patient essentially gets a pacemaker for the 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 on an anesthesia. Then the electrode is advanced and the patient wakes while a mapping is being done. Then they actually listen to the cells as the electrode is advanced. And this is how the actual training plays in.

"Cells and the different parts of the basal ganglia have all characteristic sounds."

Imaging plays an important role but most centers still do the microelectrode recording as additional means of finding the right location for these electrodes. Doing this procedure is a team effort - they have the neurosurgeon, the neuro electrode physiologist. Then a neurologist helps with listening to the cells and doing testing on the patient. If they're in the right spot, they turn the stimulation briefly on. Then they look on where the tremor gets better. So they're able to see immediate effect in the O.R. as it confirms that the space is the correct spot where the electrode is placed. Although results are not guaranteed, but there have been many cases where the tremor has really stopped. For many patients, it's a really miracle surgery.

[23:58] Working with Primary Care and Other Specialities

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 the limitations and first-end treatment does not go so well. So if patient still experience the tremor, then they should not hesitate referring them.

In many cases, we really have very effective treatments which can make a huge difference and even for people in more advanced stages, treatments like the Deep Brain Stimulation Surgery may be an option.

"Don't hesitate asking for help for someone with Parkinson's disease or tremor and we can often make a big difference."

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 care for the patient as they try to streamline care. It also helps to get input from multiple specialties as to how to serve the patient best and work all together.

They also work with social workers in their clinic. Kathrin stresses the importance of understanding how movement disorder affects someone's work or social life in, especially in later stages.

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

"Just being in medicine in general and being a physician, getting expert knowledge, you can really forge your own path and find your niche."

[27:55] What She Wished She Knew and Major Changes in the Field

Kathrin explains there are many changes in medicine. They can be burdensome and taking too much time. But as a medical student, you don't really see that side. Nobody will tell you that in the anatomy class. And 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. And this is a hidden truth.

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

That said, Kathrin saw really no surprises from the neurologic side of things. Rather, it's about how you deal with the whole business side of medicine.

What she likes most about her job is working in a setting where she gets to see the patients, doing interactive trainings and teachings as well as research. There can be lots of challenging times but in the end, Kathrin says it's all worth it. Having success in one area can sometimes compensate for another disappointment so it balances things out.

Alternatively, what she likes the least are the regulatory burdens and dealing with insurances. She's hopeful though that this gets resolved in the coming years and physicians will gain a little bit of autonomy.

Major changes she sees in the field are developments in multiple areas. One is the Deep Brain Stimulation Surgery that has already been mentioned and that these could be more individualized soon. Another interesting area is genetics. They can now do a whole genome sequencing for $5,000 which was years ago, was unthinkable to do that. So there's more discoveries and insights to come in the future.

Additionally, Kathrin wants people to understand the interplay of environment and genetic factors and how that impacts complex disorders like Parkinson's disease and other movement disorders. Hopefully, we can learn more about how to intervene and really make differences.

Lastly, Kathrin says that if she had to do it all over again, she would still have chosen the same subspecialty.

[33:55] Last Words of Wisdom

Kathrin encourages students to do an elective in neurology. That said, there are lots of opportunities to get engaged in research. She has students working with her during the summer break. And this is a good opportunity to have a good hands-on experience. Also do a little research project like see someone in their day to day or get some patient contact. See if this is something that interests you.

Links:

Parkinson's Disease and Movement Disorders Clinic

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