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In the Clinic
Health Services Researcher Lidia Moura's Journey from Brazil to Harvard — On a Mission to Address Health Inequities

ARTICLE IN BRIEF

Lidia Moura, MD, MPH, was outraged by the inequities in access to health care she observed in Brazil. Now she leads a research unit at Harvard that focuses on health services research and is working on developing strategies for reducing costs while improving the quality of care.

BOSTON—Seven months pregnant with her second child, the recipient of an AAN Career Development Award, Lidia Moura, MD, MPH, launched into a story at the AAN Annual Meeting here in April about how a 10-year-old Brazilian girl ended up investigating health services research and outcomes in neurology care at Harvard Medical School.

“When I was 10 years old, I saw my mom, a doctor, rescue a drowned kid,” began the assistant professor of neurology. “At that moment, I said to myself, ‘Oh boy, I'm going to do that for people, I'm going to be a doctor.’”

And she did, eventually choosing neurology because it was the area where she thought she could learn the most and make the greatest impact.

But it wasn't an easy journey. When competing for her residency, she took off her engagement ring and pretended that she was not planning to have a family. She went to medical school at the Catholic University of Medicine in Brasilia, Brazil; got married; and her husband quit his job to move with her to Rio de Janeiro, where she completed her residency program at the State University of Rio de Janeiro.

During a rotation at the epilepsy clinic, she met Ronan Kilbride, MD, a professor from the Massachusetts General Hospital (MGH) at that time, who gave talks sponsored by the International League against Epilepsy. She asked him several questions about her patients.

“He noticed my enthusiasm to learn more about how to give better care and improve my epilepsy patients' quality of life,” Dr. Moura recalled. “He encouraged me to apply for MGH's two-year clinical fellowship in epilepsy and neurophysiology. Initially I thought this was a crazy and unreachable idea. But I loved it. When I got home and mentioned this conversation to my husband, he said: ‘Why do you think this is impossible? I believe in you, you have all my support, let's do it.’ So, I realized I was not the only crazy person in my home.”

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DR. LIDIA MOURA said that in Brazil, she “saw people dying because of limited health care resources. There were times when we would have to decide about who gets a respirator or who would go to an intensive care unit among the patients in need. I often complained about that to my program director. I said, ‘We need to do something,’ but we all felt powerless.”

First, though, she had to complete her residency, which she characterized as “one of the most challenging years” of her life.

In Brazil, she said, “I saw people dying because of limited health care resources. There were times when we would have to decide about who gets a respirator or who would go to an intensive care unit among the patients in need. I often complained about that to my program director. I said, ‘We need to do something,’ but we all felt powerless.”

The inequities between rich and poor struck her deeply. “You could go from a public hospital, where patients waited six months to get a neurological consultation for a simple electroencephalogram, to a private hospital across the street, where patients could get them unnecessarily. Witnessing under-use and over-use was terrible.”

“I thought, if there is a place where you can change health care policy, where people will listen to you, that place must be in the United States,” she said.

There was just one obstacle: She didn't speak English. Undeterred, she met with a private English teacher, hired by her husband, every night when she wasn't on call.

“The teacher would come at 9 pm and knock on my door. I wanted to sleep but I had my goal, and I felt if I don't do this for my patients, then I'm going to continue to see patients dying due to lack of access to care. So I improved my English skills, applied to the MGH clinical fellowship program, and prepared to get my medical education credentials in the US.”

Accepting an offer to work as a research fellow at Spaulding Rehabilitation Hospital, she and her husband arrived in the United States in 2012.

“This was my first experience working in a cutting-edge teaching hospital,” she said. “I was amazed. In Brazil, medical records were still kept on paper.”

It took her a while to convince Andrew Cole, MD, the director of the MGH Epilepsy Service, to accept her into his program. “I was eventually fortunate to join a group of seven excellent fellows,” she said. “I still had a hard time adjusting to the new culture. I promised to myself that I was going to make Andy Cole proud of me.”

Ultimately, she completed the two-year clinical fellowship in clinical neurophysiology and epilepsy and a one-year clinical fellowship in advanced general neurology to focus on the care of vulnerable patients with complex neurological needs.

After that, she began thinking about her desire to improve health inequities. She applied and was accepted into the master's degree program at the Harvard T.H. Chan School of Public Health.

Now director of the MGH NeuroValue Laboratory and assistant professor of neurology at Harvard Medical School, Dr. Moura's research focuses on examining and increasing the efficiency of health care in neurology. Many of her studies assess quality-of-care and patient-reported outcomes such as patients' real-world use of anti-epilepsy drugs. As part of her AAN career development program, she will study aspects of epilepsy care financing and delivery, and their effects on medical quality and efficiency.

“Some physicians choose a specific drug because they have fewer side effects, but then it might be too expensive and some patients won't take it,” she said. “This is particularly challenging among the elderly population with limited income. I want to know which treatment strategies are best for those elderly patients to improve outcomes. Elderly patients are also often excluded from randomized clinical trials. I'm looking at patients' real-world adherence to treatment, which includes an examination of the tradeoff between affordability and tolerability. What are the best strategies to maximize adherence and improve outcomes for the publicly-insured elderly population? The results can improve clinical practice and influence Medicare policy.”

Her current primary mentor is a health care research expert, John Hsu, MD, MBA, director of the program for clinical economics and policy analysis at Harvard Medical School.

“He's not a neurologist but he believes in my dreams of improving outcomes and reducing health care inequity,” she said. “I chose him because I could learn from his background in health services research, clinical epidemiology, and health care finance and management. He is helping me bring clinical, population, and business perspectives to my studies.”

Her family's roots now firmly planted in the United States, Dr. Moura said she does not see herself returning to practice in Brazil. But she remains as committed as ever to reducing health inequities there.

“Because neurologists in Brazil learn from AAN's education programs and often follow AAN practice guidelines, I would love to see improvements there that happen as a result of my research here,” she said. “I now have my own research laboratory. I am starting to mentor research fellows and master's degree students. I hope today Andy Cole is proud of his decision to accept me into his program. I am forever grateful to him and to other professors that believed in me.”

[Update: On June 28, Dr. Moura delivered her son, Diego Moura, at MGH.]

The AAN has launched a new section for health services researchers. For more about what the section is doing and how it could impact the field, look for a story in the upcoming issue of Neurology Today.

LINK UP FOR MORE INFORMATION:

• AAN Research Program. https://www.aan.com/go/foundation/research/clinical
    • The NeuroValue Lab. http://neurovalue.mgh.harvard.edu