Article In Brief
Program staff at several training fellowships in areas specific to women's issues in neurology discuss their programs and efforts to broaden the scope of training in this subspecialty.
The tagline for the Women's Brain Initiative (WBI) at Brigham and Women's Hospital—“Tackling the gap in knowledge about women and brain conditions...finally!”—aptly describes what advocates for women's neurology have been trying to achieve...for a while.
And WBI has been working hard to make up for lost time. Though it is just more than two years old, WBI has already held two symposiums; produced an ongoing seminar series; launched five interdisciplinary, multi-year research efforts; and awarded funding to at least 13 emerging investigators through its Pilot Projects Program and Research Fellowships Program. The research areas WBI has covered are varied—from the biological reasons behind sex differences in neurological disorders and the female protective advantage in Parkinson's disease to the influence of pregnancy, postpartum, menopause, and post-menopause on women's neurological and psychiatric health—to name a few. But when it comes to women's brain health, there are still countless questions left to answer.
There are so many gaps to fill because, until recently, “research in this field has been limited,” Janet Waters, MD, MBA, chief of the division of women's neurology and associate professor of neurology at the University of Pittsburgh Medical Center (UPMC), told Neurology Today. “When I started in the field seven years ago, there was almost nothing available to educate people on women's neurology.” But Dr. Waters believes that finally she is “in the right place at the right time. Women's health is very much a growing field right now.”
Angela Mary O'Neal, MD, director of the Autumn Klein Women's Neurology Program at Brigham and Women's Hospital (BWH), agreed. Dr. O'Neal pointed out that one reason a lot of important research hasn't been done before is because pregnancy has often been an exclusionary criterion for clinical trials.
At BWH, she continued, the idea of combining women's issues and neurology made a lot of sense, because “women's health has always been a significant area of interest and expertise at the Brigham.”
The women's neurology program at BWH was a “brainchild of our chair at the time Dr. Martin Samuels and my predecessor Dr. Autumn Klein.” When Dr. Klein moved to the University of Pittsburgh Medical Center to begin building that program, Dr. O'Neal took over as director at BWH.
“Autumn Klein was an epileptologist and we recruited her to create the women's neurology division here at UPMC, but unfortunately two years later, she died tragically. At that point I took over the program and wanted to make her dream come true—and one of her ambitions was to have a fellowship program,” Dr. Waters said.
Two years ago, she added proudly, Dr. Klein's vision became a reality with the first fellow to enroll in women's neurology: Stephanie Paolini, MD. (Dr. Paolini graduated from the program last June and is now a clinical assistant professor of neurology at Palmetto Health–University of South Carolina Medical Group.)
Notably, the two institutions where Dr. Klein honed her expertise—UPMC and BWH—are currently the only ones to offer fellowship programs specifically in women's neurology.
“I think that all three of us see Dr. Autumn Klein as a pioneer in women's neurology,” said Amy B. Hessler, DO, FAAN, director of women's neurology and associate professor of neurology at the University of Kentucky College of Medicine in Lexington. Dr. Hessler, who opened her obstetrical (OB) neurology clinic in September 2018 and does clinic in conjunction with OB twice a month, considers Drs. O'Neal and Waters to be her own mentors in the world of women's neurology—and in this way, the legacy continues.
How the Fellowships Work
The fellowship program in women's neurology at UPMC is two years long and “fairly intense,” according to Dr. Waters. It usually starts with a year in epilepsy, though there is some flexibility. “Our next fellow is actually doing a fellowship in multiple sclerosis (MS) for her first year and then she'll do women's neurology in her second year.”
Fellows will generally do their first year in epilepsy or electrophysiology, while still doing some clinics dealing with pregnant women, Dr. Waters explained. “Then in their second year, they cover Magee-Womens Hospital, the maternity hospital, which handles between 9,000 and 11,000 deliveries per year.”
The fellows also do three clinics in women's neurology—“or what we call OB neurology, so that's either women who are looking to become pregnant, or are pregnant, or are post-partum, and they have neurologic problems.”
The fellows rotate through the headache and MS clinics as well. “By the end of their second year, they have a really good grounding in epilepsy and pregnancy, as well as learning how to deal with diagnoses such as preeclampsia, eclampsia, Chiari malformation, brain tumors and pregnancy, stroke and pregnancy. These are the kinds of diagnoses we see a lot in our program.”
Dr. Paolini, who was the first fellow to graduate from the fellowship program in women's neurology at UPMC, attested to the rigor and quality of the experience.
“I became interested in women's neurology during my residency training when I began to learn that specialized management was required during pregnancy for women with many different neurologic conditions. My fellowship started off with hands-on learning as I joined the high-risk obstetric service and the obstetric anesthesia teams for several weeks.
“Over the course of the year, I also learned to care for female neurology patients during all phases of life (teenage years, preconception, pregnancy, postpartum, midlife, postmenopausal). I'm interested in learning more about how diseases progress and change during an individual's lifetime,” she said. Dr. Paolini's specific areas of interest within women's neurology are headache and epilepsy.
“I think the fellowship gave me a really strong foundation with which to establish a clinical practice and also to develop ideas for further research in the field,” she added. In fact, she now has an outpatient clinic and she is building her women's neurology clinic as well.
The fellowship at BWH looks a bit different and is also brand new, Dr. O'Neal told Neurology Today. About three years ago, “we decided to think about putting together a women's neurology fellowship—and our first fellow is starting in July 2020.” The program is a joint venture between Mass General and BWH. The fellow, she explained, will have longitudinal clinics, which will include MS, epilepsy, headache stroke, general neurology, and an embedded obstetrical neurology clinic. Additionally, the fellow will have a number of electives depending on their area of interest, some of which could include neuroendocrine disorders, functional neurology, any of the women's mental health issues, mitochondrial disorders, midlife women's health, OB anesthesia, maternal/fetal medicine, contraception for women with medically complicated conditions, as well as autoimmune and connective tissue disorders.
“The fellowship is not meant to replace subspecialists in areas like epilepsy, headache, or MS who are used to thinking about women's issues within their subspecialty. Our fellow would be considered a general neurology subspecialist with expertise in women's neurologic issues,” Dr. O'Neal said.
At Northwestern University, Elizabeth E. Gerard, MD, director of the Women with Epilepsy Program and the Comprehensive Epilepsy Center began building the Women with Epilepsy Program when she arrived at the institution in 2009. Although not a standalone fellowship, “We have made exposure to women's epilepsy a key part of our epilepsy and clinical neurophysiology fellowship training programs since about 2010. All epilepsy/clinical neurophysiology fellows rotate through my women's clinic and gain important exposure to pregnancy and contraceptive counseling,” Dr. Gerard said.
The program was in direct response to the expansion of our understanding “of the intersection of women's health and epilepsy, which has grown exponentially in the past two decades. This makes counseling women with epilepsy more complex but also more personalized. It is critical that all of our trainees gain exposure to counseling women with epilepsy on how both seizures and seizure medications are influencing reproductive health.” And Dr. Gerard's trainees have gone on to translate this learning in women's neurology into both local settings—a community neurology practice and a state university hospital—as well as internationally—in Zambia.
“Our goal is to spread the field because people are afraid to deal with pregnant women who have neurologic problems. You have to do everything differently. Whatever imaging you choose, whatever medications you choose, treatments, surgery, you have to think about both patients that you're dealing with. Both the mother as well as the fetus,” Dr. Waters said.
At BWH, Dr. O'Neal said, they have regular conferences where the specialists taking care of a particular disorder come together to understand best practices. For example, joint conferences with the maternal fetal medicine group if the issues discussed overlap with pregnancy or postpartum issues or with the psychiatry group if we are discussing women's mental health. “The multidisciplinary approach has been very successful. It's always educational to hear how other specialists are approaching a problem from their perspective and what challenges they're seeing.”
In 2016, Drs. Waters and O'Neal put together the first obstetrical neurology conference. “We brought together OB, neurology, neurosurgery, obstetrical anesthesia, and offered a comprehensive course on women's neurology. Amy Hessler put together the conference for 2019. And we are going to have it again in Pittsburgh in 2020,” Dr. Waters said.
They also developed a workshop in 2018 that teaches participants how to develop their own women's neurology program at their institution.
“We had 12 people come to the workshop and a lot of them actually have either succeeded or are in the process of forming their own women's neurology programs. And we plan to do the workshop again on a larger scale at the AAN in 2021,” Dr. Waters said.
Looking ahead, she listed two of her major goals for the field: To continue to mentor other people to develop their own women's neurology programs. And to establish women's neurology as a subspecialty that's officially recognized—so that women's neurology becomes incorporated into training, both at the medical school level and at the neurology residency level, and then more neurology fellowships would be formed throughout the country, she said.
Dr. Hessler, who is a member of the AAN Education Committee, as well as the Section on Subcommittees and Specialties and Equity Diversity and Inclusion joint council, said they have been working to establish women's neurology as a subspecialty. Drs. Hessler, Waters, and O'Neal had an initial discussion with Brenda Riggott, executive director of the United Council for Neurologic Subspecialties, in February.
“There's still a lot we don't know!” Dr. Paolini said. “I hope that we can develop more women's neurology fellowship programs and attract increasing numbers of neurology residents. I think we can continue to expand our subspecialty further and offer a unique skill set to care for female patients at every stage in life.”
The big challenge is just having people recognize the need for this as a separate subspecialty, added Dr. Hessler. “I think this is an emerging area—and there's a lot of fear by neurologists of the pregnant patient and hormonal-related issues across a woman's life course. I think working in conjunction with OBGYNs and having a multidisciplinary approach is the best strategy to take care of these patients.”