Special Episode: The wisdom of our mentors: clinical pearls in movement disorders

[00:01:06] Dr. Bas Bloem: It's an honor.

[00:01:07] Dr. Victor Fung: A Pleasure.

[00:01:09] Dr. Hugo Morales: Now, I would like to start with Dr. Bloem and before asking you about the clinical pearls that were published in this paper, in your view, what is the role of mentors in advancing the field of movement disorders? And for the early career neurologists, how do you become a mentor?

[00:01:31] Dr. Bas Bloem: Well, those are two hugely important questions. Let me start by saying what an honor and privilege it is to be here together with my good friend Victor, in my favorite podcast, I always listen to the MDS podcast when I'm in the gym on my exercise bicycle. And I can highly recommend the MDS podcast to anybody who has a warm heart for this lovely field in neurology. It's a brilliant series and congratulations Hugo, to you and your colleagues for doing this. So it's an honor and a privilege. I just wanted [00:02:00] to say that.

I think mentors are crucial. We are in a field which is very interesting. Artificial intelligence is on the horizon.

There's a big issue whether AI is going to replace doctors, is going to replace mentors and I think I'm strongly opinionated that AI may make healthcare a bit more efficient, but only to allow astute clinicians to spend more time with patients and with their students and allowing to dig deep into what matters to people most.

And I have definitely become enthusiastic about movement disorders by working with people such as Bill Langston, Andrew Lees, Neil Quinn, Kailash Bhatia. And there is no other way to learn the tricks of the trade than via bedside teaching. And this is what good mentors do. And what makes a good mentor, I think it's passion.

It's the love for our job and knowing that you will not be around forever. And to share your knowledge. To spend time with a patient and to [00:03:00] tell a younger individual a particular trick, and then it works, That is so gratifying, it is such a wonderful moment and to be able to pass on the baton to the next generation is, I think, very close to my heart and to all of the authors on our paper in Lancet Neurology.

[00:03:15] Dr. Hugo Morales: And can I ask as your position as a mentor, what is it that you see in mentees that helps you to keep going, to stimulate your efforts to keep going as a mentor?

[00:03:29] Dr. Bas Bloem: What I like to see in a mentee is when they are hungry. Hungry for knowledge. And I don't want them to feel filled up by the end of the day, but I want them to go home even hungrier, to come back the next day and to be fed again. And that is so wonderful. If I see people who are there just because they need to fill the day from nine to five, that's when I lose my energy as a mentor.

But conversely, when you meet these hungry young people, nothing beats that feeling.

[00:03:58] Dr. Hugo Morales: Thank you for for detailing your [00:04:00] thoughts about this. Now, I'm gonna move to second question, and I'd like to ask Dr. Fung so what is the impact that mentors have played in your formation as a neurologist and movement disorder specialist? So what made you follow your mentor's advice and how that shaped your understanding of movement disorders?

[00:04:23] Dr. Victor Fung: So I'd actually first, I'm going to answer that question, but I actually just wanted to add a little bit to what Bas was saying about how one becomes a mentor and Bas, I think it reflects probably our nature. Bas is more generous. He's giving, whereas as a mentor, I'm actually looking to take and so, I mean, by definition, sort of when you've become a mentor, you're getting old and as Bas sort of hinted at, you're not around forever.

And so one seeks to live off the youth of others. And so what I really like in terms of being considered a mentor is actually [00:05:00] people are enthusiastic as well as you hoping to be able to enthuse them. But what I'm really looking for is someone who can actually feed me knowledge. And I'm saying this so that if people are attracted to someone as a mentor, in terms of how to actually enthuse them into being enthusiastic about you.

You know, I think one of the things is bring something to the mentor, because I think almost all good mentors are hungry for knowledge themselves. And so, what I'm really attracted to is a mentee who can teach me. And in fact that to me, that's why I said that I've got a slightly more selfish bent to sort of mentorship in that I really love to learn from the people that actually come and say they want to learn from me. And so it becomes a two way street from the beginning. 

[00:05:49] Dr. Bas Bloem: Totally echo that Victor. 

[00:05:51] Dr. Victor Fung: Whereas I think you, Simply go up to someone and say, I want to learn from you and I want to be your student, that's not [00:06:00] always, the way that you're actually going to attract the attention of a potential mentor.

[00:06:04] Dr. Hugo Morales: And now that you're saying that is a bidirectional relationship where then, both in a learning process where a mentor has a certain level of knowledge and the mentee can bring new ideas or have an update of a certain topic and then suddenly the clinics become more interesting and intellectually challenging.

So I think that's one of the roles of having also international centers to form movement disorder specialists. And that's a big role that the society has played in forming and educating new specialist. Now, could I ask Dr. Fung, the International Parkinson Disease and Movement Disorder Society has certainly amalgamated clinicians and scientists in an effort to synchronize the knowledge and the work to understand [00:07:00] Parkinson's disease and movement disorders.

Could I ask how is the society ensuring that mentorship reaches underserved areas around the world?

[00:07:11] Dr. Victor Fung: So coming into the presidency, some of you will have heard, but the three main themes that I'm hoping to be able to push and support during the time of my presidency are equality of access to care. The second thing is to increase MDS's engagement with patient voice and carer voice. But the third thing is equality of representation of different regions within the MDS. And so it's part very dear to my heart of making sure that as an international society, we do engage with people from all countries in the world. And we have over one 170 countries that have people that are part of the MDS and over 11,000 members.

The big challenge is it's obviously expensive [00:08:00] for some underserved areas, people from underserved areas from lower and middle income countries to be able to travel to train in more expensive parts of the world. So one of the key programs that MDS has established and something called the center to center program.

There's a call each year for centers to put their hands up. And the idea behind this is that a more established center then has a mentee from a less established and usually lower middle income center. And part of it is virtual in terms of a regular link in terms of interaction between the mentee and the more established center.

But part of that is ideally a shorter period of, let's say, a month or so. Where the mentee travels to that more established center and goes to clinics, sees their mentors and their colleagues in action with patients. So I think that's when it [00:09:00] started we had, I think, five centers, and I think it's just been expanded to funding 10 center to center programs each year.

There are other things we do as well. So we have visiting trainee grants each region. So of course in the MDS, there's the Pan American section, the European section, the African section, and the Asian Oceanian section, and each section has a budget of it's around 100, 000 US and that's to fund visiting trainee grants.

And it's up to each region as to how they actually invest that money in trainees. So I think the European section have chosen to send a larger number of people for shorter periods of time to different centers. Some other regions have chosen to send two or three people for longer periods of time to a center. And the idea is that those trainees will then go back to their country of origin and help further established movement disorders as a subspecialty. 

One of the things that we did during COVID, which we haven't [00:10:00] actually done so much is during COVID, we had a number of meet the expert sessions where people could sign up and spend 45 minutes or an hour with an international expert. We've not recreated that at the International Congress. But that's something that I've always thought would be good to do. And so I think if the listeners of your podcast have an interest, if they get a message back to you, you can feed that back to me and then we can look at maybe introducing that, um, either into this year or next year's Congress. 

[00:10:30] Dr. Hugo Morales: Good, thank you for keeping your door open to suggestions and other people's ideas. I want like to move to other parts of the paper that for me were very helpful.

When I read this paper, I found that the table, the supplementary material, contains clinical pearls described by different authors of this paper. And these clinical tips involve the history taking or examination techniques. that may assist in the phenomenological diagnosis [00:11:00] or even differential diagnosis.

But it seems that the majority of the experts relied heavily in the phenomenological diagnosis. And there's a lot of nuanced leads and tips here. And I'd like to ask this question to both of you, and I'll start first with Dr. Bloem. Can you give us an example of a clinical pearl from this paper either that came from you or from other authors that you want to highlight to the listeners.

[00:11:27] Dr. Bas Bloem: Yeah, sure. So maybe just to quickly go back to why we did this paper. I personally had the privilege of being trained at the Parkinson's Institute in California by Bill Langston and Jim Tatroot later on at the National Hospital for Neurology at Queen Square in London. And I realized that each of those centers has their own unique tricks of the trade that are typically passed on to residents, fellows in that clinic, but are never laid down in textbooks. So they stay confined to that particular institute. [00:12:00] And we felt that it would be wonderful to share that rich body of knowledge, which remains critical in a time of evidence based medicine with the readership of Lancet Neurology and the Movement Disorders field.

So, we basically asked 13 wonderful clinicians, what is your trick that you tell all your residents, which has not been published, that was a criterion. It should not be in a paper, it should not be in a textbook. And you tell all of them, and what is your pearl? We called it clinical pearls. And for example, Tony Lang said, a condom catheter or a suprapubic catheter can be a lifesaver for people with urinary incontinence who have a poor gait.

The combination of freezing of gait and urinary incontinence is devastating. And if you no longer have to worry about peeing all the time, it can be a quality of lifesaver. For people with, for example, Parkinson's disease, and I thought it was a brilliant example of something simple that he passes on to his students and that we now share more [00:13:00] widely.

I'm sure that Victor has other favorites. It's just one example we separated pearls from history taking, pearls from the neurological exam, and we can elaborate a little bit later, and pearls in the treatment domain. Victor, what would be your favorite?

[00:13:14] Dr. Victor Fung: So I think I actually really like the catheter one as well. And again, I think lived experience also helps us because having gone through some personal circumstances with my parents where I saw the devastating effect of incontinence. This isn't something by the way that was in the paper, but I think it is also a pearl where I think it wasn't until I faced this with my own parents that I realized that incontinence is probably one of the major dealbreakers that actually force couples to split up and one person to enter a nursing So it's a behavioral disturbance and it's incontinence are probably the two biggest factors. 

I've not read that anywhere, and I'm sure that's the case. It's the thing that really breaks carers. And so I agree that's a really important [00:14:00] one.

The one that I share with all of the people that I train with is, and it's along the same lines, the value of low dose amitriptyline for sleep in Parkinson's disease.

Because if one works with geriatricians, then amitriptyline is like the devil. But in fact, in our table, we facetiously call vitamin A. I certainly call it vitamin A because it's such a helpful drug in terms of helping people especially with Parkinson's disease who can't sleep, and they have nocturia as part of their frequent waking, and they're also a little bit depressed or anxious as well.

[00:14:36] Dr. Bas Bloem: Yeah. I couldn't agree more.

[00:14:38] Dr. Victor Fung: It treats all of those things and you just need to make sure that the person doesn't have bladder outlet obstruction or retention, but that's relatively easy to do. And once you've done that, then I think in clinical practice there's concerns raised about links between acetylcholine inhibitors and dementia but for the people that we're looking after, they're [00:15:00] relatively.

Sort of late in life anyway. I really don't think they're likely to truly cause dementia.

[00:15:05] Dr. Bas Bloem: Yeah another thing that I really liked was a recurrent theme, was listening to neurological signs. We tend to look at clinical signs, but I think the ear is more susceptible to disturbances of rhythm. For example, in bradykinesia, where the decrement in the quality of movements is essential to establish bradykinesia, and the ear is more sensitive than the eye to this decrement in the movements, and the disturbed rhythm, which is different in ataxia, Ataxia sounds different from bradykinesia, and many of us in some form, emphasize the importance of listening to neurological signs.

You can listen to gait, you can hear the spastic gait walking into your office. There was actually a tribute to seasoned secretaries who have learned to recognize the strides and the gait pattern of their patients and to [00:16:00] notice differences in that stride pattern if the treatment was effective, for example, and all in all, it's a beautiful paper.

[00:16:06] Dr. Victor Fung: I think the other thing, again, this is sort of I'm thinking of additional things that we could have put in the paper, but we didn't. But I think that the importance of listening and listening to science is what you're talking about, but I think the art and importance of listening to the patient.

And what I mean is not just listening to the content, but actually how to listen. So to give patients time to speak. So I think a common mistake for young people or some older people as well. You ask a question and then a patient might mention a clue, you know, I had tremor.

And then the temptation is immediately to jump in and say, Oh, what type of tremor was it? Was it a rest tremor? Was it... rather than actually letting the patient speak for a little bit longer because often little clues come out in the things. Sometimes it's not what they say.

Sometimes it's how they say it as well. And [00:17:00] so by cutting off patients too early, patients can lose their train of thought and forget to tell you something that they were building up to. And this wasn't in the paper, but I know that Philip Thompson, who's one of my great mentors said to me long ago, let the patient tell you their diagnosis and that's what he meant by that, let the patient speak and they'll tell you their diagnosis.

[00:17:19] Dr. Bas Bloem: Listen carefully to your patient. He's trying to tell you what disease he has.

[00:17:25] Dr. Victor Fung: Yeah, absolutely.

[00:17:26] Dr. Hugo Morales: I should add that also from the mentee perspective. Listen carefully to your mentor as well. 

[00:17:33] Dr. Bas Bloem: Just wanted to reiterate what Victor said, about this duality in between mentors and mentees stupid questions don't exist. And by asking questions, a lot of things we do in medicine is implicit. A clever question makes me realize why I do certain things and I try to make it more explicit.

And that's why mentees make me a better doctor. So Victor, you're absolutely [00:18:00] right. I just wanted to confirm that.

[00:18:01] Dr. Hugo Morales: I would like to add that. Again, From a mentee perspective as well, Is one of the things that perhaps is good way to transmit knowledge, And pass on that knowledge to subsequent trainee generations or fellows. Is observing how the expert, how your mentor examines patients. And for the mentor to take the time to teach these techniques is of high value.

And there's something that is registered in the mind of the learner instantly. So that's one of the recommendations I would say that mentors should have the time and spend time to teach that, to pass on.

[00:18:45] Dr. Victor Fung: Can I come back Hugo, cause I actually didn't answer the question you actually asked, me earlier, which was what qualities does a mentor have and one of the things that I really wanted to pay tribute to my mentors and which helped [00:19:00] tremendously is I think good mentors actually give you confidence, they encourage and they listen and they actually reinforce the good things you're doing. Bas was saying about, enthusiasm and that's absolutely important. But it's enthusiasm that they share with you, and you become part of their enthusiasm and they actually encourage you to help them and to do things.

 Whereas a bad mentor, in the sense that someone who might seem like a shining light, if they put you into shadow, that's actually not the kind of mentor that you want. You want someone who actually shares their life with you.

[00:19:35] Dr. Hugo Morales: Correct.

[00:19:36] Dr. Bas Bloem: Well said.

[00:19:37] Dr. Hugo Morales: So let's wrap up. And again, I would like to thank you both for taking the time to talk today. And for all listeners, go and read The Wisdom of a Mentor, published in December, 2023 in Lancet Neurology and go and check the supplementary table as well. Thanks again, and I'll see you in the next [00:20:00] podcast.

This unique piece of collected clinical pearls was only possible with the hard work of Dr. Rui Araujo and Dr. Conor Fearon, who worked so diligently on this paper. And both our guests today would like to acknowledge their contribution.