As a medical student, do you ever wonder what it's like to specialize in behavioral neurology? Meet AMA member Darren Gitelman, MD, a behavioral neurologist and a featured doctor in the AMA's “Shadow Me” Specialty Series, which offers advice directly from doctors about life in their specialties. Check out his insights to help determine whether a career in behavioral neurology might be a good fit for you.
The AMA's Specialty Guide simplifies medical students' specialty selection process by highlighting major specialties, detailing training information and providing access to related association information. It is produced by FREIDA™, the AMA Residency & Fellowship Database®.
Also check out Dr. Gitelman’s profile in the AMA’s “Finding My Place in Medicine” series, in which physicians reflect on what influenced their decisions when choosing where to work—and what they wish they had known earlier.
“Shadowing” Dr. Darren Gitelman
Specialty: Behavioral neurology.
Practice setting: Group.
Employment type: Employed by Advocate Health, in Park Ridge, Illinois. Advocate Health is part of the AMA Health System Member Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Years in practice: 32.
What the specialty of behavioral neurology is: We focus on how damage to the brain—for example from neurodegenerative disease, stroke, trauma, etc.—leads to changes in cognition and behavior. There are many directions this can take. There are behavioral neurologists who are mostly concerned with recovery from stroke, while others work with developmental disorders like attention deficit disorder, but my focus has always been on caring for patients with Alzheimer's disease and other types of dementia.
A typical day and week in my practice: On clinic days, I generally work from 8 or 8:30 a.m. to 5 p.m. Advocate Health is very forward thinking and recognizes that it takes a long time to see these types of patients. For initial visits, while most physicians in primary care get a half hour, maybe 40 minutes, per visit, we have 90 minutes because many of our patients are going to be slower to answer questions. Our evaluations include extensive medical, social and educational histories.
We also have the time to do more extensive cognitive testing. Just asking the patient how they are doing and the date will often not show the extent of the patient’s impairment. It's only when you start assessing executive functions, such as asking them to remember lists of words or follow instructions for drawing a picture, that you see the problem.
Aside from spending time on the evaluation, we talk with patients and their family extensively, educating them, and discussing diagnoses and treatment.
On nonclinic days, my work focuses on a number of projects, including our GUIDE dementia care program, developing new memory healthcare pathways, working with our research coordinators or planning for upcoming talks.
And when I'm not seeing patients, I address results that come into our electronic medical record. I also typically return phone calls at the end of the day for an hour or so. This may be addressing questions a patient has or helping their family member who is calling when their loved one is agitated, has had a side effect to a medicine or isn't sleeping at night.
The most challenging and rewarding aspects of behavioral neurology: One of the biggest challenges is that the treatments are limited. For example, even with the new disease-modifying monoclonal antibodies, their degree of benefit is small. Plus, patients with dementia have both cognitive and behavioral problems. Drugs that benefit the former, might not help the latter, which require their own treatments.
There’s a lot of misunderstanding that we have to work around to help patients and their families. If you have heart disease or cancer, your loved one can take you to treatments, and you for the most part retain your mind throughout the course of therapy. Behavioral neurology patients often don't retain their decisional independence and functional abilities. And so, they usually need a caregiver – and most become dependent. So, the relationship between the patient and caregiver changes over time.
It's still rewarding, even though up until very recently treatments have been limited. Diagnosis and then explaining to people what's going on is important. Explaining the behaviors and the cognitive changes really helps people understand their loved ones. A lot of it is just listening to people and understanding what they're experiencing, then letting them know they're doing a good job to help get them through it so they can live their lives.
The impact burnout has on behavioral neurology: As I grow older, I more often see patients who are younger than I am. That's hard. Even our nurse practitioners who are much younger than I am sometimes see patients near their age too. So, there's burnout related to work, but sometimes there's also burnout related to just seeing the devastation of these diseases.
There’s also always more work to be done. Medicine is nothing if not paperwork—infinite amounts of paperwork – which can be tough on people. And there's always more that patients need, so you have to somewhat compartmentalize that. Plus, people have different needs in terms of their work-life balance. Since I'm older, my children are not at home anymore, but many of my colleagues have children at home, and they're going to have different needs.
How Advocate Health is reducing physician burnout: A lot is expected of physicians and other clinical personnel in terms of caring for patients. There are a lot of rules and there's a lot that patients expect. Even when patients are agitated or the caregiver is exhausted and upset, the focus always has to be on caring for the patient and supporting their family. Advocate Health provides a variety of resources for well-being, and it’s constantly testing technological and practical tools to help clinicians get their work done.
How my lifestyle matches, or differs from, what I had envisioned: When I was in medical school, at first I thought I was going to be a surgeon, but then I thought I didn't really want to wake up early every day. Ironically, I am now up most mornings by 5 a.m. to get my day started.
There are a lot of different pathways. At a previous job, we had to do service, either inpatient consulting or hospitalist-type work, but I don't have to do that here, which is nice. It allows me to focus on outpatient care and research.
When thinking about the type of job you want, you can just be a clinician. Or you can be an educator, a researcher or go into administration. But you have to figure out your pathway, and then you have to figure out how you're going to allocate your time to that. That’s a real challenge.
Skills every physician in training should have for behavioral neurology but won’t be tested for on the board exams: I'm a neurologist and then I'm a behavioral neurologist. For behavioral neurology, you're going to get tested on the different diseases, the different areas of the brain and what they do, and how behavior relates to damage to the brain. But they don't test you on your ability to sit and listen to the patient and talk with them about a problem.
When patients come in, they have different symptoms. Some might say, “I can't find anything in the house.” Or they might say they have short-term memory loss, or they might say they can't come up with words. You can do some standard tests, like a mini mental status exam. But when I see patients, sometimes I will do more than that to try to really understand what the patient is experiencing. In the moment, you may have to think of what question or what test you can give the patient in just the next few minutes to understand how they're seeing the world or how they're interacting with the world.
On the boards, they don't really test you on how you take in a case, such as how you organize the history, the exam and then come up with a cohesive picture of that patient’s condition. You then need to explain it in lay terms to the patient and family. It's very complicated, and you have to be able to explain why is it that someone remembers events from 20 years ago, but not five minutes ago. How does that make sense?
People always ask: Do they have Alzheimer's or dementia? Those are overlapping ideas. The boards don’t test how you explain the two in a way that the person can take away an understanding of what they're experiencing and what the next steps are. You have to be able to pull that together in your mind and have a story that is understandable about what that patient experienced and then what that means in terms of a diagnosis and treatment.
One question physicians in training should ask themselves before pursuing behavioral neurology: You have to decide whether you're going to be satisfied with the diagnostic and educational process. We all hope for more treatment options, but we’re kind of where cancer was in the 1960s when they had nitrogen mustard but not much else in terms of focused oncological treatments.
We have a few new drugs, but you have to ask yourself where you derive your satisfaction in caring for patients. If it's dependent on fixing something right away, you're going to have a different approach to medicine than if you are trying to understand a diagnosis and provide education to patients and families. Both are valid.
Books, podcasts or other resources every medical student interested in behavioral neurology should be reading or listening to: I do like Will Flannery, MD, whose stage name is Dr. Glaucomflecken. I really like that he takes on important ethical, financial and treatment issues. He makes fun of physicians, which is fine, and insurance companies, which is necessary, but he never makes fun of patients. And he really takes things on with amazing humor and good-naturedness, but he also has a focused criticism for some of the business aspects of medicine. Everybody should listen to him.
Also, Atul Gawande, MD. His writing is fabulous. I've read a number of his books—everything from The Checklist Manifesto: How to Get Things Right to Being Mortal: Medicine and What Matters in the End. He's a fabulous writer and a very clear thinker.
Another book I enjoyed is The Emperor of All Maladies: A Biography of Cancer, by Siddhartha Mukherjee, MD. It was brilliant. Aside from medical topics, I enjoy listening to everything from biographies and novels to quantum physics. However, I’m still trying to get through Ulysses, by James Joyce.
Additional advice I would give students who are considering behavioral neurology: You have to think about what you're interested in. Despite the fact that I can't cure many of these diseases, I derive a lot of satisfaction from trying to understand what the patient is experiencing. And even though there aren't curative medications, talking with your patients and their loved ones and educating them has disease-modifying powers. You can educate people and give them comfort even though you can't fix the problem. That can be very satisfying.
