1. Foundation of the Consortium of Multiple Sclerosis Centers
MS Mentorship Forum:
Nancy Sicotte, MD, FAAN
Promoting the Best and Latest in Multiple Sclerosis Care

2. Overview: Career Paths in MS Patient Care and Research
Looking ahead
Changes in healthcare landscape
Role of Neurology
Importance of subspecialty expertise
Neuroimmunology
Not just multiple sclerosis
Rapidly expanding therapeutic landscape
Multiple Sclerosis as a subspecialty choice
Know what you like
Many paths are available
Multiple sclerosis (MS)
is an autoimmune disease.
cause of MS is not known
evidence that both environmental and genetic factors are involved.
pathological hallmark of MS is the formation of plaques (ie, sclerotic tissue, in areas of the brain, spinal cord, and optic nerve) where myelin has been destroyed and partially repaired.
MS strikes young adults in the prime of their life and is the most common chronic disease of the central nervous system (CNS) in young adults. In a large study involving 1844 people with MS, the mean age at onset was 31 years. However, age at onset in this study ranged from 5 to 67 years.(Confavreux)
References:
Compston A, Coles A. Multiple sclerosis. Lancet. 2002;359:
Confavreux C, Vukusic S, Moreau T, Adeleine P. Relapses and progression of disability in multiple sclerosis. N Engl J Med. 2000;343:
Fleming JO, Carrithers MD. Diagnossi and management of multiple sclerosis: a handful of patientce. Neurology. 2010;74:

3. Healthcare Trends

4. Healthcare Practice after the ACA
Care Models are changing
Less: fee for service, small single specialty private practices
More: Cost effective care, multispecialty groups, patient centered outcomes 1, Big Data/EMR, multidisciplinary care
Quality not quantity: Responsibility for delivering healthcare value
Accountable Care Organizations (ACOs)
Medicare incentives for hospitals, healthcare providers to work together to coordinate care
According to the National Multiple Sclerosis Society, there are an estimated 400,000, up from the 250,000 to 350,000 people estimated in the 1990s with MS in the United States.
Furthermore, it is estimated that approximately 2.3 million people suffer with MS worldwide.
When the relationship of prevalence, incidence rates, and latitude was examined in a recent meta-analysis of population-based studies, crude prevalence and incidence rates were significantly associated with latitude (P < and P = .038, respectively). However, when the rates were age-adjusted to the world population, the level of significance in relation to latitude diminished for prevalence (P = .003) and disappeared for incidence (P = .156), suggesting that age adjustment partially eliminates the apparent effect of latitude seen in many epidemiological studies.
Approximately two-to-three times as many women as men have MS, similar to the female:male ratio seen in other autoimmune diseases.
References:
Compston A, Coles A. Multiple sclerosis. Lancet. 2002;359:
National MS Society. Accessed: February 1, 2014.
Hogancamp W, Rodriguez M, Veinshenker BG. Symposium on multiple sclerosispart III. The epidemiology of multiple sclerosis. Mayo Clin Proc. 1997;72:
The National MS Society Information Sourcebook. Available at: Accessed on July 21, 2003.
Zivadinov R, Iona L, Monti-Bragadin L, et al. The use of standardized incidence and prevalence rates in epidemiological studies on multiple sclerosis. Neuroepidemiology. 2003;22: 1

5. Patient Centered Outcomes

6. Neurology Workforce

7. Figure 2 Comparison of alternative supply and demand scenarios: 2012–2025.
Dall T et al. Neurology 2013;81:
© 2013 American Academy of Neurology

8. Figure 3 Estimated supply and demand for neurologists: 2025 (including Patient Protection and Affordable Care Act impact).
Estimated supply and demand for neurologists: 2025 (including Patient Protection and Affordable Care Act impact)‏
Dall T et al. Neurology 2013;81:
© 2013 American Academy of Neurology

9. Neurology Subspecialties
Therapeutic advances drive change
TPA and “emergency neurology”
Vascular neurology, neurohosptialists, neurocritical care
Rise of biologic agents
Neuro oncology, Neuroimmunology
Common features:
Need for accurate timely diagnosis
Expensive, potentially dangerous therapeutics
Careful assessment and monitoring of treatment response required
Drive ancillary services: neuroimaging, rehabilitation, infusion centers
MS involves breakdown of the blood-brain barrier (BBB), acute and chronic inflammation, demyelinated scarring, and irreversible axonal damage.
Destruction of the CNS myelin and oligodendrocyte loss is the primary pathology of MS.
The major cause of neurologic disability is axonal loss.
Brain atrophy may be helpful in determining disease progression and the effects of long-term therapy.35,37,38
35. Halper J, Costello K, Harris C., eds. Nursing Practice in Multiple Sclerosis: A Core Curriculum. 2nd ed. New York: Demos Medical Publishing; 2006.
37. Rejdak K, Jackson S, Giovannoni G. Multiple sclerosis: a practical overview for clinicians. Br Med Bull. 2010;95:79–104.
38. Agrawal SM, Yong VW. Immunopathogenesis of multiple sclerosis. Int Rev Neurobiol. 2007;79:99–126.
Note: from Moving Forward Monograph.

10. Neuroimmunology

11. Beyond Multiple Sclerosis
What kinds of disorders does a “neuroimmunologist” see?
NMO/NMO spectrum disorder
Transverse myelitis
Autoimmune encephalitis
Paraneoplastic syndromes
Iatrogenic demyelination syndromes (TNF-alpha blockers)
Any weird scan with white matter changes
Who does a neuroimmunologist work with?
Rheumatologists
Pediatric neurologists
Physiatrists
General neurologists
Ophthalmologists
You exam and clinical data may be very valuable to collaborating research groups

12. Therapeutics Coming soon Preventive therapies? B-cell depleters
Hematopoietic stem cell transplants
IL-2 blockers
Remyelination therapies
Neuroprotective therapies
Preventive therapies?
Genetic/environmental risk models
Radiological isolated syndromes
High risk family members
You exam and clinical data may be very valuable to collaborating research groups

13. Career Paths
With special thanks to Jennifer Graves, MD, PhD

14. Many options for MS related careers
Clinician
Clinician Researcher
Basic Researcher
Pharma
Advocacy
Neurorehabilitation
Education
Government/VA
Outcomes/health policy
You exam and clinical data may be very valuable to collaborating research groups

15. Clinical Clinical private practice
There are private MS specialty centers
Mostly MS but also general practice
Clinical educator tracks at training hospitals
Usually can mostly practice your specialty
Can seek advanced training in medical education
Sometimes includes clinical trials or observational research
Adjunct positions
Can have private practice but be affiliated with a university
You exam and clinical data may be very valuable to collaborating research groups

16. Clinical Research Clinical trialist Observational Research
Industry studies site investigator
Investigator initiated
While not required, some training in clinical research including trial design is helpful
Observational Research
Associative studies
Translational studies
Epidemiology/Biostatistics training strongly recommended
Need to start with a mentor so you have data to work with
You exam and clinical data may be very valuable to collaborating research groups

17. Basic Research Large variety of experiences
Animal models
Human sample based work
The mentor/environment is as important as the question!!
Don’t start completely from scratch
Have 1 project that can come to fruition soon for productivity
Have another project with potential big impact but more time investment
Collaborate
You should enjoy being in the lab and problem solving
Mentor advice to Dr. Graves: “Don’t expect an experiment to work the first time”
You exam and clinical data may be very valuable to collaborating research groups

18. Industry Clinical or basic research
Some post-residency training helpful, but in some settings industry may support training needed
Some MD, PhD’s enter right after graduation
Be ready to give up direct patient contact
But potential to have effect on larger number of patients
Variety of options depending on the company
You exam and clinical data may be very valuable to collaborating research groups

19. Discussion

20. Foundation of the Consortium of Multiple Sclerosis Centers
MS Mentorship Forum:
Gabriele De Luca, MD, PhD
Promoting the Best and Latest in Multiple Sclerosis Care