The Neurologist Is In, Episode 6, Part 1: Working in Neurology in Zambia With Dr Deanna Saylor

In this episode, Rachel Marie E. Salas, MD, MEd, interviews Deanna Saylor, MD, MHS, on her path to working in global health neurology as well as establishing the first neurology residency training program and first in-patient neurology service in Zambia.

Listen to Part 2: Global Health in Neurology here!

Can't get enough of The Neurologist Is In? Make sure you're caught up on all the episodes--find the full catalogue here.

About the Speakers:

 Rachel Marie E. Salas, MD, Med, FAAN, FANA, is a professor in the Department of Neurology at Johns Hopkins Medicine with a joint appointment in the School of Nursing. She is board certified in Sleep Medicine and Neurology. Dr. Salas is the Director of Ambulatory Sleep Services at the Johns Hopkins Center for Sleep and Wellness. Dr. Salas has been the Director of the Neurology Clerkship for over a decade. She is the Chair of the Undergraduate Education Subcommittee for the American Academy of Neurology and is an appointed member of the Alliance for Clinical Education. She is the director of the Interprofessional Education and Collaborative Practice for the School of Medicine and a Co-Director for Interprofessional Teaming for the High Value Practice Academic Alliance. Dr. Salas is also the founder and Co-Director of the Johns Hopkins Osler Apprenticeship Program (in Neurology), a medical education research program for senior medical students and the Johns Hopkins PreDoc Program, a pipeline premedical college program. Dr. Salas is a certified strengths coach and uses a strength-based approach and coaching to connect to, support, and develop those involved with her educational mission and clinical practice. Dr. Salas is a 2019-21 Josiah Macy Scholar,  a 2019-20 AMA Health Systems Science Scholar and a 2021 AΩA Leadership Fellow.

Deanna Saylor, MD, MHS, is a neuro-infectious diseases specialist, Assistant Professor of Neurology and Director of the Global Neurology Program at the Johns Hopkins University School of Medicine.  Most recently, Dr. Saylor has been living and working full-time in Zambia as Director of the first and only neurology post-graduate training program in Zambia.  She also leads the only inpatient neurology service in the country at the University Teaching Hospital and has helped to launch Zambia’s first teleneurology service.

Read the Transcript:

Dr Rachel Salas:  Hi, everyone. Welcome back to the Neurologist Is In. I'm Dr Rachel Salas. I'm a sleep neurologist at Johns Hopkins, and with me today, I have Dr Deanna Saylor, who is a global health neurologist.

We're going to learn a little bit about what she's doing, and where she's doing it and just kind of pick her brain a little bit more. Deanna, thank you so much for coming on and telling us a little bit about what you're doing and how one gets into global health with neurology.

Can you tell the audience a little bit about yourself?

Dr Deanna Saylor:  Sure, thanks for the invitation. I'm happy to be here, Rachel. My name is Deanna Saylor. I'm an assistant professor of neurology at Johns Hopkins, and a neuro‑infectious disease specialist, but I've been based in Zambia for the past four years.

When I moved to Zambia four years ago with my family, there were two expatriate neurologists in Zambia and there were no Zambian neurologists.

There is also no neurology in‑patient service in the country. There was one half‑day neurology clinic available at the national referral hospital. That was the only specialty in neurology care available in‑country.

I moved to Zambia after I received a Fulbright fellowship from the United States State Department. My fellowship was to design and implement the first neurology residency training program in Zambia in conjunction with the University of Zambia School of Medicine and the University Teaching Hospital, then also to start the first inpatient neurology service in the country.

We've spent the past four years working on that and we've now graduated two classes of Zambian neurologists. We have seven adult neurologists and two pediatric neurologists.

We have an in‑patient service that has about 1,500 to 1,600 admissions per year, then we now have two substantially expanded days of neurology outpatient clinic where we see about 60 to 70 patients per day, per week, and clinic as well.

We've really changed the face of neurology in Zambia ‑‑ created a field of medicine that didn't exist when we arrived four years ago and are also starting to develop a clinical research program to develop locally relevant data that can help us improve care and advocate for policy change at the national level to try to improve the care that our patients have access to as well.

Dr Salas:  It's truly amazing, Deanna, what you've done. I know that you're not alone. You have assembled a fabulous team. It's just tremendous.

Just four years and you've not only done a ton for clinical and neurology in Africa, but also developed medical education tools and curriculums for your trainees out there. It's even offered opportunities for students and trainees in the US to go and spend some time with you.

Let's take a step back for a little bit and set the story of how you got into this and why you were so interested in it.

Dr Saylor:  It's a long and winding story. This was not at all what I envisioned as my career path when I entered medical school. I'd only been out of the country once and never to a resource‑limited setting when I started medical school.

During my third year of medical school, I met a Kenyan physician who'd come to Hopkins to rotate and became friends with him. In my conversations with him, I realized that my entire concept of medicine at that point was Hopkins. I knew that Hopkins was not really representative of how much of the US got its healthcare, let alone the rest of the world.

I decided that I needed to have an experience to see what healthcare was like in a resource‑limited setting. I ended up spending six weeks at a small rural hospital in Kenya, Kapsowar Mission Hospital, doing a general medicine elective during the end of my third year of medical school.

Again, I went thinking this was just for the experience and the exposure, not at all thinking that this was what my career would hold. I absolutely loved it. I came back thinking, that was a impactful experience. I felt like I could make a difference in a way that I couldn't make in the US where there were at least relatively ample numbers of physicians.

I decided that maybe I wanted global health to be part of my career. I also recognize that making a big decision like that based on six weeks was a little silly because you're definitely still in the honeymoon period in any place in six weeks. I applied for a Doris Duke Clinical Research Fellowship for medical students.

Was awarded that through UCSF, and was able to return to Kenya a year later and spend a full year working on a neuro HIV research project. That experience confirmed for me that this was something that I wanted to do for my career.

At that point, I wasn't sure whether I would be somewhere full‑time or build collaborations and go back and forth. I didn't know what global health would look like for me, but I continued to be active during my neurology residency at Johns Hopkins. I was able to get involved in a project looking at neurological complications of HIV in Uganda.

I went once during my third year and again during my fourth year. My fourth year, in particular, was really impactful because I was almost graduating, almost a fully qualified neurologist. I spent six weeks in this rural part of Uganda, where I realized that the research that we were doing was important.

When we left, there was no one to care for the patients that I was seeing. I diagnose a patient with myasthenia gravis and cryptococcal meningitis and strokes and epilepsy. There was a high burden of neurologic disease even at the small rural clinic.

It was that experience that made me start to think about what it would be like to set up a training program in a country where there was no training program or where there were very few neurologists, and helped to build the field of neurology in a place like that.

Push came to shove, the opportunity, and Zambia opened up, funding aligned, and I had a willing husband and partner who was willing to shift our entire family abroad. We ended up in Zambia.

Dr Salas:  Amazing work, Deanna. I'm proud of you and the tremendous endurance you've had on the medical education fronts. Now, it seems like the research is going to be wrapping up on the clinical side as well. That's amazing.

What are your goals for the next few years? Are you looking to get additional funding? Are you looking to stay there long‑term? I know you do come back to Hopkins and do some time here as well. Tell us a little bit more. What's on the forefront for you?

Dr Saylor:  Great question. That's another evolving answer. I recently was awarded a K Award from the Fogarty Institute at the NIH. That started a few months ago and will keep us here in person for about five years. At least in the short term, we expect to be in Zambia a bit longer.

As far as what I hope to accomplish in those five years, the first thing is that I always tell my trainees here and our recent graduates that my job from a clinical and training perspective is to make myself obsolete. We've trained this fantastic cohort of clinical neurologists who are excellent clinicians. They're also excellent and passionate teachers and medical educators.

My goal in the next few years is to mentor them into leadership of the program, so that they can lead both the neurology training program as well as the neurology inpatient service. In the end, making it a self‑sustaining program in service that is not at all reliant on outside healthcare foreigners to keep it running.

From that perspective, my goal is to transition the leadership of the program to the local graduates and see them thrive in those roles. I see my focus over the next few years shifting towards the research component.

My K Award is focused on adapting a stroke guidelines from the US and high‑income settings to our current setting and seeing if we can get them successfully implemented, seeing what our uptake is, and whether changing the systems of care for our stroke patients results in improved outcomes. Pivoting more towards the research focus will be the main focus of the next few years.

Dr Salas:  This all sounds fabulous. I know that we may have people interested in some of the work that you're doing. I'm curious, maybe I'm wrong, but I think you also are involved or in the process of setting up a global health in neurology, fellowship or training. Do you want to tell us a little bit more about that?

Dr Saylor:  Yeah. There's a lot of opportunities for medical students, neurology residents, neurology fellows who are interested in gaining global neurology experience, at least pre‑COVID.

We were frequently hosting US‑based medical students and residents for one‑month clinical electives where they could come over and join our residency program here and function as a part of the team that was helping us to take care of our patients.

We're starting to see visitors come back now in this current COVID times. That's always in flux, but we do hope that we'll start seeing a higher volume of those visitors coming back for short‑term electives.

The year before COVID, we had 24 visiting residents from 18 different institutions in the US. We are looking forward to having those visitors return. I did also start a global neurology fellowship. My first fellow arrived this past July of 2021.

This is a one‑year fellowship spent entirely in Zambia and focused on gaining clinical skills to be an excellent clinical neurologist in a resource‑limited setting, where the diagnostics and therapeutics that you're used to having in the US may be absent.

It also focuses on medical education. The fellow has a major role in teaching both the undergraduate medical students at the University of Zambia as well as our neurology residents, clinical neurology as well.

If the fellow is also interested in research, their opportunities to be involved in ongoing clinical research projects, or to develop their own short‑term clinical research project for the year. That is an ongoing fellowship that I hope to keep funded for at least the remainder of the time that I'm here.

Dr Salas:  Wow, that's amazing. Just to give people a little bit of context, because I know that, especially in neurology, that we have ACGME fellowships and non‑ACGME fellowships, do you think that moving forward, you envision that global health in neurology will be an ACGME fellowship at some point?

Or do you think it'll more be create your own like whether you want to do a lot more medical education or research‑oriented? What do you foresee in that realm?

Dr Saylor:  It will probably remain a non‑ACGME fellowship. Academic global neurology is definitely a growing field and is gaining increasing recognition as a viable career path in academic neurology. It's still a very niche area. I think that these types of opportunities, and currently I think that my fellowship is the only fellowship that's solely focused on a global health experience in neurology.

These types of opportunities will need to expand substantially and will likely vary depending on the location that the fellow is going, and the resources available and expertise available in those locations. For at least the foreseeable future, these will remain forever create your own type of fellowship.

Dr Salas:  I think it's really amazing and pretty unique how you've managed to take all of your passions with medical education, clinical neurology, immunology, and now research and been able to capitalize on it in a setting of limited resources and now with the global pandemic that has been relentless.

I do want to mention to the audience that Dr Saylor has done amazing work setting up programs and opportunities for not just patients, but for students and residents and fellows, and even other faculty members. She's also been really moving the needle with scholarly endeavors and publishing guidelines and recommendations on the work that she's doing in global health and neurology.

I want to thank you for doing that. A lot of people are, like you said, interested in global health and neurology, but rather than reinvent the wheel can glean from what you've learned, what some of the challenges you faced, and how you address them. Is there anything you want to comment in terms of some of the recent papers you publish on?

Dr Saylor:  Thank you for those kind words. The first thing to say is that it's really been a huge team effort. When I set up the curriculum for the neurology training program here, I was cognizant then. I was essentially training people to start an entire field of medicine that didn't yet exist in Zambia.

I wanted them if they were interested to have the tools and skills to participate in research to create locally relevant contextualized knowledge that could be used to improve the systems of care within Zambia. That has included building in a weekly research methods seminars, weekly journal clubs, where we critically appraise the recent literature, and then encouraging scholarly activity.

So far, every single one of our graduates and current trainees has embraced that challenge, and has become involved in clinical research. Much of the work that we've been able to do has been because they have worked hard and done a lot of the manual labor to gather the data and to analyze it and write it up.

I want to make sure that we give the whole team a lot of credit. A lot of our recent work has come out of a inpatient neurology registry that we did during the first six months of our training program, where we literally captured demographic and clinical information and lab and imaging test results and outcomes of every single patient that was admitted to our service.

Just look to see if we can understand who are the patients that we're taking care of, how are they doing, and what factors are impacting their outcomes? Then how can we improve the service that we're providing to improve patient outcomes? Our first batch of papers has focused on stroke, which accounts for almost half of the admissions for inpatient service.

We've had Stanley Zimba recently publish a first author paper, looking at the differences between HIV‑associated stroke and stroke and HIV uninfected people highlighting that people with HIV have increased risk of stroke at younger ages, and often lack other traditional stroke risk factors.

Aparna Nutakki, who's a graduating Rush University medical student going into neurology residency, led this project. She's published some great papers looking at the clinical characteristics and outcomes of these patients looking at predictors of mortality both in the hospital and post‑discharge, looking at sex‑specific differences of these patients as well.

Showing that female patients tend to have worse outcomes post‑discharge than male patients, even after we take into account their age and stroke type.

We've also done work looking at an effort we made during the COVID pandemic when our clinic was shut down per national guidelines. We essentially instituted a low‑resource tele‑neurology clinic and basically called our patients on the telephone because they didn't have video conferencing capability, and did our best to provide continuity of care during the pandemic.

Then we kept track of what kinds of conditions we were managing on the phone, how confident our trainees felt managing those conditions over the phone, and then later surveyed the patients to find out about their experience. One of our graduates has had this accepted as a paper to the Annals of Neurology as well describing that experience.

We've tried to leverage our clinical experience and expertise in functioning in this resource‑limited setting to publish guidelines on how to approach the management of stroke when you don't have neuro‑imaging available.

How that might differ from settings where you have more information, but how it also is the same, and trying to make those guidelines as evidence‑based as possible, that then filling in with our own experience where the evidence is lacking.

Dr Salas:  That's really great. Putting it all together, getting it out there, sharing the work that you're doing so that others can hit the ground running and other underserved areas, that's just remarkable.

I love your shout‑outs to your team. I definitely appreciate that about you. You're very team‑oriented and give it your all with everybody that's on your team all the way down, from the students, your patients to everybody. You're a great role model.

Dr Saylor:  Thanks so much, Rachel. It's been a pleasure to be here. Thanks for the opportunity to share more about our work here.