The Neurologist Is In, Episode 10, Part 1: Providing Interdisciplinary Patient Care With Neuromuscular Specialist Dr Madhu Mona Soni

In this episode, Rachel Marie E. Salas, MD, MEd, sits down with Madhu Mona Soni, MD, FAAN, to discuss exciting developments in neuromuscular neurology, the power of interdisciplinary patient care, and advice for neurologists interested in seeking a more active leadership role in academic and professional organizations.

Listen to Part 2: Future Trends in Neurology With Dr Madhu Mona Soni 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.

Read the transcript:

Dr Rachel Salas:

Well, hello, everybody. Welcome back to The Neurologist Is In. I am Dr. Rachel Salas. I'm a sleep neurologist at Johns Hopkins Medicine, and I have the pleasure of having another fellow neurologist here with me today. She's going to give you her formal title, but Mona is a neurologist that I actually met through the American Academy of Neurology. She's a fellow clinician educator, and I'm thrilled to have her on today to pick her brain about what she's doing and where she's going. Mona?

Dr Madhu Mona Soni:

Thanks so much, Rachel. Thank you, everyone. I'm Madhu Mona Soni. As Rachel has mentioned, I am an associate professor and a neuromuscular specialist at Rush University Medical Center in Chicago. I appreciate the opportunity of being here with everyone, talking to you about my experience and any advice I can offer.

Dr Rachel Salas:

Awesome. I think you are the first neuromuscular neurologist we've had on here. Tell us a little bit about that. We have general neurologists listening, but we also have learners that may be listening as well. Tell us a little bit about neuromuscular neurology. How do you get there? What do you do? What kind of patients do you see?

Dr Madhu Mona Soni:

Sure. Neuromuscular medicine is a subspecialty of neurology. There is also board certification available for that. There are one or two year fellowships in neuromuscular medicine. In terms of the cohort of patients that we see, it's really anything from localization at the motor neuron level all the way down to muscle. In terms of particular diseases, people may be familiar with ALS [amyotrophic lateral sclerosis], but also spinal muscular atrophies (SMA) at the motor neuron level. Certainly anything involving the root or plexus, neuropathies, whether they're polyneuropathies, mononeuropathies, neuromuscular junction issues, and then myopathy. It's really a broad spectrum and a wide variety.

Unfortunately, many of these patients go for a period of time undiagnosed, so really having the expertise in training, and then subsequently, as we're seeing patients, is really important to be able to provide them not only with the correct diagnosis, but with the expansion of therapeutics, implementing that in their management plan as well.

Dr. Rachel Salas:

Mona, tell me a little bit about how long is fellowship? Just for students or residents who might be interested in a career in neuromuscular.

Dr Madhu Mona Soni:

There are actually one and two year fellowships available. The two year fellowships might focus more on research during the second year, but there are one year fellowships that can be done after the neurology residency. And then after that, people can decide whether they do want to use that expertise in private practice. People continue to do general neurology, but then have that special interest or apply to academic centers for a position there.

Dr Rachel Salas:

Nice. I know you're an academic neurologist as well. We're going to talk a lot more about your educator role. I know you're also involved in leadership and wellness. We'll talk about that a little later. But for now, tell us a little bit about what your typical week looks like as an academic neuromuscular neurologist at Rush.

Dr Madhu Mona Soni:

Sure. My time is divided pretty much 50/50, in terms of 50% of my time clinical work. And within that, it's about three to four clinic sessions per week, and then a half-day session of EMGs. We do have two multidisciplinary clinics that we do monthly. One is for muscular dystrophy. We just had one yesterday, and it was a full day clinic. And then we've actually expanded from half-day to full-day clinics. Another one is the ALS clinic that we do monthly as well. That's the clinical part. Of course, based on the number of faculty that we have, we share a call within the hospital. Although neuromuscular is primarily an outpatient-based specialty, but we do offer services for inpatient consults and EMGs as well.

And then for the administrative aspect of it, I lead the section of neuromuscular disease at Rush. I'm also the director of the ALS clinic. And then with my educator hat on, I direct the neurology clerkship, the advanced elective, and then I'm the faculty advisor for our student interest group in neurology.

Dr Rachel Salas:

Wow! I mean, it sounds like you're pretty busy, huh?

Dr Madhu Mona Soni:

It's the pattern that drives us to what we do, right?

Dr Rachel Salas:

Exactly. In terms of your clinical practice, is there anything new and exciting in terms of like neuromuscular? It sounds like you're very involved with the ALS patients. Are there any tips or things that you want to share with our fellow neurologists out there that maybe something new in the pipeline in terms of treatment or just a new approach on taking care of patients with ALS?

Dr Madhu Mona Soni:

Sure. I'll expand that just in general to neuromuscular disease and probably neurology in general. I mean, this is such an exciting time. I think 2000 was called the decade of the brain, but even now we're seeing therapeutics really expand and explode. We've had conferences that just focus on the therapy of neurology. Sharing that with not only our colleagues in practice, but also our trainees in terms of the opportunities and options for patients. We've had FDA approved medications for myasthenia gravis, for example, where when you and I were in training, we probably didn't have it back then.

Specifically for ALS, this is really a novel time in terms of the landscape for clinical trials. There are these platform trials that are testing medications more sort of simultaneously, if you will, than traditionally in the past. What we're trying to do is really come to, if not a cure, at least palliation of symptoms. I would like to encourage those who have patients with ALS or are considering the diagnosis to make sure that it's seen in a multidisciplinary setting, because we have resources available. We know that multidisciplinary clinics play a role in extending survival, as well as potentially having an impact on patient's quality of life. I think this provides them with the opportunity for symptomatic management, but also that opportunity to engage in clinical trials and receive up-to date-care.

Dr Rachel Salas:

You bring up a good point, and I'm so glad that you're talking about the interprofessional collaboration part. I mean, that's really where we need to be as a healthcare team working together to provide the best care that we can for all of our patients. If you're in private practice, if you're a neurologist in private practice, you're obviously seeing a lot of different patients with different neurological disorders. But can you give us a sense of what your center, when you say interprofessional or interdisciplinary, who are those people? Why, if I was a general neurologist, should I be like thinking about when I need to refer my patient to maybe an academic center and what kind of other perspectives are going to be part of that care?

Dr Madhu Mona Soni:

Sure. One thing to think about is the convenience for the patient coming to an office visit, even though it's going to be a longer office visit, to have sort of a one stop shop, if you will, for them to be able to see the care team that they need. As an example, not only will they be seeing the neurologist, we have a nurse. We have a social worker. We have a dietician, physical therapist, occupational therapist, speech therapist, respiratory therapist, particularly for our patients with ALS. But then in the muscular dystrophy clinic, for those who have respiratory muscle weakness, being able to assess periodically what their respiratory muscle strength is like. We actually have a pulmonologist in the clinic to help us with noninvasive ventilation, cough assist devices. We have an orthotist in the clinic for bracing, and we have a genetic counselor. The genetics has really expanded as well. And then when we talk about future targeted therapy based on genomics, that's an important part of this as well. So you can see we've got multiple team members that basically rotate in and out to see the patients. We have about 20 minutes allotted per discipline. It's not that every patient has to see everyone all of the time, but based on what their needs are. We have a nurse actually that does intake in advance to determine who they should see during that particular clinic visit.

Dr Rachel Salas:

I really love that. I mean, that sounds like Rush is right in line with precision medicine, which is really seeing the patient, finding out what their needs are, and then meeting them where they are and who they need to see. I really love that approach. I know my colleagues at Hopkins also have a very multidisciplinary approach. I just think that you all are--neuromuscular, the specialty itself, is very much ahead of the game in terms of having this big interprofessional practice. I will say for sleep too, we're there. We also have big team. I think this is kind of what you'll see quite a bit in neurology, right? A lot of different people coming together to better care for our patients with neurological disease, right?

Dr Madhu Mona Soni:

Exactly. I think that there's a role for patients in terms of, again, symptom management, but all the other needs and really approaching them holistically.

Dr Rachel Salas:

Is there anything that we should be thinking about even outside the kind of standard practice of care? Like for instance, I know in my sleep practice many patients now are coming and asking like, "Well, what can I do besides medications or coming to my doctor's visits?" Are there like music therapy, acupuncture, like anything else? What are some other things that we should be thinking about to promote for these patients?

Dr Madhu Mona Soni:

That's a great question. It actually touches on something, a project that I'd like to do. With music therapy, we actually have a music consultant, who I first saw on the inpatient ward and I thought, "Hmm, this would be so neat to incorporate," and then also pet therapy. That's another thing I'm thinking about. We've heard about art therapy as well. I think it comes down to talking to patients and saying, "What brings you joy?" What is it that they would like to spend time on, because we can't generalize it. And then using that to perhaps promote some of these things that may not be necessarily, as you said, standard of care, but it really helps meet their needs and expand the quality.

We also do utilize palliative care in many of these cases, and I think we underutilize that as well it's not only patients who are necessarily terminal, but who really need that holistic multisystem or symptom management approach. I do think that there's room for actually research in this area to really see what the outcomes are, but definitely I think there's a role for this nontraditional care.

Dr Rachel Salas:

I'm glad you mentioned palliative care. We had Dr Lauren Treat several months ago come and talk about her experience with palliative care in neurology. I think it's something that a lot of neurologists are in interested in. For those of you out there, this is another specialty of neurology that you can think about doing, neuropalliative care. It's so important not just for patients that may be going into hospice, but just even for chronic disorders in neurology as well. Thank you for bringing that up. I'll put a plug for Dr. Treat's podcast that we can link to as well.

Mona, let's transition a little bit, because I know you have such a big role in education, not only at Rush, but also nationally and even globally. Why don't we talk about, first, how you got into education? What made you say, "You know what, I'm interested in being a clerkship director?"

Dr Madhu Mona Soni:

Well, I'm going to give all the credit to my genes. My mom was a teacher. I think that some of it is inherent there. We all I think are educators based on whether we're educating our younger siblings, our patients, friends, colleagues. What was interesting is after my fellowship in clinical neurophysiology actually, I really enjoyed the breadth and the general neurology, the variety that we could see. At that time that I finished my training, there really wasn't sort of the role of a clinician educator after a one year fellowship staying in an academic center. I would've loved to have done that. Things have changed since that time. I went out into private practice at a place where we were actually affiliated with the academic institution. It was wonderful. First diagnosis, patients coming into the office or in the hospital.

But what I really missed was I missed educating medical students. That was really my draw back to Rush, to the academic center. I actually maintained an affiliation there. When the clerkship director position opened up, I expressed an interest. For a period of time, I actually continued in the private practice role, but then I would come back to the medical center to do orientation, give teaching sessions, et cetera, around with the residents. And then after a period of time, it just got to be doing two jobs. I needed to make a decision at that point. Wellness came into it as well.

That was really my story. Believe it or not, I've been a clerkship director for almost 22 years, and I love it. Otherwise, I wouldn't be continuing in that role. Really, Rachel, as you know, your passion and then opportunity--that is the perfect storm to kind of find other avenues to express your voice and share how you want to improve things for our future physicians. I've been involved with the AAN since being a senior resident, and then really would just kind of attend conferences. But I remember having a conversation with the chair of the AAN's undergraduate education subcommittee many years ago. There was a poster session. We happened to be talking about an education poster. And then shortly thereafter, I got an invitation to be on UES. And that was just as a member. I guess based on my role there, eventually evolved to becoming the chair, first of the Consortium of Neurology Clerkship Directors, and then of the Undergraduate Education Subcommittee.

I think it's a combination, for all of our listeners out there, is if you have a passion, you have an interest, have the conversation. Network. This could be through the AAN. It could be through other organizations. We now have many electronic platforms, the synapses through the academy in areas, whether it's sections, education related, or subspecialty related. It's really a nice opportunity to participate and contribute. I guess that's sort of my journey.

Dr Rachel Salas:

Wow! 22 years, that is fabulous. Wow! I will say that, just for those listening, Mona has not only made her mark in education nationally, but has also like kind of almost crossed over and is doing a lot to support others. She's very much a sponsor mentor, really trying to advocate other neurologists and other learners to kind of get where they're going, right? We're going to talk a little bit more about your other roles at the national level regarding leadership, and then, your newer role, which is kind of getting into well-being and wellness. Why don't we talk a little bit first about your roles in leadership and sponsoring others?

Dr Madhu Mona Soni:

I completed my third term as chair of the AAN's Undergraduate Education Subcommittee last spring and passed on the baton to you, who's doing a wonderful job. I am currently the physician liaison for the Women Leading in Neurology program. This is a wonderful opportunity for women who are interested in leadership positions, whether it's at an academic institution, whether it's from private practice, whether they're clinically-based or research-based or a combination thereof. It's something that stemmed from the Women in Neurology subcommittee that then evolved into having this program. It is an application-based program that is being held annually. I think we are currently in the perhaps fourth year of it. This is the first year that I'm the physician lead for it, but it is a great opportunity where we also pair each of the participants, and we have 10 per year, with an individual mentor. There's a mentor-mentee relationship, which they can use to develop further areas of interest. And then we have a content expert that has an ongoing curriculum with them as well.

Dr Rachel Salas:

Yeah, that's really great, Mona. I know that these programs can be very competitive. Do you have any recommendations, especially for people that haven't even applied, or if you have applied and haven't got accepted, what are some things that you can do that could help your maybe being selected for either this program or another leadership program, either locally or nationally?

Dr Madhu Mona Soni:

I would encourage people who have already applied, maybe didn't get accepted, to reapply. We certainly look upon that as well. We are interested in diversity as well. We have a very diverse group of participants this year. We look not only at ethnic background, but also we look at diversity from the standpoint of geography, where they're practicing, what their subspecialty is, what their interest areas are. I recently just got a message from our content expert who said, "This is the most diverse group that we've had during the duration of the program in its existence. It enriches the conversation so much."

I would encourage whoever's interested, they could reach out to any of the AAN staff members, to me also. If there are any questions, we do have information on the AAN website about it. There are people who already have some roles within the academy, but you don't have to have that. We are looking. And that may be an interesting aspect, if it is this particular program that our listeners are interested in, is to gradually get involved with the academy, whether it's through the sections, through the conversations, because that's an opportunity for collaborative projects. We do look to see what engagement has been there in the past as we're looking through the applications.

Dr Rachel Salas:

One of the questions that I get asked in terms of like leadership programs are like, well, which one, right? Because there's like the Transforming Leaders, there's the Emerging Leaders, the Women's Leaders, there's the Palatucci, there's the private. What would your recommendations be to finding the right fit?

Dr Madhu Mona Soni:

I think a helpful aspect would be to take a look at the description for each of the leadership programs to see which one speaks best to the individual. There might be certain aspects of the curriculum, whether there is an individual mentor-mentee relationship; I think most of them actually do have that aspect as well. They can apply for one. And if they're interested, they can apply for a different one a subsequent year or the same one, but that would probably be my suggested approach.

Dr Rachel Salas:

I'm a big advocate for leadership programs, not only the ones that the AAN offers, but even like local ones. I mean, they're all different. If you do a local leadership program, then you get to know your institution a little bit more, and you could probably navigate opportunities even outside the Department of Neurology, which I think I'm a big advocate for, especially for the educators. A lot of times educators will stay footed in neurology. I want to kind of say, "Maybe you want to consider stepping outside and looking for leadership roles like in the curriculum and other places, like in the preclinical year or in GME or even at the faculty level."

Dr Madhu Mona Soni:

I agree. And then I think that that's a nice stepping stone because it then informs what they may be looking for in a national program.

Dr Rachel Salas:

What do you say when people say, "Yeah, I would love to do a leadership program, but I'm in private practice. I'm very busy. I don't really have time for this," because I hear that quite a bit. What are your recommendations for that?

Dr Madhu Mona Soni:

I think it depends on what the goal is. If the goal is to continue clinical practice and you don't have the time for it, then perhaps thinking about when you might have that time, because it is a commitment. For people who are accepted into the program, we do ask for that time commitment for the curriculum meetings and the learning circles. It does involve travel during in-person meetings, or in the virtual world, taking that time apart. There does need to be the support from the other members who may be working with these individuals to allot them the time. If somebody's a solo practitioner, for example, it would be something that they would need to work into their activity. If they're first starting out and maybe this is not the time, something as a goal to work towards maybe in subsequent years and to keep on their radar.

Dr Rachel Salas:

I want to echo what you said a little earlier, which I think the biggest aspect that I found from these leadership programs are the networking, getting to know other fellow like-minded people, and then people that you probably wouldn't interact with for obvious reasons. As a sleep neurologist, obviously I interact quite a bit with other sleep neurologists. But when I got into education and doing some of these leadership roles, now I'm meeting different types of neurologists, different types of educators. I'm a big advocate for even doing these programs just for the networking just by itself, but let alone all the other bonuses that you get.

Dr Madhu Mona Soni:

I completely agree. I think it opens up avenues. As we evolve through our careers early, mid, later, there are certain things that change in terms of where our focus may be or what we may want to spend more or less time in. This really just opens up those doors.

Dr Rachel Salas:

Yeah, that's really great. I'm so glad that you are doing a lot of work in leadership to support others that are coming through no matter what their other interests are, education, research, academics, private practice, whatever. You're very supportive of that. That's great. All right. We'll catch you all next time with our next neurologist. Thank you.

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.

Madhu Soni, MD, FAAN is Associate Professor and Senior Attending Neurologist in the Department of Neurological Sciences at Rush University Medical Center. She graduated from Northwestern Medical School and completed her internship, residency training and clinical neurophysiology fellowship at Rush- Presbyterian-St. Luke’s Medical Center in Chicago. Dr. Soni is board certified in neurology, clinical neurophysiology and neuromuscular medicine. She is head of the section of Neuromuscular Disease and Director of the multidisciplinary Rush ALS Clinic. She was Co-Director of the MDA clinic from 2006-2010 and program director for the Rush Clinical Neurophysiology Fellowship from 2008-2011. She has a busy clinical practice and also has a special interest in medical education.

Dr. Soni is director of the neurology clerkship and advanced neurology elective at Rush. She is also faculty advisor for the Rush Medical College (RMC) Student Interest Group in Neurology (SIGN) chapter. She has served as a mentor for local high school and college students, as well as for medical school and neurology trainees at Rush and nationally. During the 2017-2018 academic year, she received the RMC Neurology Preceptor of the Year Award and was nominated for the school’s Positive Learning Environment Award.

Dr. Soni is a member of the Rush Medical College Committee on Curriculum and Evaluation and was Chair of the Core Curriculum Work Group from 2007-2010. She served as Assistant Dean of Accreditation and Continuous Program Improvement for Rush Medical College from 2011-2016 and successfully led the medical school through its most recent LCME accreditation visit.

Dr. Soni Co-Chaired the American Academy of Neurology (AAN) Consortium of Neurology Clerkship Directors from 2014-2016 and she is currently Chair of the AAN’s Undergraduate Education Subcommittee. She is also a member of the AAN’s Education Committee and many AAN work groups, including for the Medical Student Pipeline and Women in Leadership. She has served as a course director and speaker at the AAN annual meeting for several years.

Dr. Soni is a Fellow of the AAN. She is also on the Medical Advisory Board for Conquer MG (formerly, the Myasthenia Gravis Foundation of Illinois), the Executive Council of the Alliance for Clinical Education, and was recently appointed to the Board of Directors for the Illinois State Neurological Society. She is member of the American Board of Psychiatry and Neurology Professionalism Committee, American Association of Neuromuscular and Electrodiagnostic Medicine, Peripheral Nerve Society, Association of University Professors of Neurology, and Association of American Medical Colleges Council of Faculty and Academic Societies.