The Neurologist Is In, Episode 12, Part 1: Thriving as a Neurologist in Private Practice With Dr C. Debbie Lin

In this episode, Rachel Marie E. Salas, MD, MEd, talks with with C. Debbie Lin, MD, to discuss why she pursued private practice, the excitement she finds in practicing as a general neurologist, and what changes she's noticed in the field over the last 10 years.

Part 2 coming soon!

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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.

C. Debbie Lin, MD, was born in Taiwan, moved to the US when she was 12, and grew up in the suburbs of Philadelphia.  She received her medical degree from Jefferson Medical College.  She went on to complete her internship at Georgetown University Hospital and completed her neurology residency at the Mayo Clinic in Rochester, Minnesota.  She then moved on to complete a clinical neurophysiology fellowship at Johns Hopkins Hospital.  Dr. Lin has been cited as a top neurologist many times in Washingtonian Magazine and Washington Checkbook.  In her free time, she likes to spend time with her family, travel and shop.

Read the Transcript:

Dr Rachel Salas: All right. Hello, everyone. Welcome back to the Neurologist Is In. I am Rachel Salas, a sleep neurologist at Johns Hopkins, and we're continuing the series, but this time we're doing it with a neurologist who's out in private practice. With me, I have Dr. Debbie Lin. I know Debbie from several years ago, we met in training during our fellowships at Johns Hopkins. It Is a privilege to have her here, she is our first private practice neurologist, and I'm curious to pick her brain on how her practice is going, and just some other questions. So Debbie, I'd like to invite you to introduce yourself.

Dr Debbie Lin: Hello, how is everybody? My name is Debbie Lin. I trained at Georgetown for my intern year, and I went to medical school in Philadelphia: Thomas Jefferson Medical College. And then after that, I went to the Mayo Clinic for three years for my neurology residency, and I did a one year fellowship in clinical neurophysiology at Johns Hopkins, and I've been in private practice in the suburbs of DC, Rockville to be exact, since I finished fellowships. I've been here for about 15 years.

Dr Salas: Yeah. I can't believe it's been that long. So you mentioned how you decided on a specialty of neurology.

Dr Lin: All right. So when I went to medical school, I was 100% percent sure I was going to be a pediatrician. I like kids, I was going to be a pediatrician, until I did my clinical rotations. I realized I didn't want to be a pediatrician, I want to do something else. So in the end it was between cardiology or neurology, and I really was fascinated by the fact that neurologists are just problem solvers: putting things together, solving the problem, localizing, like putting a puzzle together. I really like that aspect of neurology, so I decided that's what I wanted to do. There are a lot of unknowns about neurology, which is pretty exciting.

Dr Salas: Yeah, thank you for that, and I'm curious to know, because a lot of times in med school, we're trying to decide what our field, or specialty is going to be, but not a lot of times, are we thinking, sometimes we are, but not always are we thinking, are we going to do academic or private practice--did you know you were going to do private practice while you were in med school, is that what you were thinking?

Dr Lin: In fact, not at all. I was not sure what I was going to do. Throughout training, you get a taste of what academic medicine is like, but you get very little exposure to private practice. But at the Mayo Clinic, they had a community outreach program. So once a month I would follow an attending out to the community in Minnesota and they would do a day of clinic, so that was my taste of what private practice was like. But keep in mind, it's still within the Mayo Clinic system. And the reason I landed with private practice was, the opportunity arose for a private practice job versus staying a academia, and because my husband was working in the suburbs of DC at the time, it just made more sense for me to take a private practice job rather than academia, because Baltimore's just too far to commute. So, that's how I ended up in the private practice job.

Dr Salas: Okay. So, it's just an opportunity that came, it's not like you decided during residency or even in med school, "Hey, I definitely want to do a private practice." It sounded like you were more open to whatever opportunities came your way

Dr Lin: Right, and in the end it was more about commuting location, trying to figure out how to make life work between my husband's work and mine, that I ended up in private practice.

Dr Salas: Okay. And so tell me a little bit more: why choose clinical neurophysiology fellowship versus one of the others, like neuromuscular or epilepsy. How did you get there?

Dr Lin: So, at the Mayo clinic, when I was doing residency, you'd rotate through all of the different subspecialties and you can actually do a mini fellowship at the Mayo Clinic for [electromyography] EMG, and that's what I picked to do. It was fascinating, all the various disease states conditions and electrodiagnostically, you can make determinations of the different conditions,. It excites me, plus it makes sense, everything can be localized electrophysiologically, so that's why I chose EMG neuroclinical phase, because I like what it could do, it's a diagnostic tool, it's pretty important for neurologists.

Dr Salas: Yeah. And I think, I mean, it was almost like you had the premonition before joining private practice, because I feel like clinical neurophysiology, that fellowship is really something that primes you and prepares you for being a general neurologist out in private practice. What do you think about that?

Dr Lin: Oh, that's for sure the truth, but in my practice we have a lot of different subspecialists and subspecialty training. So, it's nice, but clinical neurophysiology is definitely a great skill, especially EMG nerve conduction for private practice.

Dr Salas: And how do you identify as a neurologist? I identify now as a sleep neurologist. What kind of neurologist are you?

Dr Lin: Initially I was hoping to do more peripheral nerve neuromuscular work, but now I'm really just a general neurologist. I see everything that comes through: migraine, epilepsy, Parkinson's, peripheral neuropathy, so whatever walks through the door. It's pretty exciting because every day is a different day. You have some patients that are new, so they're coming in for a diagnostics, a diagnosis, some patients who you have known for a long time follow up, so you know their problem, you can help manage it. So I would say I'm seeing everything and I like that, I like a variety.

Dr Salas: Yeah. That's really great, because as you know, our field of neurology has a ton of specialties, and it's only growing. There are close to 30 [Accreditation Council for Graduate Medical Education] ACGME neuro fellowships, ACGME fellowships, but there are many more, especially at academic institutions like Hopkins, Mayo, that are doing these non-ACGME further training, and just to give the audience some examples, neuroimmunology, even movement disorders, that's not ACGME yet, but it's kind of niche a little bit as well, depending on where you do that practice. So, there's a lot of specialization and in fact, and this will relate to our pipeline shortage, so there's not enough neurologists out there, and now because many of us have subspecialized in neurology, there's actually a great need for general neurologists. So I'm interested to get your perspective and your thoughts, because you're on the field, you're seeing our patients with neurological disorders out there, how busy are you? What do you think the landscape is in terms of needing more general neurologists?

Dr Lin: So, to answer that, I think you have to think about, so what do you like? If you're somebody who says, "I really just like one, I want to focus on one thing and that's all I want to see every single day," then private practice probably isn't for you. For private practice, I was really told we see whoever needs help. So there were things that I probably wasn't as comfortable with when I initially started out, that I brushed up on the skills, the knowledge, migraine treatments, movement disorders, those are the things I thought I was weak on. So I just said, "you know what? I'm going to read about it, do a little bit of learning, do some conferences to get comfortable in treating these conditions." But keep in mind, being a general neurologist is kind of like being a primary care [physician]. I can see everything, but when it comes down to a really complicated or someone I'm really having trouble with, I can still refer to the specialty clinics, Hopkins, University of Maryland, around DC there's Georgetown. So I think it's very important to keep all of your skills. If you're somebody who says, "I'm excited by all aspects of neurology, rather than becoming a special specialist." But special specialists are much appreciated from my standpoint, we totally need you.

Dr Salas:

Yeah. Thank you for definitely saying that, I'll represent the subspecialty neurologist for now. And I will say, just to go to plug for a sleep neurologist, I do feel like we get to see a general breadth of patients with neurological disorders, because any neurological disorders, really, is a risk factor for a sleep disorder: patients with epilepsy, patients with migraines, patients with multiple sclerosis, many of them have a lot of sleep issues. So, I definitely can appreciate how a general neurologist, you get to see all the patients that we all went through residency and learned about. I know you're in a very busy practice, so maybe let's go into that a little bit more. What does a typical week look like for you in general neurology practice?

Dr Lin: So because I do EMGs, I do two full days of EMGs, so I see about 12 EMG patients for a full day. We do have technicians that do the nerve conduction tests, so that's the day I can catch up on paperwork, phone calls for prescription refills in between, and the other three days are my full clinical days. So clinical days, I alternate between a new and old patient, and I see about 18 patients a day now.

Dr Salas: That's pretty busy. And do you currently, because I know that there are neurologists out there and certainly as we went through training, it's very typical, just like private practice clinicians, you have your clinic, but then you also go admit your own patients to the hospital and things like that. Do you do any inpatient work?

Dr Lin: So, many years ago when I first joined, we did do that. We would finish clinic and then go over to the hospital and do consults. But over time, hospitalists find that, that particular model doesn't work well, because you have to wait for your neurologist to finish clinic before they come over, so the entire day is wasted waiting for the neurologist to come. So now they all have neurohospitalists that are there full time. So we got out of the hospital business because it was not really an efficient use of our time, and like I said, not for the hospitals either because they have to wait until the neurologists come in after hours to get a plan. So we got out of the hospital business probably seven years ago; I haven't had to do any admitting or hospital work since.

Dr Salas:

Yeah, I think that's very interesting because it's definitely very different from what we saw coming up, which I had mentioned is, what you just said, doing your clinical practice and then running to the hospital, admitting and consulting patients. So yeah, neurohospitalist, yet another specialization for the field of neurology for those out there interested.

So Debbie, tell me, how big is your practice? What does your practice look like? What kind of neurologists are in there and is it all neurology or do you have other specialists involved in your center?

Dr Lin: Right. So my practice has about six locations all throughout the DC Metro area, and each location probably has 3 to 7 neurologists rotating through. Because I've been here a long time, I'm only out of the Rockville location, but some of our partners do travel between two offices. We have sleep specialists, we have a sleep center, we have movement specialists, we have quite a few epilepsy specialists, we have, of course, neuromuscular clinical neurophysiology, and--I'm trying to think if we have anyone doing anything else--I think that's what we do, but we do offer a wide variety of clinical neurophysiology testing. So we do transcranial doppler, ultrasound, EMGs, nerve conductions, EEGs, sleep study, [videonystagmography] VNGs and a big component of our practice is actually neuropsychology. So we see quite a few patients with memory loss, dementia. So we do almost everything, we are like a little mini academic center.

Dr Salas:

Oh, that's interesting. So let's talk a little bit more about the neurocog component. So, does your center also do assessing people if they're able to drive? Because I know that's something that we frequently see when patients are having memory issues, getting, quote unquote, cleared to drive, not that we can clear somebody to drive, but there are programs out there that patients can go and get somewhat of an assessment on whether they should be driving. Anything like that?

Dr Lin: So we don't have a driving evaluation. We send those out to the driving schools around here that they would do that, and then also the motor vehicle center also has a driver fitness test that patients can take, but based on the neuropsychology reports, the neuropsychologist will often make a recommendation based on what they see the patient's performance and say if they feel that the patient either needs evaluation, needs to stop driving, or can probably continue driving with supervision. So they do make those recommendations, but we don't actually do the driving evaluations.

Dr Salas: Okay. So, we talked about the change in your practice and probably the case for many general neurologists and private practice out there, not necessarily having as big of a role or any role now inpatient, are there other changes that have also evolved over the last five to 10 years in terms of how when you first started and how it is now?

Dr Lin: So, when I first joined, many moons ago, 2007, we were doing things such as dictating and then sending the transcript to an outside service and they would transcribe it. So we had paper charts, paper charts with typed notes, that's how we did it initially, and then we evolved into EMR, so electronic medical records. And then we started using dictation systems. And then over time we also got medical assistance, we got scribes, we have physicians assistants. So I think we are growing in our ancillary support for our physicians, it's pretty much what it comes down to, because there is also only so much that one person can do, it's hard to do everything. So we increase efficiency by getting ancillary help. I see that as a good progression and progress to make life a little better and a little easier for the neurologist.