The Neurologist Is In, Episode 6, Part 2: Global Health in Neurology With Dr Deanna Saylor

In this episode Rachel Marie E. Salas, MD, MEd, continues her interview with 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. Dr Saylor shares advice for those with goals of working in global health.

Listen to Part 1: Working in Neurology in Zambia 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. 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, where she is doing it, and just pick her brain a little bit more.

Deanna, thank you so much for coming on and telling us 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, and 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. I've actually been based in Zambia for the past four years. I moved after I received the 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.

Dr Salas:  We'll circle back at the end on your work again. Here you are in Africa, in a setting when we're all trying to find time just to enjoy things in life. What are you doing for fun, or just to get away? What are some of the things that have brought you some joy or happiness?

Tell us a little bit about that. I know that people are often interested in hearing, what we as neurologists, what do we do to disconnect from the hospital when we need to, and reconnect with ourselves and our families?

Dr Saylor:  That's a great question, and the very timely question as this pandemic just lingers and lingers and lingers. For me, I'm in a stage of life with young children. I have a four‑year‑old son and a six‑year‑old daughter. A lot of the past several years has been focused on them and spending time with them.

I always feel like I never have enough time to spend with them, so I'm pretty protective of my weekends, and trying to soak them up while they're still young, watch them learn about the world and enjoy things. Being in Zambia has provided some unique opportunities, especially during the pandemic and stay‑at‑home orders, or trying to stay at home as much as possible.

We've been blessed that the weather in Zambia has been amazing. There's always the opportunity to be outside in our yard. There's some great forests nearby, going on hikes, watching our kids enjoy the giant beetles, different bugs, and things that we can find, the lizards and chameleons that are all around.

We like to travel a lot. While international travel has certainly been curbed in the past couple of years, we've tried to take the opportunity to explore Zambia. Our kids are incredibly spoiled in that they get to go on safari a couple times a year.

We've been visiting the National Parks here and enjoying the amazing wildlife in their natural habitat, sitting in our safari jeeps with lions not too far away, or an elephant blocking our road or in a boat surrounded by hippos, and enjoying nature and wildlife.

For me, nature is a way to ground myself and remind myself of priorities and reconnect with the peace that being in nature brings me and then adding in and watching my kids learn to enjoy it and appreciate it. It's been a real pleasure as well.

Dr Salas:  That's so great. I haven't had the opportunity to go down there and explore, but I'm excited at some point to be able to make it there and definitely do some of the things that you're talking about. That's really great. What a wonderful experience!

As you reflect back, was there any specific program that you did or something in particular? I know you spoke earlier about your experiences as a medical student, which guided you and got your interest into the work that you're doing.

If you were speaking to a medical student, or any student in healthcare, and any training in healthcare that's interested in going down the road of global health and neuro, are there any recommendations that you would have for them that they should be thinking about?

Dr Saylor:  That's a great question. My advice is probably multifaceted. The first thing is to know that there are many different pathways in global health. Oftentimes, I think those pathways change throughout one's career as well.

I always tell people...I'm currently based full‑time in Zambia, I was lucky to have a husband whose job was flexible and who was willing to move abroad, and that made this possible. If that's not possible with your circumstances, then there are definitely ways to be involved in global health in other ways.

You could choose a place where you go once a year to teach or to provide clinical care and allow the sole provider in that hospital maybe to take a vacation. In those situations, establishing relationships where you keep going back year after year helps to build trust and meaning for both you and your host as well.

If you're more academically and research‑oriented, then you can always field collaborations with researchers in international settings. Again, continue to cultivate those collaborations over years. Maybe go to the location a few times a year for a week or two to oversee research or to build those collaborations in person.

Over time, those become meaningful collaborations as well. For my own career, in five or six years I envision that we will go back to the US, but I'll continue these collaborations and building in Zambia. Zambia will always be part of my work, and I'll always spend some part of the year here. At some point, my path will transition from being here full time.

The first advise is that there's lots of ways to do global health, and your path doesn't have to look like my current path. Then, when you're thinking about just getting started, there's two potential ways to get started.

One way is to say that there's a particular country, or a particular region, that you're passionate about, and that you want to return to. Maybe you are someone who is from somewhere in South America, and you want to go back to your home country and build neurology, or build research there.

You can choose the project or the type of work you're doing, based primarily on getting back to that location and building relationships in that location. Another way to approach this, which was more how I approached it, was that I had become interested in neuro‑infectious disease and neuro‑HIV as a medical student.

I looked for global health experiences that were centered around neuro‑HIV, which happened to be primarily in Sub‑Sahara Africa for me. It was my academic interest that determined the locations that I went to. Choosing one of those two paths.

The last part is building relationships. You've heard me talk about that in each part of this advice. It's much more meaningful and impactful to continue to return to the same place, and to build on and strengthen collaborations, and relationships with people over time, than it is to go to place A in year one, and place B in year two, and place C in year three.

Then you're not making a sustainable difference or building equitable partnerships. The last piece of information is to find a place that's a good fit, then continue returning in whatever frequency that fits for you, so that you can build those relationships and partnerships over time.

I said I only had three pieces, but I have a fourth. This is something that I tell all the medical students and residents who approach me about coming to Zambia for opportunities. Oftentimes, people say, "I want to come for a month and I'd like to do a clinical elective, and also do a research project." I always tell them no.

The reason for that is that it takes at least a month, and in actuality longer to get to know a setting, and to understand the needs of the providers and the patients in that setting. It's not realistic to think that you can develop a research project that is meaningful, and impactful, and responds to local needs on the ground when you've never visited the setting before.

The last piece of advice is to go as a learner on your first trip to a location. Go expecting that you may not contribute all that much, but that you're going to soak in and learn as much as possible from your host physicians, and host institution.

Then after you've been there and understand the setting, and understand the problems and the needs facing the patients and the providers, then you can start thinking more about how you can contribute. That added tune of being a learner first and building relationships, will enable all of our global health partnerships to be more equitable.

Dr Salas:  That's really important advice, and thank you for teaching me, because I often have students, not just medical students but health profession students that may be interested in global health, maybe even in neurology, and that's great advice for me to share. Of course, I always try to connect them with you, but that's helpful as a starting point for the discussion.

We often get for our second years that are interested and not sure where to start. I love that idea about starting off as a learner. If you think back, you talked in the beginning about limited resources, having to make adjustments, having to make new guidelines.

With the resources that you have, what are some take‑home points in terms of how you've become a better neurologist by your experiences of first working in the US and getting trained in the US, and then going feet on the ground?

What are some lessons learned or reflections you might want to share with people that might not have had those experiences or may never have those experiences?

Dr Saylor:  That's a great question and an interesting one to think about. The first thing to say is that I'm so grateful for the training that I received. I was lucky to do all of my medical training at Hopkins, from medical school and residency and fellowship.

Was exposed to a wide array of neurological disorders and got to learn from experts in virtually every field. I'm thankful for that.

Another piece of advice, going back to the last question, for people who are interested in global health, they often ask me, "What subspecialty should I go into?" I always tell them that in a place with no neurologist, they need every sub‑specialty, but they also need good general neurologists.

Making sure that you get a solid foundation across all aspects of neurology is really important. Thinking about adapting to clinical practice here, I'm certainly a much better clinical neurologist now than I was when I arrived in Zambia four years ago. It's primarily because we have so few diagnostics to rely on.

We have to be parsimonious with the diagnostics that we do have because patients are paying for every single investigation that you order. It forces you to hone your exam and to hone your clinical reasoning skills.

People often asked me what the biggest differences between practicing in the US and practicing in Zambia, I always end up at the point where I say that in the US, you rarely move forward in uncertainty.

Occasionally, you'll empirically treat someone for something, but for the most part, you can continue testing and continue investigating until you either confirm the diagnosis, or you've rolled out virtually every known diagnosis, and you're trying something to try to help the patient.

Here in Zambia, I always say we rarely proceed in certainty. When a patient comes in with stroke, we're trying to manage them. It may be five or six days before that patient's family can pay for a CT scan. We're making decisions in those first 48 hours not knowing if this is an ischemic or hemorrhagic stroke.

Do we start in anti‑platelet? Do we lower their blood pressure? No, it's your clinical reasoning and your clinical skills that are helping you to make those decisions. You hone that clinical rationale. You think about your differential, you have to rank your differential.

It's a matter of being comfortable with that uncertainty, and confident enough to start an empiric treatment, but also, always thinking through how you're going to monitor that empiric treatment. How are you going to monitor clinical response?

At what point are you going to say, "OK, this empiric treatment doesn't seem to be working. How do I reconsider my diagnosis and treatment approach? Is there additional information I need or can obtain, and then refine my approach?"

That's a completely different skill set than what we're used to practicing with in the US. It makes you think about your approach about what you know, and hone your clinical reasoning skills, which is something that I love about practicing here is that, in all of neurology, patients are like puzzles that you have to put together.

Here, it's you and your brain and your exam, trying to put those puzzles together without a lot of other ancillary information to help you.

Dr Salas:  I just thought when you were talking, that reminded me of obviously, I do sleep medicine, but my first love was neurology. You summed it up very nicely about the clinical reasoning and the puzzle pieces and the physical exam, the neurological exam.

For those that are there listening, many of the neurologists are definitely going to resonate with what you said. That's perfect. Is there anything else that you're working on that's new or that you'd like to share?

Dr Saylor:  One thing that is, again, an unanticipated direction that I'm veering off towards now is a new focus on implementation science. In medical school, I had the opportunity to do a Masters in Health Sciences and Clinical Epidemiology.

All of my work prior to Zambia was focused on more traditional clinical research, but being here in an under‑resourced setting, and in a hospital with fledgling systems of care, I've come to appreciate the importance of well‑functioning and optimized systems of care in improving patient outcomes.

My K Award is focused on leveraging implementation science in order to improve outcomes in patients with stroke.

For people who might not be as familiar with implementation science, which I don't think I was up until a couple of years ago, and then heard the term and realize that it fit, but I was hoping to do. Implementation science says that there are a lot of clinical trials and a lot of evidence‑based guidelines that have been developed from solid, strong clinical research.

The benefits of the research results and of these evidence‑based guidelines are often not realized in clinical practice. There's this implementation gap between how well things work in the clinical research world and the benefits that they have in clinical practice.

Implementation science is focused on, how do you reduce that gap? How can we maximize the benefits from research in real‑world clinical settings? In our setting, that is even more important.

When we don't have the optimal way of providing this evidence‑based intervention, how can we adapt it and still implement it in order to gain as much benefit as possible, even if it's not done in 100 percent, the ideal way?

Now that we've trained excellent neurologists here in Zambia, we've hit a ceiling as far as how much we can improve patient outcomes by having better‑trained doctors and having neurology specialists available.

If we're going to continue to make gains in patient outcomes, it's about figuring out how to optimize these systems of care, how to introduce these evidence‑based interventions in a way that is generalizable in our setting and monitor whether or not they're having the impact that we think they should.

If not, what are the barriers to allowing them to have a greater impact? I'm excited about learning the tools of implementation science in shifting my research focus to implementation and adaptation of guidelines, and using those tools to improve patient outcomes here.

Dr Salas:  There you have it. I certainly learned a lot. Dr Saylor is doing amazing work in all realms of academic medicine and in neurology. I want to thank you. I don't think we say thank you enough for all that you do for your patients, for the next generation of clinicians. I love that you're focused now on implementation science.

For me, that brings in that interprofessional healthcare team approach. That's where we need to be. Just tremendous work. It's always great catching up with you learning about the amazing things you're doing.

You're going to go on to continue to inspire not only future neurologists, but neurologists that are really dedicated to reaching and bring neurological care to people all over the world. Thank you so much, Deanna.

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

Dr Salas:  For those interested in learning more about the work Dr Saylor's doing, we will have her bio posted. Feel free to reach out. Dr Saylor is very involved at the national and global levels in leadership with some of the neurological societies and is doing some great work there.

It's always easy to contact and learn more about the work she's doing and what opportunities are available. Thank you so much. We'll see you next time.