The Neurologist Is In, Episode 8, Part 1: Discussing Neuro-Oncology With Dr Nimish Mohile

In this episode, Rachel Marie E. Salas, MD, MEd, interviews Nimish Mohile, MD, MS, FAAN, about his path to neuro-oncology, how telemedicine is shaping patient care, and Dr Mohile's experience in the Transforming Leaders Program within the American Academy of Neurology (AAN).

Listen to Part 2: Diversity Training in Neuro-Oncology With Dr Nimish Mohile now!

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.

Nimish Mohile, MD, MS, FAAN is a Professor of Neurology and Oncology at the University of Rochester, where he holds the Ann Aresty Camhi Professorship. He serves as the Associate Chair for Career Development and Leadership, Neuro-oncology Division Chief and Leader of the Neuro-oncology service line. Dr. Mohile completed his residency training at Northwestern University, followed by a fellowship in neuro-oncology at Memorial Sloan-Kettering Cancer Center. In 2007, he joined the neurology department at the University of Rochester where he built and fostered the neuro-oncology division and multi-disciplinary brain tumor program. His research focuses on developing and testing therapeutic and supportive care interventions to improve and extend the lives of patients with malignant gliomas. He is a UCNS fellowship program director, serves on the UCNS Certification committee, chairs the American Society for Clinical Oncology Glioma Guidelines Panel and is currently the Chair-elect of the AAN section for Neuro-oncology. As an Associate Chair for Career Development and Leadership, he has spearheaded innovative programs that emphasize personal values, identity and reflective work in the professional development of faculty, administrative staff, advanced practice providers and residents. He also directs departmental leadership programs for residents and faculty to develop leadership skills, implement change and develop resilient teams. At the AAN, he serves as the Physician Lead for the Transforming Leaders Program.

Dr. Mohile aspires to help organizations transform into multicultural, antiracist and equitable entities. He is an advocate for incorporating principles of inclusion, diversity, equity, antiracism and social justice into the profession of neurology. At the University of Rochester, he serves as a departmental diversity officer. He is a member of the NINDS Health Disparities workforce development and diversity panel. At the AAN, he chairs the Diversity Officer’s Subcommittee and is chair of the AAN Anti-racism Curriculum Work Group in addition to being a member of the IDEAS subcommittee and a member of the AAN Special Commission for Racism, Inequity and Social Justice.

Read the Transcript:

Dr Rachel Salas: All right. Welcome back, everyone. This is "The Neurologist Is In." I'm Dr Rachel Salas. I'm a sleep neurologist at Johns Hopkins Medicine. I have the absolute pleasure of having an interview with Dr Mohile. I'm going to have him introduce himself, Dr Mohile.

Dr Nimish Mohile: Hi, Rachel. Thanks for having me today. I'm Nimish Mohile. I am a neuro-oncologist at the University of Rochester. I've been here for about 15 years, where I run the Brain Tumor Program. I have a couple of other roles in neurology at the University of Rochester. I'm the associate chair for Career Development and Leadership. In that role, we work on staff and faculty career development and promotions.

Then I also serve as a diversity officer in our department. I work with other departmental diversity officers here to implement some of our DI roles and our anti-racist missions.

Dr Salas: Fabulous. I definitely want to make sure that we have some time to talk about that because it's very unique. Not a lot of neurologists are doing work in that area, which is very important, not only for our field but for our patients. Let's get started to hear a little bit more about your clinical work.

Let's start off with, how do you become a neuro-oncologist? What got you started? What got you interested in this?

Dr Mohile: I didn't even know that neuro-oncology existed when I was in medical school and even as I started out residency. I had always enjoyed neuroscience in medical school. Everything I did there kept taking me back to neurology. One of the things that I was really fascinated by in medical school was also cancer and pathology.

Then, when I was an intern in medicine, I remember admitting a patient to the hospital who had a new diagnosis of a brain tumor, and having that conversation with him and his wife. I remember thinking that that was something that I wanted to be part of.

I started looking into it and realized that at the time there were a handful of fellowships around the country where you could do neuro-oncology after neurology training, and I started pursuing that. I was lucky enough to be in a residency where we had some neuro-oncologists at the time. It wasn't very common. I got exposure during residency and then did a fellowship.

The field has pretty much exploded since then and so there's probably around 30 UCNS certified fellowships in neuro-oncology right now. The most common path for that is doing a residency in neurology, and then a one to three-year fellowship in neuro-oncology at one of these places.

For folks who are in child neurology, they can do that path but some of the pediatric neuro-oncologists are also in a path where they started out in pediatrics and did pediatrics hematology-oncology.

Dr Salas: I'm curious, and I've been wanting to ask this question for a long time. What if you did internal medicine oncology, could you then go and do neuro-oncology?

Dr Mohile: Yes, you can. You can do that officially through being certified through the UCNS. That is a pathway that's allowed for the UCNS. There are many medical oncologists who have done that and have decided to then focus in brain tumors.

You don't have to have a UCNS certification for that, you'll be boarded in hem-onc, and you can do that. The challenge with that pathway is that brain tumors are pretty uncommon. You'll easily go through a medical oncology fellowship and not see a lot of brain tumors and get that expertise.

The other challenge in that and one of the reasons that neuro-oncology was built up as a field is that these patients have so many neurologic issues. You have to have a comfort level with the brain, with reading images which we spent a lot of time looking at our own MRIs. You have to have a comfort level with epilepsy.

Then dealing with a lot of those issues that neurologic patients have -- hemiparesis, aphasia, headaches. We see the whole gamut of neurologic symptoms. There are people who do that and you can try and get some of that neurologic exposure during that time, but it's not as common of a path anymore.

Dr Salas: I see. That makes sense. It's just something I've always wondered. Tell me, sometimes there may be some learners like medical students, maybe even some residents listening in on this and I'd like to show.

What is a typical week look like for you? An academic neuro-oncologist doing all the fabulous things you're doing, but what does it look like for you?

Dr Mohile: For me, I typically am in clinic about two days per week and my clinical practice covers the breadth of neuro-oncology. The core of that is primary brain tumors. Most commonly, we'll be seeing patients with gliomas during that portion of that. In that care, we're their primary physician and coordinate all of their care with neurosurgery and radiation oncology.

We create some intense relationships with patients when we're taking care of them with their brain tumors. A lot of neurology there, a lot of oncology, a lot of medicine, and a lot of palliative care in that type of practice.

The other things we see are neurologic complications of cancer. There you're functioning as a neurologist for cancer patients and trying to understand whether this is a neurologic disorder. Is it something related to their cancer, direct or remote effects of their cancer, or is it something related to some of the treatments that they've gotten for their cancer?

In this, you're doing classic neurology where you're localizing lesions and figuring out which parts of the nervous system are involved. Then you're also understanding some of the newer

therapies that are going out, that are causing some interesting and unique complications related to cancer.

The third main area of this is brain metastases. Today, you can devote an entire career to CNS metastases taking care of patients with brain and leptomeningeal metastases from systemic cancers. This has a lot of neurology, oncology, and a lot of therapeutics, as there are increasing oncology therapeutics that are working in the brain.

Those are the three classic pillars of neuro-oncology. I'd say the fourth area that's become interesting for a lot of people, and people are focusing their entire careers on are the neurocutaneous syndromes. These are disorders like neurofibromatosis type 1, neurofibromatosis type 2, tuberous sclerosis, schwannomatosis.

The reason that neural-onc is taking care of them in adults is that they have tumors associated with them. They are cancer predisposition syndrome so they can develop other kinds of cancers. There's some role in screening for them. A lot of the therapeutics for them are similar to oncology therapeutics, having some comfort level with those therapeutics matters.

These are pretty prevalent diseases. Some of them are like neurofibromatosis type 1 is a prevalent disease. You can build an entire practice around something like this.

Dr Salas: Wow. It seems so much. The field is just like you said, it's blossom, for sure. I could quickly think of several other neuro-oncologists that I know. There's some very important work. I'm curious if you'd share with the audience, what's new in the field? Start talking about some of the research that you do.

Dr Mohile: In primary brain tumors, there's a couple of shifts going on. One of the key shifts is emerging therapeutics in primary brain tumors. If you go back when I started training, there was not a single FDA-approved drug for gliomas, and even the role of chemotherapy was really in question.

Over about the past 15 years, we're seeing mounting evidence for chemotherapy across different types of gliomas. In some of these, particularly in lower-grade gliomas and in oligodendrogliomas, we're seeing them significantly impact survival to the point that patients are living decades and decades from these tumors.

One of the areas of interest is how do we optimize those therapeutics? How do we develop new therapeutics? How do we do that while also preserving quality of life for patients? Another area that has been interesting is understanding how we think about and classify brain tumors.

Traditionally, that was something that was based on what a pathologist saw under the microscope. Today, it's increasingly based on molecular genetics. The most recent classification system that came out this past year in 2021, is one that's very much dependent on what the genetics of the brain tumors are.

That has potential ramifications for targeting therapies, but allows us also better understand prognosis, and how to best classify these tumors and think about them. The other areas that I've become more interested in when I started my career, I was most interested in therapeutics. I have become more interested lately in how we deliver care to our patients.

I work in Rochester, New York and people don't often know the geography of that, but we are serving them in the middle of a very large state. We have a very large rural catchment area and many of my patients would live three or four hours away from the University of Rochester.

What can we do to better deliver really specialized care of patients in these rural communities, who already don't have great access to tertiary care hospitals or even the primary care physicians sometimes.

We've been interested in figuring out how to use telemedicine for this, how to better improve access to palliative care for patients in these communities, how to be more creative in how we deliver care so that we can get everyone to have that same standard of care that you'd expect by a major teaching hospital.

The other area of this is now starting to understand what might be the disparities in care, also based on race, in patients with brain tumors. We don't have a lot of great data on that, but we do in other cancers and we do in neurologic disease.

It's a fair assumption that we probably have pretty significant disparities. I wouldn't be surprised if they're even more significant than in some other diseases just because brain tumor care has been so specialized for so many years.

Dr Salas: Sounds like a lot of important work that really...I'm seeing the thread here of how your clinical work and now your clinical research is trying to thread with health disparities, which is fantastic. I can't think of anyone else that's doing that work, although I don't know everybody in neuro-oncology, but I suspect you're probably the leader in this.

Dr Mohile: There is a growing number of people, I think, who are really have become interested in both the quality of life aspects of our patients with brain tumors but then access to care, and just really thinking about it...Here it's access to all these specialized elements of care, like a neurosurgeon who has a lot of experience of brain tumors, radiation facilities that have the most up-to-date technology.

Pathologists who can do the newest genetic sequencing and testing, and then neuro-oncologist who have a lot of experience in taking care of these tumors.

It's complicated to figure out how to get that access when we don't have a lot of these centers, particularly in the middle of the country, in rural areas and then, due to insurance and health inequity reasons even in big cities, where we have these centers, some parts of those cities don't have great access to them.

We're having a greater understanding of this and more interest in figuring some of this out.

Dr Salas: Right now in your clinical practice, do you have a telemedicine clinic? Is that just temporary for you or is it here to stay?

Dr Mohile: That's an interesting question. We have been trying to build a telemedicine in our clinic probably for about 10 years. Our physician assistant Jennifer Serventi has been passionate about this and did a capstone project on this probably around 10 years ago.

In New York State Law, prior to the pandemic, you could only do telemedicine if you were going into another clinic, so that patient had to go into a primary care's clinic or someone else's clinic in an underserved region of the state and then we could do an tele-appointment with them.

That became complicated because no one have space in their clinics, they don't have extra rooms sitting around. It got rid of the benefit of the convenience of telemedicine. Then the pandemic hit, so then suddenly we were able to transition because the laws changed and we had a large telemedicine clinic at the beginning of the pandemic.

We have continued that and because our patients are so far away, particularly for follow-up appointments, it's become a important part of our care. Neuro-oncology works very well because our patients will get local MRIs. Once they are established patients with us, that neurologic exam is not as critical.

We can follow their MRIs, we look at their labs, we can do most of the visit pretty successfully on telemedicine. It's hopefully here to stay and an important part of how we can access more distant and rural communities.

Dr Salas: I couldn't agree with you more. Certain colleagues, our fellow neurologists that require movement or epilepsy, the neuromuscular that rely on the physical exam and neurological exam, but other specialties like neuro-onc, and for me, tele-sleep lands you to telehealth. I haven't seen a patient in person, since even a month before the pandemic because we were already preparing.

It's great. I even have insight on the sleep environment sometimes of my patients because they are calling me from their bedroom or in their house. When it comes to circadian rhythms and things like that, I actually can do I think sometimes even a better job by doing the telehealth visit.

I agree with you with access at a big academic institution like you're at. We have patients coming from all over, not only from the state but from even outside the United States. It makes sense for there to be a global medical license so that we're not doing state to state, because at the end of the day, we're not reaching the patients that we need to reach.

I don't know what your thoughts are, but I'm hoping when this crazy pandemic finishes and where we're at, that some of these telehealth regulations are changed.

Dr Mohile: Absolutely. We've seen so many other benefits beyond just the convenience for patients to be able to do this from their home. You do get a window into their homes and

what's going on. We have a patient who has three daughters in three different continents. They are all able to participate on a single appointment with us and be completely engaged in their father's care.

One of the things that we started as the pandemic hit, was we were starting to do formalized advanced care planning visits in our clinic and those were going to be in-person. There's a challenge with that because you need a room to see that patient. It takes a long time.

Patients have to come in for an extra visit. We ended up switching that to tele-visits. We weren't sure how that was going to go and it ended up being so much better than the in-person visit because you're having this complicated conversations with patients about their potential end of life. They're in their comfort zone because they're at home. They're sitting on their couch.

You can get all of the family members that are important to them on that same visit and be as fully engaged in that visit. We're meeting kids, grandkids, nieces, friends who might live in different parts of the country, who that patient really relies on for advice and their care.

We're meeting them much earlier in the course of their disease. That's been really valuable for us to learn more about the patient and to help them in figuring out what their goals are in life.

Dr Salas: That's really great. I bring this up, I feel like in almost every episode of these podcasts, which is what I think you give a great example of. What that is, is personomics. Precision medicine is all about doing what you're saying. The genetics, your new classification for the neuro tumors and what not.

Using those biological features and traits to better recommend treatment strategies for the patient, but at the end of the day, talking with their support systems, seeing their environments they're in. It's like the new doctor's home visit for today. This is allowing physicians to get back and do those home visits, really connect, really understand the patient, and meet them where they are.

This is a fabulous example of personomics. I always have to give credit where it's due. Dr Roy Ziegelstein is our Vice Dean for Education, he's a cardiologist. He coined this term because it's so important.

You could have the most fabulous treatment strategy based on evidence and research, but, at the end of the day, if the patient doesn't have the resources to go get that treatment, or their family member or their friend said, "No, don't go get that because I know another friend that did that and it didn't work for them," then they may not do it.

Dr Mohile: Right.

Dr Salas: This is great. I'm hoping that you're going to maybe write something up about the work that you're doing and how because I don't think I've thought about what you just said

about having these challenging, sometimes difficult conversations not only with the patient but with their family members.

What telehealth has allowed you to do. I hadn't thought about bringing the family. When I see people on telehealth, it's usually their spouse or family member that happens to be with them. I've never had to bring in people from outside the house. It's really fascinating. I think an important point to make.

Dr Mohile: Yeah, we have a medical student who is going to be writing up our qualitative experiences with this. With patients and their caregivers, interviewing them to hear how they felt about these visits, did doing it on video interfere? Was that a challenge to have an end-of-life discussion on video?

Then she's also going to interview all our providers and talk to them about how they felt about the visit. Anecdotally, I will say all of our providers feel this has been just great, and a really important service to our patients.

Then we're also doing this as part of a prospective clinical trial. We're doing it in a very rigorous way where we're then measuring some of the end-of-life outcomes to see if it improves our documentation of advanced care directives, and improves access to things like hospice closer to the end of life.