Dr. Danielle Pier: Pediatric Neurologist

Join me and Dr. Pier, a pediatric neurologist working at Mass General in an outpatient clinic setting! Dr. Pier and I talk about what led her to a commonly unknown specialty and what she enjoys about her work on the day-to-day. We talk about deciding to work with kids or adults, research or no research, and sub-specializing in pediatric fields. 

Transcript

SPEAKER_00 0:02

All right. So welcome back to In Practice. Today I have another wonderful guest here with me. I have a pediatric neurologist, which is a new specialty for us. And so I wanted to welcome Dr. Peer here with me. Dr. Peer, if you could just like introduce yourself and maybe talk a little bit about where you're working and what you're doing.

SPEAKER_01 0:23

Yeah, thanks for having me. So I do pediatric neurology at the Mass General Hospital in Boston. And currently I see patients three full days a week. And then I have admin time the other two days where I'm doing a variety of teaching, coaching, some admin stuff, you know, common doctors, things like that. And then three weeks a year, I do an inpatient uh block where I am seeing patients in the hospital versus like in a clinic.

SPEAKER_00 0:52

Nice. Awesome. Tell me a little bit about how you landed in pediatric neurology and what sort of brought you there.

SPEAKER_01 1:01

I am so glad I found it. It is not a widely known specialty. I don't think that all medical schools necessarily offer it as a early rotation. And some folks sort of mistakenly think that they can choose it after doing like a general pediatrics residency. And while you can, the more traditional route is to actually apply to it from medical school as its own residency program because we do a combined program. So I didn't know about it going into medical school. I actually thought I would maybe like do neonatology because I really liked babies and I done some um some shadowing in NICUs when I was in high school and um and college. But I always knew I was going to do pediatrics. And then I ended up just doing a research project between my second and third year of medical school. Um I think that's fallen out of favor, but at the time it was very popular to do what's called a fifth year of like a research project to sort of bolster your um CV going into residency. And I ended up signing up with a high-risk obstetric radiologist who was doing fetal brain MRI research. And super cool. Um I did a year of research with her, it was lovely. And at the end, I actually then was trying to decide between like general pediatrics, pediatric radiology, and pediatric neurology. Okay. And ultimately decided that I thought neurology was going to be a good fit for me. I liked seeing patients being in front of them. I liked having a specialty and feeling like I could help patients with less common pediatric problems. I really liked the neurology exam. I thought it was really fun. And you have to kind of modify it for little kids who are less cooperative. Um, you know, that being said, I do think I would have ended up being pretty happy in other specialties. I don't necessarily believe there's like one perfect field for everyone, but generally I'm quite happy with it. I think it's a really fun specialty for kids, for people who like kids, um, find the brain interesting, um, and enjoy um, you know, getting to like change up the exam based on how the person is tolerating the exam.

SPEAKER_00 2:52

Yeah. Yeah. Um, so interestingly, you you mentioned that you didn't, well, maybe you did want to do general pediatrics, but decided that neurology would be more interesting. Sort of what what what led you away from just doing general PEDs and instead wanting to subspecialize?

SPEAKER_01 3:09

Yeah, there wasn't anything wrong with pediatrics. Um, I think my my draw towards neurology was um I really liked neuroanatomy. It was actually my favorite course in medical school, which was surprising because I majored in chemistry. So I didn't do a lot of neurobiology in college. Um, and so I got to medical school and I was like, this is really cool. Like I found, I just for whatever reason, I found braid anatomy fascinating and interesting to learn. Um, and then I really liked the neurology exam. I thought it was really fun, really clever. Um, you got to test different pathways in the brain while kind of for kids making it fun and like a game. Um, and I just enjoyed that. And while I certainly enjoyed the general pediatric exam, I think I just I enjoyed the neurology piece a bit more. And I was more intellectually interested in neurological problems than general pediatric problems. So I think that's and ultimately why I lean towards neurology.

SPEAKER_00 3:58

And then pediatric psychiatry is also sort of a related but different field. What is it about neurology versus psychiatry that made you lean neurology? Is there something that made you never consider psychiatry at all? Um, anything like that?

SPEAKER_01 4:15

I don't think I considered psychiatry mostly because that is a talking job. Um, there's less exit. Yeah. I mean, I do think there are some psychiatrists who do a physical exam, but it's not um, you know, considered standard. I think most psychiatrists are doing more of a questionnaire type or a conversation type visit. And um, and the exam I thought was really fun. Um, I also, you know, psychiatry is interesting, but it does share a big overlap with psychology. And so, you know, I I had sort of this, and I don't know that this is accurate, but I had this sort of um thinking of like psychiatry, there's more about like finding medications to help people feel better. And then in psychology, there's more like techniques to help people feel better. And I thought with neurology, it's it's maybe a little bit of both. Like I'm I'm doing quite a bit of medication management for some of my patients, and then a lot of times I'm giving them like lifestyle tips and techniques and um helping them navigate, you know, school with their condition and things like that. So I think that probably appealed to me a little bit more. Um, yeah. Yeah, that makes sense.

SPEAKER_00 5:15

Um, they are, I think they're sometimes psychiatry and neurology for people outside of medicine are a little bit conflated, but I think inside medicine they're very different and they're like the practice of them is very different.

SPEAKER_01 5:26

And we certainly share a lot of patients. I have a lot of patients who see psychiatry for related conditions, and certainly having a chronic neurological condition can cause psychiatric, secondary psychiatric issues. So certainly there's a big overlap, but we do have sort of distinct roles in medicine.

SPEAKER_00 5:39

Yeah. And then it seems like you were pretty set on something pediatric from the beginning. Um, I'm curious when you knew you wanted to work with kids in medicine and like how you knew you wanted to work with kids and not adults.

SPEAKER_01 5:55

Yeah, I I came in to I I've always really enjoyed children and and and and just like pretty early on knew that I would probably end up having a career with children, something geared towards kids. So it wasn't that I necessarily didn't like adult medicine. Um, I just sort of have always enjoyed working with children a lot. Um, and then I it, you know, this is interesting. I think I might have said this to you offline, but um, a lot of people will like hear what I do and be like, wow, there must be some really sad cases. And like that's true of all medical specialties. There's always sad cases in every aspect of medicine. But I generally was not super sad by my experiences, even with the occasional sad case, which of course you're sad, but as an as a sort of like gestalt big picture, like most of my kids are doing awesome and I'm helping them and they're feeling better and I'm curing some patients, right? So it there's a lot of joy and like personal career satisfaction that comes into my career. And there are other careers that I personally found um like intellectually less interesting, but also like physically, I didn't think I could handle, like I couldn't handle surgery or like ophthalmology. Like I think vision's great, but I don't want to touch an eyeball. And like thank goodness there are other physicians who find those things fascinating and want to do them because otherwise there would be, you know, gaps in medicine. Right. Um, you know, somebody likes spending 12 hours a day doing neurosurgery on a spine, and other people like doing complicated, you know, touching eyeballs and things like that. So I think a lot of it is like deciding what like is is something you like, and then also realizing like, oh, maybe this is not the thing for me because I'm a little either like sad about it or maybe it's like a little gross to me, you know, things like that. You sort of end up peeling away the the onion layers of of possibilities until you get to a couple of smaller options that make more sense for like who you are and what you like.

SPEAKER_00 7:48

Yeah. Um, and then just tactically, if you could talk a little bit about, I know you and I have talked about this previously, but if you could talk a little bit about what the path is like, I uh obviously there's four years of medical school, and then for pediatric neurology, what was the residency and fellowship like for you?

SPEAKER_01 8:03

Yeah. So the fastest way to apply to be a pediatric neurologist is to apply straight out of med school because you end up doing it a combined residency where you do two years of pediatrics and then three years of neurology, um, about a third of which is actually adult neurology, and two-thirds is pediatric neurology. Um, and part of that is because adult neurology, there's a lot more um abnormal pathology and like things that you you need to know to be able to recognize them in pediatrics. But like, for example, strokes. Kids do have strokes, but to see and recognize a stroke in a child, if you spend a couple months look like taking care of adult stroke patients, you get much better at that. So that's part of that is that's part of the reason the adult neurology piece is in our training, and then it is on our boards as well. So I believe after five years of this combined residency, we are board certified to take care of both adults and children. So it does give you a bit of flexibility. Like if you have a rare disease that you'd like to follow and you would like to follow those children into adulthood, you don't necessarily have to like sign them over to adult neurology when they're like 18. Yeah. So that's the traditional pathway. There's lots of other ways to do it. There's a research pathway where, if, like, for example, you're an MD PhD and you're doing a research and you don't want to give it up, you can do instead of two years of pediatrics, you can do a year of pediatrics and a year of research, and then your three years of neurology. And the only difference there is that if you do the traditional five years of two pediatrics, three neurology, um, you at the end are eligible to be board certified in both neurology and general pediatrics. And there are folks that want to do that.

SPEAKER_00 9:34

Yeah.

SPEAKER_01 9:34

Generally in large hospitals, like in Boston, I think in the big cities, most pediatric neurologists are not bothering to get certified in pediatrics because they're just not using it. And you do have to pay quite a bit of money to keep up certifications and licenses and stuff. So generally, most folks I know, even if they were board eligible to sit for a pediatrics boards, just certified in PD neuro and only see neurology type patients. Um, so if you do the research year where you do one year PEDs, one year research, three years neuro, you are not board eligible for pediatrics, only pediatric neurology. Um and then there are folks who find neurology late, find pediatric neurology late. So they do a full traditional three-year pediatric neurology residency. So that is three years instead of two, and then they're applying sort of off-cycle for their three years of neuro at the end. And the only reason that's less desirable is that it's a six-year residency instead of five. You might be doing it in different cities because you might not match in the same city that you matched for pediatrics, but that is also very acceptable and generally fine.

SPEAKER_00 10:35

So is there no situation in which you would do like a pediatrics residency the three years and then sort of like a pediatric neurology subspecialty fellowship? Is that because a lot of, you know, like with things like cardiology endocrinology, like that's sort of how it works. You do internal medicine and then you do like a cardio fellowship. Um, is that not something that's super typical for PD Neuro?

SPEAKER_01 10:57

Yes. Right now it does not exist in a traditional like ACGME sitting for a boards situation. I believe if you, unless you do at least three years of neurology as part of a neurology, either adult or pediatric neurology residency, um, uh residency, not fellowship, I don't believe your board is eligible to sit for the neurology boards, even adult or PES. There are other pathways. Um, the ones I can think of most common is there are folks who do a traditional three-year pediatrics residency and then do a PICU fellowship, like a pediatric and care fellowship. And as part of that PICU fellowship, they're doing like a neurointensivist um like type of fellowship. That I don't think that's its own separate boards, though. I think they would still sit for a PICU board specialty. Um, but those are folks who are mostly doing, in that case, neurology care in the PICU. Yeah. Um, and that is certainly possible. You're just not gonna end up seeing patients in a neurology clinic per se. That would be sort of its own pathway.

SPEAKER_00 11:58

And then I do believe you did a uh neonatology fellowship or something like that to explore that interest that you had. If you want to talk a little bit about that and what that was like.

SPEAKER_01 12:10

I've always really liked the NICU and I thought NICU medicine was fascinating. And when I was trying to decide between pursuing neonatology and pediatric neurology, ultimately neurology won out just in terms of my interest, but I never gave up my interest in NICU care. And so I did a neonatal neurology fellowship. Um it's actually the full name is a fetal and neonatal neurology fellowship. So taking care of people very young people, you know, under three months old before and after birth who have neurological um conditions or disorders. And that is not an ACGME accredited fellowship. I do believe that's coming in the works and soon. Um right now there's not like a neonatal neurology boards that you can sit for. So it's a little bit of a um, and there's a lot of this in pediatric neurology, like say you want to you're you do a your five-year neurology pediatric neurology residency, and then you do a fellowship in neurogenetics, or you do a fellowship in pediatric movement disorders. The their choices there is you can you can do an adult fellowship where they kind of work pediatric cases in, or you can do a pediatric only fellowship that's just kind of you craft it with your with your mentors and your team. Um, so when I was applying for fetal neuro fetal and neonadult neurology fellowships, there were only a couple in the country and most of them were not funded. And so I I used uh it's called an R25 grant. It's an NIH grant for medical uh medical residents in their last year and the first year after residency to basically fund a fellowship. So I was able to use the R25 to do, I was doing fetal neurology research and it's kind of getting it that way. But I do think since I've graduated, there's a bunch more fetal neonatal neurology fellowships that have come out as sort of sort of formalized funding fellowships that you would apply for as a more traditional route and not necessarily need external funding or NIH grants or anything like that to make it happen. So I do think it's getting better and it's getting more formalized. And eventually there might be neonatal neurology boards that you could sit for and get certified for uh officially.

SPEAKER_00 14:06

Yeah. And then it it's allowed you to see sort of a wider age range of patients, I assume.

SPEAKER_01 14:13

Yeah, I think um if you want to subspecialize in an already limited specialty, you have two career choices generally, and not there, of course, there's many, but there's the two most common career choices for folks like me who went through my type of training is one, if you just want to see neonatal neurology patients or fetal and neonatal neurology patients, even in a big city like Boston, um, you are likely at most seeing like maybe one full day of clinic patients in that category. And then the rest of your time, um, you're either filling it with research or seeing general neurology patients. Uh they're just thankfully, because babies are generally resilient and relatively healthy, there just aren't enough sick babies with neurological problems that you would need to see full-time, like five days a week or even three days a week, which is what I do. So um I tried research. It wasn't for me. I'm thankful that other people like research because it needs to be done. But at a fellowship, I was able to get this position where I'm a clinician educator. That's the sort of category of it. Okay, mit. Um, and then I'm so while I am seeing general neurology patients, I am known for having this specialty in fetal and neonatal neurology. And so a lot of the PCPs, as they get to know me, will send me the babies that they're concerned about. Um, our admins know if somebody calls and is like, who do you recommend for a two-year-old, right? They might um point them towards me, or there's a couple others who have a neonatal interest. Um, and then there's a few that don't have a neonatal interest and they'd much rather see some, you know, adolescents. And so it's a little bit more of an informal approach in our in our hospital. Um, whereas at other hospitals, there is like a neonatal neurology clinic, and all the NICU graduates go there who have neurology needs. Um yeah, so there's lots of ways to do it. The other thing I do is I do a monthly neonatal stroke clinic, um, which is uh enough of a subspecialty, you know, it's it happens commonly enough that I can fill a one-month clinic. There's actually other two other folks in our division who do that. Um, and that has worked out well to be able to supply a clinic for a sub special a sub-subspecialty, but with like high needs. And so these children um are often meeting with me as well as a pediatric physique and a um pediatric hematologist. Um, and that I think is a nice way to like bundle in some post-stroke care for an infant.

SPEAKER_00 16:35

Yeah. Well, that's super cool. All the all the different stuff that you're involved in. Um you you also mentioned you do three weeks of inpatient um like hospital. That's just um sort of a what what is why? Why, I guess is the question.

SPEAKER_01 16:52

Most academic hospitals have a clinic, so the outpatients, and then they have an inpatient where the patients who need to be hospitalized are staying overnight. Right. And um there's various ways to do this. Um, some hospitals, mostly freestanding children's hospitals, will have their own neurology floor where if you have a primary neurological issue, you're on that floor being cared for by neurologists. Um at our hospital, we have a um uh clinic, uh, sorry, we have a um just give me a sec, sorry. Sorry. Um our hospital we have a um consult-based service. So our um clinic is um based in on one floor, and then on a different floor of the hospital where the pediatric patients are hospitalized, we'll go and do consults just on the folks that need neurology care. So it's a just a different way set up um of a very sort of similar um need. But you know, generally seeing patients who are in the hospital, it can be tiring. And also at night we're often up taking phone calls from the hospital overnight issues. And so we just break it up. We all take turns doing a week. It's kind of like I think of like a night watch or you know, century, like you just take shifts. So um, you know, when I first started in the teens, um, some folks were doing like two straight weeks twice a year. There was a couple old timers who were doing like a full month straight. Um, but I think just with our busy schedules and the acuity generally has gone up over the last decade. Um, most of us are now taking a week of call and breaking it up over the year just so that we don't get too tired or too behind sleep.

SPEAKER_00 18:38

Um, and then my last question would be why you or how you decided research wasn't for you and wasn't something that you wanted to do um after, you know, medical school and residency.

SPEAKER_01 18:50

Yeah. Um, you know, research was super important and and it's definitely needed. Um, I think for me, I'd had a couple of research experiences where um it I don't think I the the draw for the question I was asking was um like the intellectual draw while it was there, it didn't really overpower the joy I was getting from like the day-to-day problems of clinic. Right. So that a lot of a lot of neonatal neurology questions are what happens in 15 or 20 years after we do something, or even what happens in four or five years. And so I would ask this question, and then you just need this huge patience and teamwork and infrastructure to to follow these infants as they grow into kids and teenagers to ask these really difficult questions. And I sort of didn't have the patience for it.

SPEAKER_00 19:41

Yeah.

SPEAKER_01 19:41

Um and I I just yeah, I really I think I I got a lot more career satisfaction out of seeing patients and like seeing them back in three to six months and seeing things get better, or if not, yeah, trying to shoot in the moment. And so that just that was more satisfying to me. But I, you know, I have colleagues who just have these really burning important research questions, and to them, the the the wait is worth it. And so they are putting in a ton of time and effort to build a team who can follow people for you know a decade or more to find out the answers to their questions. And I'm so glad somebody has the patience for that because it need these questions need to be asked. It's just very, very hard to do it.

SPEAKER_00 20:18

Yeah. Makes sense. Well, thank you so much for your time. I know you have lots of meetings today um as part of admin work twice a week. Um, so I will let you get back to it. But it was so great to to hear about sort of your journey and what you do um in PD Neuro. It's it's a really, really interesting field.

SPEAKER_01 20:36

Thank you so much. Yeah, please spread the word. We need more pediatric neurologists and people don't always know about it. So any questions can come up. Yeah, of course. All right, thank you so much. Take care, thank you.