A Strengths-Based Approach to Medical Education & Patient Care - Dr. Rachel Salas, Professor of Neurology at Johns Hopkins University

Shiv Gaglani: Hi, I'm Shiv Gaglani and today on Raise the Line, I'm happy to welcome Dr. Rachel Salas, a professor in the Department of Neurology at the Johns Hopkins School of Medicine, with a joint appointment in the School of Nursing. She's also the director for Ambulatory Sleep Services and assistant medical director at the Johns Hopkins Center for Sleep and Wellness. 

Other leadership activities include being the former director of Interprofessional Education and Collaborative Practice for the School of Medicine and director of the Neurology Clerkship.

She's also a past chair of the American Academy of Neurology Consortium of Clerkship Directors. 

Dr. Salas is a certified strength and life coach and uses a strength-based approach and coaching to connect to, support and develop those involved with her educational mission and clinical practice. 

I first had the opportunity to learn from Dr. Salas about a decade ago -- the first time I was in med school at Johns Hopkins -- and I'm looking forward to speaking with her about what it takes to be successful in the Neurology Clerkship and beyond into practice.

So, Dr. Salas, it's great to reconnect. Thanks for taking the time.

Dr. Rachel Salas: Yeah, thanks for having me. I'm happy to connect and talk about med school.

Shiv: So, obviously I know a bit more about your background than our listeners right now. So we like to ask our guests to, in their own words, tell us what got them interested in a career in medicine and then, in your case, neurology.

Dr. Salas: I don't think I was interested in medicine growing up as a kid. I didn't have any family members or close friends of the family that were in healthcare. But in middle school, I remember a group of high school students from a magnet school in San Antonio came to tell us about their high school -- which was Health Careers High School -- and it was a program that you had to apply for. So, I applied and, in that school, I really got exposed to physicians, nurses, medical technologists, physical therapists...just the whole gamut and that's the first time where I thought, you know what, I think I really like healthcare and I'm not sure what I want to be, but I know that I want to be involved in healthcare. So, that was kind of the early start.

Shiv: Yes, that's great. Those pipeline programs or those early exposures seem to be a common thread among many of our guests as far as what they differentiate into ultimately. So, you're in med school. Is that when you decided to go into neurology and then sleep medicine? How did that come about? 

Dr. Salas: I wasn't sure, you know. I liked internal medicine. I thought that's what I'd probably go into once I started my clerkships. But I would say that going into medical school, I thought I would be interested in OBGYN and then in third year, I really was fascinated with internal medicine, but I knew that I probably would want to focus. I was thinking rheumatology, and then I did my neurology clerkship kind of towards the end and just really was fascinated by it. 

I felt like it was the only specialty where it could actually change who a person was, right? You know, if you have a stroke or a tumor in the brain, it could actually impact someone's personality, which I had not seen anywhere else. It could affect who they were. That was very fascinating. I also saw there was a lot of opportunity in this particular field.

Shiv: Before we go into sleep medicine, I actually want to double click on that, because you obviously had a really important and life changing Neurology Clerkship and now you've been chair of the AAN Consortium of Clerkship Directors in Neurology. Was that kind of a full circle moment for you? What's been like a highlight of being so involved in running neurology clerkship and then also helping the AAN with their consortium?

Dr. Salas: Yeah. As I just kind of reflect on where I am now and really trying to have an effect and maybe even an impact on future healthcare clinicians...so I was the chair for the Consortium, but now I actually am the chair for the Undergraduate Education Subcommittee at the AAN. Basically, our committee is really charged with overseeing medical education in neurology. I could say even globally, because the AAN definitely has a global presence. 

So, you know, helping with the pipeline, getting students exposed to neurology...because like I said, even for me, it was kind of on the later end and I think a lot of students come through our clerkship and are very interested, but they feel like they don't have enough time to apply. They feel like it's too late. That's actually not the case. So, I want to have that national and even global impact and the American Academy of Neurology has allowed me to do that. It's just really rewarding to be involved.

Shiv: Definitely. That's awesome and, you know, there's that saying of ‘act locally, but think globally.’ Obviously you're helping have a global impact on neurology education. So, one of the main reasons I've come back to med school is actually because of my interest in neurology and psychiatry -- brain computer interface, AI, psychedelics those kind of things. As you may know, Hopkins is a leader in several of those. I'm curious, what advice would you give to me, thinking locally for approaching the neurology clerkship before, during and after, because I know many in our audience may be interested in hearing from a clerkship director.

Dr. Salas: Yeah, I always say to be open during your clerkship because I think a lot of students have an interest when they come into med school and that might be propagated or changed in your preclinical years and then you have this idea. If you know that you're interested in a particular area, like in your case, neuro or psych, then it may be worth trying to -- if you can, sometimes you can't -- get it a little earlier or, you know, reaching out to faculty or some of the residents in that specialty and asking them what do they like about the field and what the field's like for them? What are they going to do? What are their career plans? 

I think by listening to people that are currently in it gives you some really great insight. I think that listening to why people go into specialties and what they've gotten out of it and whether or not they have regrets, I think is very telling. But then also observing them. What is their typical week like? And if you only talk to faculty or if you only talk to residents, I think that field of view might be a little bit skewed.

Shiv: Yeah, definitely, because they're obviously in the in the thick of it and depends on who you talk to. There's private neurology, there's academic, there's a lot of industry work happening in the field. So, I kind of interrupted you as you were going into how you focused on sleep medicine. Sleep has become a very important field. It was always important, but it's become much more in the public consciousness over the last several years. One of our guests on the podcast was Arianna Huffington, who's written a book or two about sleep and she -- along with Matt Walker and several others -- have really raised the profile. Tell us about your interest in sleep and how the work you do at Hopkins is related to that.

Dr. Salas: So, I was having a conversation with one of my peer residents several years ago, and I was thinking at the time that many in neurology are fascinated with stroke or neurocritical care and that's kind of where I was feeling that excitement. But I remember having this conversation with my peer and telling them that I really liked electrophysiology and was thinking maybe about epilepsy...doing some training there. 

My chief resident at the time was in the room and he had already matched. He was going to go to a sleep fellowship at UNC. He heard me talking and he said, “Rachel, why? I'm listening to you. Why haven't you thought about sleep?” And I turned to him and said, “Because I just feel like it's too much sleep apnea. It's like very pulmonary.” And he was like, “No, it's actually very neuro psych. There's narcolepsy, there's insomnia, restless leg syndrome, REM, behavioral sleep disorder.”  He opened the door and he said, “I really think you should do a rotation, an elective and just check it out because it really has a lot of the components and I know you also really liked internal medicine. I think that you'll really like sleep medicine.” So, I listened to him. I did a one-month elective rotation in sleep and I've never looked back.

Shiv: Yeah. Obviously we spend a third to a fourth of our life doing it. What are your observations on kind of where the most exciting research areas are? Because I've heard everything from lack of sleep contributes to dementia and even early onset Alzheimer's in addition to all the other chronic stressors that that people face. So, is there anything you want to comment on about your research on sleep?

Dr. Salas: I think that the field is just wide open. We're learning so many things. Sleep is one of those basic human needs that crosses all fields, no matter what type of specialty you go into -- whether it's orthopedics, OBGYN, pediatrics, whatever -- your patients very likely are going to suffer from some sleep issues, right? At least at some point or another. 

But what I think is fascinating right now, kind of getting into precision medicine, is the timing of things. Timing is so important. I think that there's a lot of focus on getting seven to nine hours of sleep, and obviously that quantity is important. But for some individuals, the timing is either just as important or even more important. 

So, in other words, if you're sleep deprived like I was in residency or in med school -- not only was I sleep deprived, but I would go to bed at different times, wake up at different times -- and that actually was doing more harm. So, what I think is fascinating now with the research is we're finding that taking certain medications at certain times in certain people is actually important. You actually get benefits from taking it at the right time.

Shiv: That's fascinating. I think you're the first guest we've had on the podcast to mention the timing aspect, because obviously everyone talks about the quality and how they measure sleep with various devices.

A funny story. A decade ago, the first time I was in med school, I bought this EEG headband called a Zio. They're since bankrupt, but there's other EEG headbands that have become popular. I would sleep with it just to understand my brain waves and what phases of sleep I was in and I would try listening to med school lectures while sleeping to see, you know, would that affect my REM or affect anything? The results showed that actually it resulted in more micro waking up moments. I didn't remember waking up that much, but obviously I was and so the overall sleep quality was decreasing. So, we couldn't really learn by osmosis and just listen to lectures as you're sleeping. That did not work, or has not worked yet, as far as I know. 

Going into this topic of sleep and health burnout, you mentioned when you were a resident, you weren't getting much sleep. I'm also interested because of your background as a strengths and life coach. Clearly, sleep and overall health are very important to you. Tell us about what got you interested in that and if you have any observations on whether that affected maybe your interprofessional education interests, since you work at the School of Medicine, School of Nursing, and you have this strengths and life coach background.

Dr. Salas: Yeah. I think it was in 2015, I participated in a leadership program at the American Academy of Neurology and that was the first time they sent me a link for the CliftonStrengths Analysis. At the time I was like, “OK, what is what is this horoscope stuff?” But, you know, I'm always interested in learning something new, so I took it. At the end of it, I got a really pretty nice report. And for the first time, I recognized that, hey, they're looking at the things that I'm kind of already good at, right? 

A lot of times as a clinician, I feel like we're being told, ‘you need to see more patients, you need to do more, you need to publish more, you need to do more research.’ You’ve always got to work on your weaknesses. And so I really liked this positive psychology approach. Like, what are you good at naturally and let's hope you'll be better. That was my first exposure and then I went to the workshop, and we had a full day session on the CliftonStrengths and how you know what your strengths are. What do they mean? What are your weaknesses in relation to that? 

It was a transformative moment for me and then they said, “OK, now we want you to meet with the coach.” I remember thinking, “I'm going to meet with this person for an hour.

They're not a clinician. They have no idea of what I'm going through. I'm busy. I have a lot of other things I should be doing.” I almost was going to get out of it, but I went and that changed my life forever. That was the transformative moment for me. 

So, I went home and kept thinking about it and so I reached out to the coach -- her name is Carrie -- and I said, “How can we bring this to Hopkins? I have an undergrad program, a pre-med program at the college. They're trying to figure out if they want to be a physician, a nurse, a researcher. But in reality, what I really think they need is to figure out who they are. To have some insight. I would really love to bring this to them.” I would have loved to have had this experience so much earlier in my career. Here I was, mid-career and barely getting this. So I convinced her. I told her that I couldn’t pay her because coaches charge quite a bit but I said, “I'm going to try to get some grants, but if I can bring you here, maybe we can kind of study this and build something.” And she agreed. 

So, she came and I started working with my pre-docs. They loved it and then over time, I brought in my med students because I have a medical education research elective. It's called the Osler Apprenticeship that started in neurology and now I think at this point, almost all of our core clerkships at Hopkins have an apprenticeship kind of version of our O.A. program. They get the coaching and they get that experience. Then I brought it through to faculty and I actually even do it with patients. 

At one point I said, “Carrie, I need to find a way to pay you. I can't get these grants. I think coaching might still be too new. How can we continue this?” And she said, “Rachel, you should go get certified.” I thought that was crazy. I was like, I'm too busy. I don't have time. But I did it and I've never looked back and like I said, now I'm coaching patients. I have coaching involved with everything I do and all my programs and it's kind of my way of giving back. 

I run a house staff program, a track for health system science and health humanities and I have coaching in the health system science track. I do it as much as I can and it's just been so great. I hear good feedback from the people that are in my programs that have access to that. So, you know, I'm hoping that it continues to grow, but we'll see.

Shiv: That's awesome and I love the diverse groups you're working with, ranging from premeds to patients. What's the one-to-two-minute elevator pitcher on strengths and life coaching? Like what's the framework? And where can our audience go to learn more, et cetera?

Dr. Salas: Coaching has really gotten a lot of interest, especially in health care and academia. You know, there's a push for precision medicine on the clinical side, but I think on the academic side, there's a push for this precision professional development, this precision mentorship. So, the strengths-based approach...up until the 1990s psychologists were kind of focused on what's wrong with people, and a group of them said, “Well, what happens if we focus on what's right with people and help them be better?” So, that's kind of where that positive psychology approach started. 

The idea here is you take a self-inventory and there's many out there. CliftonStrengths is not the only one. There's DiSC, there are tons of other ones that have this positive psychology approach. There's the WIA strengths, the virtues in action, which I like to use, too and the idea is that you identify what your top five kind of signature strengths are and then you look to see where they show up and how they show up for you. 

So for me, my top strengths in CliftonStrengths, are: individualization, strategic, adaptability, arranger, and activator. Now, when I first saw those words, I was like, “I would never say one of my strengths is individualization.” So, when I learned about that -- this was actually something that I think is a talent for me -- but I was assuming everyone had it, right? If you assume that everyone has one of your strengths, you don't even recognize it. 

Take individualization.. how it shows up for me is I'm really good at finding the right person for the right job. I'm pretty good at seeing if someone's going to fit in our culture in our sleep center. If we're hiring someone, I'm really good at pulling out ‘the diamond in the rough.’ When I think about my pre-docs, I asked them, “What are you interested in? What are your hobbies? What do you like to do?” And I'm pretty good at figuring out something that they might not have seen for themselves. So, that was one of the strengths that I did. I recognized I had it, but I didn't think it was a strength. 

Then take my last strength, the activator. On the positive side, I'm really good at getting people motivated, excited, getting things started. But for me, even though it's one of my strengths, it was so raw that it was actually a weakness for me. It was getting me in trouble more than it was helping me. When I learned to harness that and put some intention to really grow it...I hadn't had so much success in my career until I did that. 

So, I think that those kind of transformative moments for me to kind of identify something I wasn't even giving myself credit for and then with one another of my strengths, it was too raw and toning it down...I think that experience has allowed me to really connect with other people and identify who they are, who do they want to be? 

At Hopkins -- I think you could relate to this -- it’s a very traditional place. You know, you come in here, you get your K award once you are faculty, you get your R01, you publish, you go do lots of global talks and then you get promoted as professor, right? But that's just not how it is anymore. We want people to be their authentic selves. Who are they? Who do they want to be? What are their strengths? How can we help you match your strengths and values with the work and the meaningful career you want to have? I think that there's a big shift and I'm seeing that at Hopkins. There's a lot of faculty getting interested in coaching and there's different ways to do that.

I really love the strengths-based approach and highly recommend that for anybody. It's just done wonders not only for the work I do, but for me personally in and outside of work.

Shiv: I love that. We could have an entire podcast just on this and related to concepts like ikigai, which we've mentioned on the podcast before...trying to get people to be more self-aware before they even decide to go to med school, or maybe PA is more relevant for their skills. There’s a fellow Hopkins professor that maybe you know, David Yaden, who we had on the podcast a couple weeks ago. He's at the Center for Psychedelic and Consciousness Research and worked with Martin Seligman on positive psychology. I love this focus that you and he both have on human flourishing and making sure your mentees flourish. 

Before we move off this topic, I did want to allow you to talk a bit more about how you do this with patients, because I think behavioral counseling of patients is a really important skill for all physicians and clinicians, since so much of health care is chronic and preventable. If you're able to kind of do motivational interviewing and counseling and shared decision making, it can make a big difference. Is that how you're applying strengths and life coaching with patients, or is this something else?

Dr. Salas: Yeah, yeah. You know, with the push again about precision medicine and personalization... we have limited time with patients in the room to figure out what's going on and what we're going to recommend. So, when I have patients do their strengths and they share those top five with me...I'm not going to label them, but I kind of know a little bit more about them.

For example, if someone is a learner, I know that this type of patient probably is going to like some materials to read about their diagnosis. They're going to want to go look up more information and so I try to put that in their after-visit summary. If someone has a strength of analytical, I know that I'm going to probably need to spend a little bit more time reviewing their sleep study report, talking about the different numbers or if they're on CPAP, looking at those numbers from their smart card. So, it's helped me kind of tailor my clinical care to my patients. If I had it my way, I would have all my patients complete this. Right now, I just offer it to some people that I think might benefit. 

What I mean by that is there's patients with insomnia -- which is the most common sleep disorder that we see in our center -- and I realized when I was getting trained in the strengths-based approach, “This sounds like some of my patients with insomnia who sit up at night and they're worrying.” I wondered, maybe they have the strength of empathy that's dialed up too much. It's too raw, so when they lie down to go to bed, they're constantly thinking like, “This could go wrong, or I'm worried about my family member.”  

Then on the flip side, there's a strength called the achiever, which is actually the most common strength worldwide. These are the people that tend to have a ‘to do’ list and like to put things on the list and check them off. So, if you're an achiever and it's raw, then I have seen that kind of come out at night for some of my patients that are thinking about all the things they need to do still, or the things they haven't done. So, as a small pilot, I offered it to some of my insomnia patients and I said, “If you do your strengths, I can come up with a personalized cognitive behavioral therapy for insomnia and implement some of these strategies.” So, we try to be more intentional with some of these strengths and fine tune them.

I've had a lot of success with it and, again, it's been kind of a pilot side project for me. I'm hoping at some point to maybe apply for some grant funding, but it just makes sense to me... finding out who people are, and why naturally they can't help it. That's how they are and using that to help provide better care for them and connecting with them.

Shiv:  I love that. I think that's a great, great message. And frankly, you've preempted the question I had on advice for learners. We talked about advice for going into Neurology Clerkship. You're talking about strengths and life coaching which is good advice for anybody to become more self-aware, maybe double or triple down on strengths. 

I want to be aware of the time, so I only had two other questions. The first is, what general advice do want to give to our audience about meeting their career as a current or future healthcare professional, especially because someone like you has worn multiple hats as a clinician and researcher, a coach, an educator, etc.

Dr. Salas: I think the biggest advice I give now is really thinking about who are you, who do you want to be and what do you want to do? Get connected with your authentic self, because at the end of the day, if you're chasing something that maybe perhaps your parents want you to do -- like be a doctor, or be a cardiologist or neurologist, whatever it is -- then it's going to catch up with you. I think that's why we see problems a lot of times with wellness later is because I don't think people are really living out who they really are, who they want to be. I see that with my coaching with all of the students, you know, and even early career faculty now.

There's a lot of inventories out there that at least give you something to react to. They're not perfect, but it's something to react and kind of reflect on and learn a little bit more about. So, that that would be my first advice. I think that applies to students coming on to the clerkship, right? How do I learn best? Who do I connect with? What are my strengths? “Oh, I'm really good at connecting with people.” Great, then that's where you're going to be able to shine and so maybe you'll do better with your clinical evaluations, right? Or if you're somebody that likes to learn and do practice questions, maybe more on the analytical side. I think knowing these things about you really can set yourself up for success. 

The other recommendation as a clerkship director and as an educator is to be proactive. I think that sometimes learners find themselves in situations outside of school, -- personal things. Especially coming out of a pandemic, there were some crazy, tough things happening for some of our learners, right? I think in medicine, it's always like, “Well, you’ve got to be strong.” You’ve got to handle everything. What have I found and what I saw is that sometimes our learners wouldn't ask for help, and then they would take a test or, you know, kind of push through the clerkship. It might show up on your evaluation. 

So, if you have something going on, reach out for help. I mean, your clerkship directors, your deans, even your peers are very supportive now and we're starting to bring those silos down and be authentic and vulnerable with each other. We all know that it's tough to be a med student, it's tough to be a resident, a fellow in faculty, any clinician, right? We deal with life and death. So, I want to encourage people to talk if you're having issues at home or if you're having difficulty comprehending the information. There's so many resources that are available and I honestly don't think that they're adequately used to the full potential.

Shiv: Yeah, that's wonderful advice. My last question, is there anything else you want to share about you, about any of the programs, pre-docs or the Osler Apprenticeship Program, your work at the School of Nursing...anything else you want our audience to know about you before we let you go?

Dr. Salas: Yeah, I guess I could kind of thread the way I structure my programs. One, I get inspiration from reality TV shows. I know, I know! Don't judge me on it, but I love a good reality TV show and my pre-doc program was inspired by Project Runway. I kind of see myself as Tim Gunn...maybe Heidi Klum, but more Tim Gunn. I get inspired. What I try to do is think back to when I was a college student or a med student and I think about what would I have loved to have? So, I try to do that for my program. For my pre-doc program, it’s inspired by Project Runway, but modeled like an internal medicine residency. Because for me, I didn't know what a resident was, what a fellow, what a...grand rounds, what is that, you know? So, all of my programs have been very experiential. 

In my pre-doc program, I have three chiefs that I select. These are students that are with me for a couple of years. They run the program and so they get the opportunity to lead and peer mentor. They work on many projects with me. All of them end up at least with one scholarly product by the end of the program. All of them have gone into healthcare, not necessarily to be physicians. Some of them have gone into industry, like you mentioned earlier. Some of them have gone into medical law, veterinarians, you know, but they've all had that healthcare. So, I do think the pipeline is very important.

Then for my Osler Apprenticeship, these are students that are interested in education, so they kind of get to see behind the scenes. They have to do the clerkship first. Then they work on a scholarship in education, typically in the neurology clerkship, to make it better and then they get kind of to see behind the scenes of what being a clerkship director is like. Because as a student, I remember doing the same thing. You kind of go through and you're like, “Why are they making us do this busy work? Why are we doing this?” And it's like, okay. So, as the OAs come in, we de-identify some of the feedback for the year. They get to see what their colleagues are saying. They get to ask us questions like, why can't we do this? And we explain, “Well, we actually did that five years ago and here's what we learned, and this is why we're doing this.”

So, I think if you're interested in med ed as a student, looking for opportunities like programs like this could be beneficial. If you're a faculty listening in, you know, how do you get promoted, especially at a place like Hopkins which traditionally has been very research oriented? That is fabulous, but what about the educators? I was able to get promoted as an educator. The same criteria, everything. I just did it through education. One of the ways to be that productive is to build and lead programs like this, where it's a win-win. It's a win for the learner. It's a win for the faculty and, you know, why not celebrate that, right?

Shiv: That's awesome. That's really great. My hope is some listeners reach out after hearing this episode and whether they're a faculty member and they want to maybe bring a version of the Osler Apprenticeship to their institution or they’re a student who's just interested in career advice or strengths in life coaching, that they'll reach out. 

So, with that, Dr. Salas, I'd like to thank you very much for taking the time to be on the Raise the Linepodcast, but more importantly, for the work that you've done over the past several years and decades to actually raise the line and strengthen our healthcare system.

Dr. Salas: Well, again, thanks for having me and, you know, I’m happy to talk to anyone. We called it the Osler Apprenticeship and the pre-doc Program for a reason, because you could take it to your institution and make it your own. We actually had the University of Rochester in New York start their own pre-doc program. We have one starting in the Southwest. So, there's opportunities. Why reinvent the wheel? Just take what's there and make it your own, right? Modify it to adapt to your health system or your environment. 

So, thank you so much for talking with me and chatting and letting me talk about all the work I'm doing. I wish you the best of luck. You've done some amazing things and I think getting that education out, connecting with others...I think the work you're doing is amazing. So, congrats to you as well.

Shiv: Thanks so much, Dr. Salas. Really appreciate that and I look forward to seeing you on the wards in a couple of months. So, with that, I'm Shiv Gaglani. Thank you to our audience for checking out today's show. Remember to do your part to raise the line and strengthen our healthcare system. We're all in this together. Take care.