Deep Community Ties Enhance Medical Education – Dr. Allison Brashear, Dean and Vice President for Health Sciences at the University at Buffalo Jacobs School of Medicine

Derek Apanovitch: Hi, I'm Derek Apanovitch, and today I'm happy to welcome Dr. Allison Brashear to Raise the Line. She's the dean and vice president for Health Sciences at the University at Buffalo Jacobs School of Medicine and Biomedical Sciences, a role she has held since December 2021. Previously, she was dean of the University of California Davis School of Medicine and served as chair of Neurology at Wake Forest School of Medicine. 

Dr. Brashear is an internationally renowned researcher for several rare neurologic disorders. During her thirty-year career, she's led more than forty clinical trials aimed at developing potential treatments for spasticity after stroke and abnormal involuntary movements of the neck. Her work has fundamentally transformed the way spasticity and dystonia are treated and has led to three FDA-approved medications for treating patients with disabling muscle spasms. 

Thanks so much for being with us today, Dr. Brashear. 

Dr. Allison Brashear: My pleasure. 

Derek: All right, I'd like to start with learning more about you and what first got you

interested in neurology. 

Dr. Brashear: So, I grew up in Indiana and my father is a physician, and so I'd already been intrigued with patient care. I can remember as a young child my mother and father talking about challenging cases at the dinner table. Then when I went to medical school, I was just intrigued with neurology. I had a wonderful teacher named Dr. Robert Pascuzzi at IU School of Medicine, and I learned there that neurology was about taking a history and the physical and then putting that together. So, it's the ultimate in problem solving because the information that you get from the physical exam and the history are what really is packaged together to be able to kind of go forward. 

A neurologist can determine whether you spend thousands of dollars on an evaluation or nothing based upon their abilities to kind of assess and put together that information. 

Derek: In terms of your research, what made you focus on areas like stroke and dystonia? 

Dr. Brashear: So, back when I started my practice at IU School of Medicine, there was a new drug on the market. At that time, it was called oculinum. You know now that drug to be Botox. There was no one really in the state, but maybe one person, treating these patients and they had terrible painful spasms in the neck and debilitating spasms in the eyes. Some patients had cerebral palsy and were walking on toes and had terrible spasms in the legs, and of course, there were stroke patients who had fisted hands and bent elbows and couldn't walk. I learned that this treatment could decrease that pain, that spasm, and so it was really something that I felt immediately benefited patients. There was a large number of patients that needed that treatment, and it was a great opportunity to give back to the community. 

At that time, I also was invited to be one of the investigators on a pivotal trial in cerebral palsy and so when I was immediately out of my training, I started doing that clinical research study that was being done all over the country. I had the good fortune to be the person in charge of that study at Indiana University and one study led to another study and we were able to really bring those research studies directly to patients -- both at Indiana and at Wake -- that really benefited the patients, gave them new treatments that weren't yet on the market,

and then led to FDA approval of many of those type of drugs.

Derek: Thanks for that background. Are there any areas today in neurology that you think we'll be seeing major developments in? You know, there's a lot of discussion always about Alzheimer's disease, and there's a lot of talk about merging technology with the brain. I'm just curious if you have any thoughts in those areas that are very topical today.

Dr. Brashear: So, let’s go back in time. When I finished my training, there were no drugs for MS except for steroids; there were no drugs for stroke except for aspirin; and there were definitely no drugs for migraine except for something called Inderalor propranolol. That's about it. There were very few new seizure drugs. 

Fast forward to now, it's a dramatic change. Dramatic. We can now prevent MS, which is quite disabling. We have current acute and chronic treatments for migraine, and what we've been able to do with epilepsy, with brain surgery, and implantable devices was never even conceived back then. In my thirty-year career, the pendulum has swung so widely.  I would anticipate, given the rapid uptake of information, that we're going to have dramatically more treatments. Gene therapy wasn't even conceived thirty years ago. So, I think that the world in neurology is really opening even more and more and more. 

We see that in psychiatry as well. Psychiatry is now one of the hot areas for residents to go into because there's so much going on, there's devices, there's pills, there's psychotherapy, there's all these interventions that never before were known. So, I think the fast-pacedness is just going to mean that we're going to have more and more treatments. 

Derek: We can shift gears a little bit and talk about the University at Buffalo as a research institution in these areas and just the importance of the research that's going on there in your

field and maybe others under your purview. 

Dr. Brashear: So, University at Buffalo is an “R1” institution, which means it's one of those top-ranked intensive research institutions. Our strengths in the School of Medicine are really in addiction and translational clinical trials, and we have strengths in MS and stroke. We have one of the largest number of stroke populations on the East Coast. We see about 2,400 stroke evaluations per year in our hospital that's just across the street from me. So, we have this great depth of learning and we have a very good relationship with our community that sees the university as a partner. 

UB has strengths in the health sciences. We have five schools of health: the School of Medicine, of which I'm dean; and then in my role as vice president, I have strategic oversight in the other schools of health that include dentistry, nursing, public health, pharmacy and pharmaceutical sciences. Then we also, on top of that, have a School of Social Work and we have a School of Biomedical Engineering that's part of the engineering school that's supported by the School of Medicine and the School of Engineering. So, there's really this very rich health sciences background here at the University at Buffalo that I think is really going to be a game changer for Western New York and the region. 

Derek: You know, often medical schools are looked at as being more standalone, but you have undergraduates, you have these other schools. How does that enrich the medical school experience, having all these other kinds of students in and around the medical school? 

Dr. Brashear: Let me set the stage here because the medical school graduates about 180 students a year and we also graduate about 200 bachelor students a year and a combined ninety masters and PhDs. So, our medical school is graduating more non-MDs than MDs, even though we have a very large MD program. In addition, our medical school trains almost 800 residents and fellows a year. We have responsibility for multiple different hospitals and residency programs that all roll up to one of the amazing leaders we have in our school, Dr. Greg Cherr. It's a very across the continuum part of medical education going all the way back to bachelors, masters, PhD, MD, PhDs, and then MD degrees, and so UB really has a very, very strong presence in biomedical education in addition to MD education.

Derek: That must be fantastic to get all those different perspectives. Within the medical school itself, there are definitely some issues that are in the papers these days on physician satisfaction and burnout. I know you’re probably confronting those issues in the classroom with students, but maybe you can provide some perspective on that because I know UB has deep connections to the community as well. You're probably seeing this full life cycle...you know, teaching the students, having the physicians practice in the community, getting community feedback. What's your perspective on how to make this better for doctors in the field? 

Dr. Brashear: Well, I think what's important to think about is why doctors go into medicine, and that's really to take care of patients. In fact, everybody at a medical school is there to take care of patients in one way or another. Our basic scientists are here because they think that they're going to improve the health of the community and individual patients. Our clinicians are here for the same. So, I think when we focus people on patient-centered care and we try to make the rest of it easy so that they can take great care of the patient -- whether that's dealing with the EMR or making their clinic run better or dealing with burnout and trying to take care of the whole person -- then we can get the doctors to focus on taking care of the patients and their families, and that's what doctors are supposed to be doing. 

I will say, you mentioned earlier the Buffalo community. You know, the Buffalo community has been absolutely rocked by the racist shooting last May and the healing and addressing the systemic racism has caused a lot of conversation here in Buffalo. I'm so proud of our medical school that has really partnered with the community to try to understand the needs of the community and support the community as the community and the entire region attempts to deal with such a horrible act. 

To that end, I just would mention that Dr. Aron Sousa, who is the Dean at Michigan State. He and I were at a meeting in February of a bunch of deans, and we listened to the CEO of Northwell talk about what they had done about gun violence. So, as part of the remembrance on the May 14th event here, we had about five Michigan State students come with a faculty member to Buffalo and share time with us. We're trying to figure out a way to continue that sharing so that we're engaging medical school and medical students in advocacy around gun violence, around how to be an anti-racist, how to really connect with your community. 

I think that's different for medical students than when I went to medical school and that means we're really training leaders who are going to be the next critical thinkers in medicine about how to take care of the whole patient. Because if you don't understand the social determinants of health of your patient, then you're not going to be able to make a difference. It's important to understand that when you give a patient a prescription, if they don't have the co-pay or gas or even a car to get that prescription -- let alone any other issues that may impact them being able to take the prescription -- then they're not going to be able to follow their recommendations and things are going to continue to flounder. 

So, patient-centered care is what it's all about. That's what we want to do for our community. That's what we want to do for our providers. I believe that when you focus on that, you lift all boats. Providers do better, the patients do better, the family does better, and frankly, it should provide lower costs.

Derek: Yeah, that's helpful. Are there specific ways you're introducing these themes into the curriculum the first couple of years of medical school?

Dr. Brashear: Yes. We've been focused on developing an anti-racist curriculum in our medical school. We're also focusing on addressing health inequities with our students. There's an elective where students can go do health in the neighborhood, and so they actually kind of walk in a patient's shoes. Those are all ways that we're trying to be out-of-the-box thinkers on how

to train medical students. 

I think it's really important to also realize that we need to have more and more doctors in Western New York. The Association of American Medical Colleges estimates that there's going to be a shortage of 124,000 doctors nationally, which means we need to train more doctors and I want them all to stay in Western New York so they can help take care of all of our patients. We have an aging population in Western New York, but that's part of what as a medical school we need to do: build research and find great cures, take great care of patients, and also train the next generation to be critical thinkers and to take great care of patients. 

Derek: In terms of getting graduates to stay in the community, lots of areas of the country have this as a challenge where graduates -- not just of medical school, but it could be other kinds of schools -- go away, right? They leave the place where they grew up and they go to a big city because maybe they think there's more opportunities. How do we get doctors to stay in the community, to build family practices and to engage more as opposed to moving on to somewhere else? What do you think we need to do as a society to make that happen more frequently? 

Dr. Brashear: We're working with some of our alumni and donors to build something called the Western New York Scholarship Fund that's designed to keep primary care doctors and psychiatrists in the community. Those scholarship funds are available to individuals who commit to being in primary care and then stay in the community for at least five years. We're also trying to have our medical students want to stay and do residencies here, and we're working with all of our healthcare partners on ways to enhance that experience for medical students. 

But you're right, generally what happens is when people are residents, they want to stay in the community because they've kind of developed roots. So, I think that actually one of the things to address is getting people to stay and do their residency here. We are a great place to do a residency program because we have a diverse group of patients. We have multiple health systems that we work with, including a public benefit corporation, which is ECMC. We work with Kaleida Health. We work with the Catholic Health System. We work with the VA. We have a variety of Federally Qualified Health Centers that we also work with.

So, residents here and students get a really diverse portfolio. They see all kinds of patients from all walks of life. Our children's hospital, Oishei Children's Hospital, is one of the largest referral areas for children, particularly for specialty care, in the region as well. There's a wealth of opportunities to learn here in Buffalo, and that's one of the things that makes it really great. 

The other thing that makes it really great here is it's a city of good neighbors. People are just so incredibly welcoming, which is one of the reasons why we moved here. I'm originally from Indianapolis, and Buffalo just feels very much like a nice midwestern town like Indianapolis.

Derek: Oh, that's great. In terms of recruiting faculty, what do you look for in terms of a great faculty member? 

Dr. Brashear: Any faculty member needs to want to be here to do great things and have an impact. And like I said, everything we do in the School of Medicine touches a patient in some way, whether that's doing research on addiction or that's doing research on HIV or that's being at the bedside and delivering care or seeing people in the clinic or working with some of our amazing sports teams. Our faculty are out there on the football field. Those are things where people want to really make a difference, and it's about that commitment to make a difference. 

Our faculty are the people who are role models for the next doctor who's going to walk across that stage and get a diploma and hopefully be those primary care people that are going to take care of me when I need that primary care. All of us want to make sure that we're training the next generation to be critical thinkers and not just memorizing. I think that's a real important point for medicine about how to begin to think outside the box, think innovatively. How do I take care of this patient? My father taught me a long time ago that the best place for a patient is at home with their family, and we should be able to do things to design medicines and processes and care models to keep people at home with their families whenever possible.

Derek: So, the hospital at home concept for a lot of conditions... 

Dr. Brashear: Correct. 

Derek:  I know that's something that a lot of healthcare systems are working on. What do you think those systems need to do to get that right? How much of it is on the technology side and how much of it is on training and the healthcare team? What advice would you have for a healthcare system that's looking to go into that in a big way?

Dr. Brashear: I think that we need to look to the future to figure out how things are going to get paid for. Medicine has gone so much into this procedural reimbursement, right? We need to move much more towards the patient-centered focus. I think when you're in that patient-centered focus, then everything kind of rises and all the other costs and sights of service all kind of follow in line. 

I do think that the alignment around incentives in the future is about trying to really get people to see that care at home in the ambulatory setting is ideal. Our hospitals are so important for people who are critically ill. Our emergency rooms are so important for people who are critically ill. But, they shouldn't be used as the place where people get routine medical care because the routine medical care that you get in those environments is fragmented and the follow-up is fragmented and then people don't understand you because you're seeing a different person every day, right?

It goes back to that scenario where you hand someone the prescription. Do they have the money, the gas, are they on a bus line, do they have family that can get them to that next follow-up appointment...all those things that unless you really understand the patient and their family, they're not going to get that done. So, I think as we move in healthcare more towards value-based payments, that's going to be where people are going to need to begin to think about how they're delivering care. You know, if we can figure out how to keep people at home and provide them with those wraparound services, I think that's going to be really a patient-centered approach. 

Derek: There are two topics that I wanted to try to cover at the tail end here: artificial intelligence and medical education. I’m probably not the first person to ask you that question, but it’s on all of our minds. What would you say, based on what you’ve seen, on how artificial intelligence tools can be helpful in medical education and what should we be a little bit wary of? 

Dr. Brashear: I think AI is going to contribute tremendously to more accurate and faster diagnosis, but I don’t think it’s going to replace doctors. I don’t think it's going to replace nurses. You know, we can think about how things were. I mean, you didn't even have a smartphone. You didn't have all these things that now are just routinely helping with care. So, I do think AI is going to make things, as we mentioned earlier, faster paced, quicker, more accurate. It's going to really be a tool...it’s going to complement physicians and the other healthcare team members. 

I’m really excited about it. I’ve been impressed that the New England Journal of Medicine has lots of coverage right now on AI. I think doctors need to understand it, and we need to be able to train and teach about it and make sure we’re incorporating it as something we do to take care of patients. But again, it also needs to be managed because we wouldn't want the computer just making a diagnosis, right? We know what happens when people just put symptoms into a computer and wait for that to spit out. It's not always accurate. Plus, there's that human touch in medicine. I don't think the art of medicine, is going to be replaced by AI. 

Derek: I think that's fair. In 2023, Osmosis has a campaign called Year of the Zebra. Each week we're highlighting a rare disease, and there's thousands of these diseases affecting millions of people. Based on your research and background, would you want to highlight a rare neurologic disorder for our audience...something that they may not hear a lot about, but has a really big impact on those who have the condition?

Dr. Brashear: Absolutely. In 1991, I started studying Rapid Onset Dystonia Parkinsonism. That's a disease I have studied my entire life and it's caused by a genetic mutation in the sodium potassium pump and in the brain and in the conduction area of the heart. Patients with these mutations can be normal until they have some type of physiologic stressor -- be that childbirth, running, alcohol, stress, fever -- and suddenly they can go from being a normal walking, talking individual to being unable to talk or walk or swallow. It can run in families and people can have de novo mutations. It's been the most fascinating disease because it is an interaction between the environment and genetics. I've had the absolute honor to get to know people with this disease. What we're trying to do is to study the genetics, the biochemistry, and the phenotyping -- the clinical presentation -- with the idea of coming up with a future treatment or understanding how the brain works here.

This is a rare disease. About a couple of thousand people in the world have it and the phenotype is actually quite broad, from rapid onset dystonia parkinsonism, which is what I described, to something else called alternating hemiplegia of childhood. That occurs in children under eighteen months of age who can have learning disabilities and often intractable epilepsy and status, terrible dystonia and then there's a whole myriad of phenotypes that are kind of in between. It's a disease that needs a lot more study and that's one of the things we're funded by the NIH to do. We've been funded continuously since 2008 to learn more about this disease and then try to think about some treatments. 

Derek: Thanks so much. We'll try to take a look at that and let's see if we can get something out there to raise awareness. 

Dr. Brashear: We have a Facebook page and we're recruiting patients. It is a disease that is very interesting because patients don't necessarily know they have this genetic mutation, and then when the right circumstances come, or unfortunately bad circumstances, then the patients develop sudden onset of a severe neurologic disorder that doesn't go away. 

Derek: Okay, thanks for that overview. All right, as we wrap up, we've got a lot of students who listen to the podcast who are thinking about healthcare careers. What advice would you give them as they embark on this journey, having had such a successful and diverse career yourself? 

Dr. Brashear: Be open to change, love working with people and seize opportunities. My career has changed a couple different times and I've always been able to embrace opportunities that were presented. That's how I became a neurologist. That's how I entered research projects. That's how I entered some leadership roles back in Indiana when someone gave me an opportunity. I said yes, and I always got a lot of support for those things from colleagues and friends. 

Medicine is one of the most amazing careers you can have. It's changed, as I mentioned earlier, dramatically over time and so I think those are all really, really important things. I think sometimes people see medicine as just one thing, but it's not. It's really quite diverse and there's a lot of different things you can do in your career, in your lifetime, in medicine. It's always changing, and it makes it really, really fulfilling field to be in. 

Derek: Well, thanks for those heartfelt comments. I really appreciate the time today.

Dr. Brashear: My pleasure. Happy to talk anytime and thank you for inviting me.

Derek: I'm Derek Apanovitch. Thanks for checking out today's show. Remember to do your part to raise the line and strengthen the healthcare system. We're all in this together.