Building a Strong Neurology Department Amid an Ever-Changing Field

Stephen D. Samples, MD

The field of neurology has seen immense growth over the past decade, led by research that has advanced the understanding of the underlying pathology of several neurologic disorders. Building a well-rounded neurology department can be a challenge for some institutions, considering the costs affiliated and the lack of neurologists currently available.

In October 2023, Allegheny Health Network (AHN) announced it named Stephen D. Samples, MD, an international recognized headache specialist and physician leader at the Cleveland Clinic, as the network’s Department of Neurology chair. In his new role, Samples will lead a team of 29 AH neurologists, 18 advanced practice providers, and 105 support staff members, providing inpatient and outpatient clinical care across all facilities in the health system. Additionally, he will oversee AHN’s academic neurology program, which includes 15 residents and 2 clinical neurophysiology fellowships.

Samples, who previously served as chair of the Neurological Institute at Cleveland Clinic Abu Dhabi, sat down with NeurologyLive® to discuss his recently appointed role and the challenges that come with managing a neurology department. He spoke on overcoming issues with the shortage of neurologists, the qualities to look for in clinicians, and how much the field has changed over the years. Furthermore, Samples, who specializes in migraine, neuralgia, and intracranial hypertension, spoke on the emerging concepts within migraine medicine and the ways care has improved.

What have been your early impressions as chair of the neurology department at AHN?

Well, I think the remarkable group of physicians exhibits exceptional skill, knowledge, and professionalism. My job is to maximize their skills to help our patients. I see my role as making it as easy as possible for them to provide the best care.

How do you handle the constantly evolving field of neurology?

I've tried to remain humble. There's no possible way that I can keep up with each of the different disease lines and what's expected for the knowledge base in neuroscience and their areas. It's just way too much information. What I'm doing is I'm dividing up the doctors by disease lines, with a leader for each one. For example, there's a leader of epilepsy, movement disorders, multiple sclerosis, and headache. Those doctors are responsible for the clinical guidelines for their area. I expect those doctors to be world experts in their area and not have to worry about other areas as much. I think my job is to organize it and make it as easy for them to do what they need to do. But I try to let them make the clinical decisions in their area in their expertise.

People don't seem to understand that neurology is a lot like medicine in the 70s. You do a medicine residency. Before the 70s, you saw your internist for everything, but once they started having lots of fellowships in cardiology, nephrology, pulmonary, ID (infectious disease), patients started then going to their specialists to get care from people who knew that area exceptionally well. Neurology is the same thing. We all do a neurology residency, and then we all do a fellowship. Whether it's epilepsy or movement disorders, or headache or stroke, we do a fellowship in that. And we specialize in those areas, in the same way that our colleagues in medicine now specialize in cardiology, and pulmonary and such. When I was trying to explain this once in a community talk, I actually went to the library at Cleveland Clinic, and I pulled every journal for that month or that period, that they I would need to read to keep up with everything. And I put it on one desk and took a picture and it was stacked, not only was a table full, but it was stacking up in multiple areas. There's just no way you can pretend to know all the information. That's why you trust your experts in those areas to make those decisions for you.

We're [neurology] going to be the area [of focus]. I always follow the NIH money. Now, this is going to be very strange, but in the 50s, and 60s, the NIH paid for cardiac surgery, research, etc. And by the year 2000, less than half the people who should have died from heart disease based upon what they had, were dying. In the 70s, they put the money in cancer, as you're seeing people with low grade breast cancer living full lives basically completely recovered, and other areas as well. And then in the 80s, you had HIV, and all the money went into HIV. My joke is that Magic Johnson had HIV for 30 something years and is 70 pounds overweight, which is something you would never have thought possible in the 90s. Once NIH puts money into these areas, we start seeing huge benefits a decade or two down the road. The 90s was the decade of the brain, so we're really starting to see the benefit of putting the NIH money into that research. I think it's safe to say that stroke took advantage of that first, but in a lot of ways they could piggyback cardiology. Because again, it's vessels, we use a lot of the same techniques, we use a lot of the same medications. We’ve now revolutionized stroke, and we're seeing the same thing in multiple sclerosis, epilepsy, movement disorders, and headache. We're seeing just an explosion of treatments that are now available for things that when I trained. We were pretty hopeless [back then].

How have advances in headache medicine advanced and changed the way clinical care is delivered?

When I was a medical student, they were still giving narcotics for migraines. And the first triptan started to trickle out early 90s, by the beginning of the first part of this century. And that revolutionized care. We had ways of stopping a headache that didn't require narcotics, that would actually work. And I know that Botox didn't come out until 2010 or so but we were using it at Cleveland Clinic back in the early part of this century. We saw dramatic improvement in people. Those that were having 30 days a month of severe headache we're getting down to having maybe three or four moderate or mild headaches a month, just phenomenal improvement, which was frankly, heartening. My favorite day of the week was Botox clinic day, which patients were so appreciative. If I hear someone say “you changed my life,” it's almost always Botox.

We started realizing we couldn't treat the patients with heart disease, vascular disease, and strokes, so we started experimenting on CGRPs (calcitonin gene-related peptides) 10-12 years ago. We found out they actually didn't need to be that subset of patients, those medicines actually worked for most everybody. That gave us a whole other thing in our arsenal to help treat them with, whether it's preventative, or whether it's abortive. I have found that those medications have been very helpful. Whether you use it with Botox or separate from Botox, it's really been a game changer. The next big step is going to be with the stimulators. There's a number of stimulators on the market. There's one that's basically a tens unit for the super orbital and super trochlear nerve. The nice thing is you can use that with pregnant patients. It works fairly well, there's no medicine interactions, there's no real problems, they put it on for 20 minutes a day, and they do well. And you can use it also for 60 minutes when they have a headache on a different setting. They have ones now for the greater occipital nerve and the frontal, super orbital nerves. They have some as a vagus nerve stimulator. We're coming out with a whole new generation of treatments based upon basically tens units and stimulators that I think is going to really make a big difference. I used to never see anyone over 65, and now, a good percentage of my population is over 80 [years old]. And then you have to really start worrying about medicine interactions and things like that. These don't have that. This is going to be a next giant step and migraine treatment.

What are some of the major unmet needs for patients with migraine that still need to be addressed?

I don't think it's as sexy as some of the apparatuses or the fusions and things like that, but we know that many people with migraine have comorbid problems such as depression, anxiety, sometimes some mild OCD. And it's just because it's a genetic syndrome of neurons that are hyper excitable and hypo excitable. We know that these manifestations occur, and if we don't begin to treat some of those issues at the same time, the patients don’t get better. There have been several studies that aren't terribly well publicized, but we certainly see in headache, people with chronic daily headache have an incredibly high percentage of had PTSD, physical abuse, but more often sexual abuse, particularly growing up. Some studies show it's as much as 80% of women with chronic daily headache. I find that a trauma therapist is essential to have as part of our arsenal to help those patients, we can't patch up with medicines. If we don't begin to get to the cause of those things, as well as treating them with medicines that help, I don't think we're going to make a huge dent in the populations the chronic daily headaches.

What are concepts and values that set apart a great neurology department?

I think the next thing that this place needs to do is we need to have more people in each disease line. Because right now, many people are having to cross over and help general neurology and other areas, if we can keep people in their specialty, with the expectation that they're world experts in that area, we help people complementarily. If we have someone who specializes in movement disorders, someone who specializes in headache, and someone who specializes in Alzheimer, we have general neurology and we cover all of the areas, but not with one person trying to do all of it. We do it with super specialists in each one of the areas so that we can really focus on the people that know the most, helping the patients that need it the most.

Transcript edited for clarity.