Treating Millennial Patients With Multiple Sclerosis

Mitzi Joi Williams, MD

The treatment of patients with multiple sclerosis (MS) has evolved drastically since the introduction of the A-B-C drugs in the early 1990s, with more than 15 additions to the therapeutic arsenal and further research into the disease setting a foundation for a rapidly growing landscape. Additionally, recent trends in care have provided patients more personalized approaches to care and more influence in the decision-making process.

Now, as the millennial generation moves into middle age, they make up a growing percentage of the patient population, bring generational differences with them into the clinic. These differences, coupled with the massive advances the field has taken since the turn of the century, have required the occasional shift in approach to patient communication.

Mitzi Joi Williams, MD, board-certified neurologist and multiple sclerosis specialist, and founder and CEO, Joi Life Wellness Group Multiple Sclerosis Center, spoke with NeurologyLive about her clinical experience to further discuss the state of care for this generation of patients and how it compares to others.

NeurologyLive: How do millennial patients with MS differ from the prior generations of patients who have been seen for the last 20-25 years?

Mitzi Joi Williams, MD: The millennial patients with MS have changed, really, because we in the MS field have changed in terms of the options that we have for treatment and our goals for treatment. When I first started practicing, we had very limited options. We didn't have a lot of infusion medications, and our goals were really to try to keep people from getting worse, although they continued to slowly get worse over time. Now that we have more effective treatment options, our goals have really shifted to see if we can really stop MS in its tracks. Can we get to that goal? Our studies now have No Evidence of Disease Activity—meaning no changes on MRI, no changes in the patient physically, no disability progression—as a measure. So we’re asking, how can we stop it? That's a good thing that shifted.

The other thing that shifted in the way that we look at MS, is that now we’re looking to see if there are ways that we can see improvement, which is also something that we traditionally didn't look at 10 or 20 years ago as closely as we look at it now. It's a game-changer. It's been a revolution.

How are millennial patients approaching their treatment decisions? Does it differ from prior generations?

That's a great question. I think that in some cases, the younger patients maybe are a little bit more willing to take risks than some of my older patients, in terms of potential adverse effects for some of the treatments. So, when we think about our higher efficacy treatments, we think about more potentially serious adverse effects, right? There are many who are willing—because they're at the height of their careers or want to have a family in the future—to go with some of those treatments that are higher efficacy that may have more potential adverse effects because they do want to be aggressive with the disease.

But again, every person is different, and so it's not quite a monolith. Depending on their previous experiences, depending on if they have experienced with family members or friends who have MS and different treatments they may have tried—they may already come in with the knowledge base and maybe want to shy away from certain treatments because others they may have had difficulty with them, or lean toward other treatments because other people they know may have done well. The main thing is that patients are very educated, and they are very involved in the decision-making, especially for the millennial group. They are not the ones that are saying, “Do whatever you want, doctor, just tell me what to do.” They're definitely hands-on. They’ll say, “Let me think about it,” or “Let me talk to my family about it, and then let's circle back and make a decision together.” That's a good thing as well.

Do you find that the millennial group tends to come to the table with a higher base level understanding of their disease and/or a desire to be more involved in decision making?

I do feel that, in some cases, they are a little bit more involved. That certainly can be a plus in some instances, but in others, it can be a bit of a minus. I always tell my patients, when I first see them, “Please don't go look up an exhaustive list of symptoms of MS because it will scare you to death.” I have people coming in with his mindset that, “Oh, my gosh, am I going to have every one of these symptoms that I saw on this list,” or, “I was in this Facebook group, and everyone's story seemed very scary.” And so sometimes, too much information in the beginning can be a bit overwhelming, and kind of biases them in a negative way. But again, I do find that my younger patients are much more active in seeking information. Many of them have looked up different websites, found out about the different societies, and even looked into different support groups and things on Facebook, all before they come for that treatment visit where we talk about treatment options. They do come in with a very good knowledge base at baseline.

What are some of the best practices with how to approach this younger generation?

The best advice that I have would be, certainly, to recognize that if you see 1 patient with MS, you've seen 1 patient with MS. Everybody is different. We’re really moving towards trying to create individualized treatment plans, so the most important thing is to look at the person that sitting there in front of you and work with them to make the best treatment decision.

The other thing that I found very helpful is kind of breaking up those visits into bite-sized pieces. A long time ago, we used to be able to talk about the treatments and choose a treatment all in 1 visit and diagnose you with MS. But now that we have more and more options, I usually break up those visits. We have several small visits so people can digest the information, and then come back and ask questions. So, we may have a visit where we just talk about the diagnosis; and then we have another short visit where we come back and we talk just about treatment options, and we narrow it down to 1 or 2 options; and then we come back and then we pick a treatment. I have found that breaking these things up into these bite-sized pieces makes it more digestible for the patients and gives them some time to kind of think about what the options are, and really be informed when they are participating in that shared decision-making process.

The other thing that I will also emphasize is to not forget about the holistic aspect of caring for people with MS. People often want to know about diet and exercise. So, it's important for us, as healthcare teams, to make sure that we're keeping up on the latest research about diet and MS, about risk factors like smoking, obesity—things that are modifiable—because people often, especially my younger patients, want to know what they can do to improve their health. We have to combine that shared decision-making about disease-modifying therapy with more of a wellness approach and helping people understand what they can do to help themselves as well.

Transcript edited for clarity.