Interviewer: Jameela Lawal
Editor: Meenakshi Subha Vipin
Closer: Sarea Leung
After majoring in neuropsychology and philosophy of mind and completing medical school, residency, and a fellowship, Dr. Aleksandra Yakhkind is a neurointensivist and assistant professor of neurology and neurosurgery at Tufts University School of Medicine. Her deep-rooted interest in neuroscience as a child has led her to become a dedicated practitioner in the field.
Read more about Dr. Aleksandra Yakhkind’s inspiring journey and her insights into the world of neuroscience below.
Could you give a brief self-introduction about yourself and your relationship with neuroscience?
I am a neurointensivist and assistant professor of neurology and neurosurgery at Tufts University School of Medicine. What is a neurointensivist? I practice neurocritical care, which means I take care of patients with severe neurologic injuries in the ICU. This includes large strokes, brain bleeds, spinal cord and traumatic brain injury, brain tumors, seizures that don't stop (status epilepticus), and neuromuscular weakness. Basically, anything that requires close observation, continuous medications, or intubation to decrease the chances of disability and death. To become a neurointensivist, I had to go to medical school. I then did a neurology residency and a neurocritical care fellowship. Doctors who study internal medicine, emergency medicine, or surgery can also practice neurocritical care. We also work closely with physician assistants (PAs), nurse practitioners, nurses, speech and swallow specialists, and experts in occupational therapy, physical therapy, respiratory therapy, and social work, all of whom specialize in diseases of the nervous system.
In the neurocritical care unit, our relationship with neuroscience is clinical and granular. A lot of brain injury can cause the brain to swell, and one of our main goals is to prevent the swelling to keep neurons from dying. This can be done mechanically with the help of our neurosurgery colleagues by literally creating more space for the brain, or through medication. Our other goal is to keep the rest of the body as much in homeostasis as possible to give the brain time to heal. That means helping a person to breathe with a ventilator if needed and preventing complications of the ICU like infections, blood clots, stress on the heart, and delirium. Diagnostically, we can tell which part of the brain is injured based on a patient's physical exam and imaging. As an academic medical center, we participate in clinical trials based on neuroscience research that aims to improve the way we treat neurologic emergencies.
To my understanding, a neurointensivist takes care of critically ill patients afflicted with neurological illnesses and diseases. This sounds like a rather challenging and important role to take on. Could you offer a perspective on the ins and outs of the career as someone who works in the field themselves? E.g. What are some of the tasks? What does a typical day look like? What do you enjoy most about your job?
Great question! This is very challenging work. Outpatient doctors often say, "I don't know how you do what you do." I say the same thing back to them. To me, working in an ICU is fulfilling for several reasons:
Teamwork: You are never alone, there are always experts to discuss cases with. No one who works in an ICU doesn't want to be there because the work is hard. There is very good comradery because we go through hard things together. And when things are stressful, it's real stress, and we work through it together.
Schedule: I am on call 24/7 for 7-day stretches. On one hand, this is exhausting. On the other hand, when I'm not on call, I can focus on my non-clinical work without distraction.
Existential: We see really sick patients on the brink of life and death. This reminds me every day to be grateful for health and the amazing things bodies can do. Sometimes we can help patients and they walk back into our unit to say hi. Other times, our technology and medicines, and tools are too limited to save them. This is really hard. I have to broach the topics of death and disability with patients and families often for the first time. I learn so much from the families and patients I meet in the ICU. I don't leave a day at work without being transformed.
A typical day for me as a neurocritical care attending is:
Overnight: On-call for emergencies, admissions, and transfers. Most of the time, I take calls from home while resident physicians (in training), nurse practitioners, and physician assistants manage patients in the hospital.
7 am: Arrive at the hospital and run the list of patients with my team. The residents and PAs then pre-round and check in with each patient's nurse.
8:30 am: Rounds. We go through each patient's events, labs, and imaging, and plan for the day with painstaking detail. Our hospital has multidisciplinary rounds, in which nurses and respiratory therapists, and sometimes social workers actively participate.
12 pm: Didactic conference for residents.
1 pm: Finish rounds, do admissions and transfer patients, call consulting physicians, do procedures (which include lumbar punctures, central lines, arterial lines, bronchoscopies if indicated), and meet with families of patients. These tasks may also interrupt rounds if they are emergent. Some intensivists do more or different kinds of procedures.
Usually around 6 pm: Go home, on-call overnight again (for seven days at a time).
Each neurocritical care unit is different in its structure. Some neurointensivists are consultants rather than primary physicians for each patient. Some cover the hospital in-house at night. Some do not have as robust teams. Different types of neurocritical care units are described in this article.
What is the progress like so far in bringing state-of-the-art resources to help those threatened by possibly fatal neurological diseases and illnesses? What have been some recent milestones in this area?
This is such an important topic. Progress in research is slow. Oftentimes, we take one step forward and two steps back. Meaning, the results of research sometimes contradict previous trials and we end up back at ground zero. Luckily, an area of research that has made tremendous advances with life-changing effects on patients' lives is that of the treatment of ischemic stroke.
Thirty years ago, a large stroke would have been a death sentence or worse-- severe long-term disability. Since the advent and application of thrombolysis and thrombectomy, outcomes after ischemic strokes have significantly improved. What are these interventions? To take a step back, ischemic stroke is usually caused by a blockage to a blood vessel bringing oxygen nutrients to brain cells. Strong blood thinners break up the clots and procedures physically remove them. These interventions do not happen in a vacuum. Successful stroke care requires public education so that people know stroke is a treatable condition and call for help in time. An intricate network of ambulance services is necessary to triage patients to hospitals capable of these procedures. Hospitals must be equipped with specialty protocols and staff to ensure the most evidence-based care for patients with these diagnoses. Rehabilitation is irreplaceably important for recovery. Lastly, primary care physicians and neurologists alike must be up to date on the most recent practices in primary and secondary prevention of stroke. In summary, successful care of patients with stroke depends not only on appropriate medicines and interventions, but on healthcare infrastructure that encompasses prevention, treatment, and rehabilitation.
Unfortunately, many low to middle-income countries and remote regions of high-income countries do not have this infrastructure or the expertise. Some countries even lack data on the prevalence of neurologic disease and the number of neurologists (1). A lot of work is left to be done to equalize the playing field and ensure these advanced technologies are available to all people.
One other area of neurology that I find fascinating is the treatment of autoimmune neurologic disorders. Some of them can present with psychiatric symptoms. Over the last 15 years, researchers have discovered auto-antibodies that cause these conditions, which can now be treated with immune suppression and removal of what's causing the antibody production, which is sometimes a tumor. This brings us one step closer to discovering the cellular and anatomic basis for disorders of the mind.
What is something that you have learned while working in neurocritical care that you think could also serve as a general life lesson?
As I mentioned above, I learn so much every day. I am reminded to be grateful for my health and to value each moment with my loved ones. I have learned to "trust but verify" information that I am told by patients, families, and team members. I have learned that the diagnosis is in the history and the details, and if you don't find it-- ask again and look again. At the same time, I have learned that our medical technology is limited. While sometimes signs and symptoms all point towards a particular diagnosis, they cannot be verified by a simple test. Sometimes we have to treat "empirically," meaning with a presumed diagnosis in mind, and sometimes we don't have treatments. Every year, new tests and treatments are discovered, which is both inspiring and humbling. Lastly, I have learned that the trauma of patients, families, and staff in the ICU is often unspoken. Making time and space to acknowledge it is a start for healing those invisible wounds.
What is one heartwarming or interesting story from your work that you can share with us?
I had a 19-year-old patient who spent a year and a half in the ICU on the brink of death due to complications from severe autoimmune encephalitis. Her parents never gave up hope and a year after being discharged, she is learning to drive again and enrolling in college courses. There were days I worried that she wouldn't make it. I love it when I am proven wrong.
It's widely known that many in the medical profession often have to endure years of hardship to get to where they are today. What obstacles did you face on the path to getting where you are?
I didn't know what I was getting myself into. I had no family or close acquaintances in medicine and blindly took my pre-med advisor's warnings as a challenge. There were days when I watched my friends get married and start families and buy homes while I bounced between stages of medical training, in which I second-guessed my choices. During these days of no more than five hours of sleep, while working nights for six-week stretches, I lost touch with what drove me to medicine and who I was as a person.
Now, three years after completing training, I love my job. I'm lucky to call some incredible people lifelong friends, and my experiences inform how I treat others. It is normal to have feelings or be appalled by not feeling in response to something as challenging as medical training. My advice to anyone in this type of situation is to talk about it, with a professional or with friends (2). You will find that you are not alone and that all feelings pass.
Why did you choose neuroscience as a career?
I became enthralled by neuroscience when I learned my sister was diagnosed with a disorder of the brain when I was nine. Given the choice, every one of my science projects had a neuro focus. I majored in neuropsychology and philosophy of mind as an undergraduate and considered neuroscience research or medical anthropology as a career. At the end of the day, medicine fits my personality: I love working with people and am fulfilled by helping others.
What is the biggest misconception made about you or neuroscience?
Being a woman physician, I am still often asked if I am a nurse. A lot of my colleagues who don't meet the generic doctor bill face the same misconceptions. Another misconception is that doctors know everything. It is impossible to know everything. The doctors I respect the most know what they don't know, are lifelong learners and shape their knowledge as new data emerges.
There are a lot of misconceptions about neuroscience based on bad (meaning un-replicated or falsified) science, science fiction, and fake news. Science in general requires patience and impartiality, which the world could use more of these days.
How did you get yourself ready for a challenging career in high school? What advice would you give to students considering Neuroscience?
I enjoyed science. It came easily to me in high school and I worked hard. I also had fun in high school. College-level science classes were much harder. I would advise students to ask themselves these questions every few months: Am I happy with what I'm doing at least 20% of the time (3)? Is what I'm doing in line with my goals?
It's okay to change course and change course again. I got an internship at a developmental psychology lab the summer between high school and college, which exposed me to the world of research. It also showed me the type of work I didn't want to do for the rest of my life.
References:
Buckingham, M. (2022). Love and Work: How to Find What You Love, Love What You Do, and Do It for the Rest of Your Life. Harvard Business Review Press.
GBD 2019 Stroke Collaborators. Global, regional, and national burden of stroke and its risk factors, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Neurol. 2021 Oct;20(10):795-820. doi: 10.1016/S1474-4422(21)00252-0. Epub 2021 Sep 3. PMID: 34487721; PMCID: PMC8443449.
Landry, E. (2022, January 26). 5 resources available to a doctor with depression. The MedCommons. https://themedcommons.com/support-for-doctor-with-depression/