Clinic offers a ‘one-stop shop’ for brain care

“One of the best things that I’ll never take for granted is being able to have a conversation.”

Laura Michaluk suffered a traumatic brain injury in a vehicle accident in 2004 and three concussions between 2008 and 2015, affecting her short-term memory, her sleep, her ability to work and her relationships.

Michaluk saw multiple neurologists but said she was left feeling hopeless. One spoke too quickly for her to understand. Another, she recalls, essentially asked her what she wanted him to do about it.

“I just remember being really heartbroken because I thought this is going to be my life,” says Michaluk. “My world got very small. It’s really hard to try to be your own advocate and navigate for yourself when your main tool is damaged.”

In 2018, her family physician referred her to Sara Mitchell, a neurologist at Sunnybrook Health Sciences Centre and an assistant professor at the University of Toronto. In 2021, Michaluk was transferred to the Brain Medicine Clinic, a virtual clinic that is housed at Sunnybrook, where Mitchell is the director.

The Brain Medicine Clinic – a novel clinical model that is a “one-stop shop” for diagnosis, symptom management and treatment – is serving those who “don’t have a clear home elsewhere in the health-care system,” says Mitchell, also the director of the Azrieli Brain Medicine Fellowship Program.

The idea for the Brain Medicine Clinic, which opened in 2020, was sparked by conversations between Mitchell and Sarah Levitt, a psychiatrist and the inaugural Brain Medicine fellow who is now associate director of the fellowship program. “We identified that there was a subset of patients that we were noticing were getting sort of shuffled around the health-care system,” says Levitt.

There’s a “ping-pong approach” in specialty care, says Mitchell, with patients bouncing around specialists for different symptoms of their brain disorder. The Brain Medicine Clinic has multiple brain-related specialists in one interdisciplinary clinic, allowing for timely diagnoses, integrated approaches to patients’ treatment plans, and thorough management of patients’ complex brain disorders.

The clinic is also, “a fertile training ground for this new phenotype of physician, the Brain Medicine specialist,” explains Levitt. “(Fellows) learn skill sets outside of their specialty of origin, so that they would be able to look at the brain more holistically in the ways that we imagined.”

Patients in the Brain Medicine Clinic present with symptoms in at least two out of three domains: affect (mood), behaviour, and cognition. Mitchell says this allows the clinic to see “a broad range of pathologies or etiologies for complex brain disorders that span from neurodegenerative (disease), structural disease, traumatic brain injury, functional neurological disorders, inflammatory autoimmune conditions, etc.”

Mitchell notes that the goal of speciality medical education is to create physicians who are the best in their area of specialization. However, she says this is creating a “Tower of Babel” phenomenon in which there are many physicians trying to perform the same task but lack shared foundational knowledge and vocabulary for treating patients. The Azrieli Brain Medicine Fellowship Program aims to train physicians who can treat patients more holistically by applying knowledge from multiple brain-related specialties such as neurology, psychiatry, geriatrics, neurosurgery, and physical medicine and rehabilitation.

The clinic provides “prescriptions for living.”

Carl Froilan Leochico, a physical medicine and rehabilitation specialist and an Azrieli Brain Medicine fellow says, “I’m able now to look at the person as a whole and detect any psychiatric conditions or any neuro conditions that may hinder participation in the rehab programs.”

One of the challenges to implementing and sustaining interdisciplinary care is the funding model, says Mitchell. “I think that oftentimes, OHIP doesn’t reimburse for the time and effort that we need to put into complex patient care, and this creates difficulty for clinicians who are often reimbursed for the number of patients they see, not the complexity of the patients they see.”

The University of Toronto-led program recently received a philanthropic commitment from the Azrieli Foundation.

“Often, people lack that philanthropic support to really be able to do something novel like this and try to expand the clinical care model,” says Mitchell. The funding will cover adding additional fellows, a research assistant, administrative support, a patient navigator, project management, research grants and the ability to host an annual Brain Medicine global conference.

“The goal is really to create a pilot program that can then be expanded beyond our individual centre,” says Mitchell, a model that could be applied at academic institutions regionally, nationally and internationally. The Brain Medicine Clinic is expected to gain in-person space in the new Garry Hurvitz Brain Sciences Centre at Sunnybrook in 2024.

Michaluk says there is a notable difference in her overall wellbeing. “My life just isn’t the same,” she says, adding that the clinic provides “prescriptions for living.”

Michaluk compares her brain to a thermostat, and for her to have optimal memory and brain function, she needs to stay within a certain “temperature range” by implementing lifestyle adjustments to her diet, sleep schedule and relationships.

“Being a patient is an educational experience,” Michaluk says, adding that the team advises her how to better her health, but more importantly the context – “the why” – behind making those adjustments.