Dr. Alina Ivaniuk talks with Dr. Fábio Nascimento about his career path and how his decisions and initiatives have shaped him professionally and personally. Director of Washington University’s Adult Tuberous Sclerosis Center Clinic, Dr. Nascimento is co-creator and co-host of EEG Talk, a YouTube channel dedicated to EEG education, active in professional associations, and associate editor & social media editor for Epileptic Disorders.
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Transcript
Dr. Ivaniuk: Hello everyone and welcome to the first episode of our podcast series on career development. I’m Alina from the ILAE’s Young Epilepsy Section and today I have the very special pleasure of welcoming our first guest on the series, Dr. Fábio Nascimento.
Dr. Nascimento: Yeah, thank you so much Alina – I’m really excited to be here and meet you and talk to you. As you mentioned, my name is Fábio Nascimento, I’m from Brazil, born and raised, I did medical school there and came to North America for training and I’m wrapping up my epilepsy clinical fellowship at MGH [Massachusetts General Hospital] in Boston.
Dr. Ivaniuk: Thank you Fábio! Many of our listeners may know of you from your other contributions to epilepsy, from your contributions to EEG education, from your involvement in professional societies, or perhaps from your famous, quite famous, YouTube series. We will cover all of this involvement in a bit and try to see how they evolved along your career pathway. How about we start at the very beginning – you mentioned you are from Brazil.
Dr. Nascimento: Yeah, so I was born in a relatively small to medium city in the south of Brazil, the state’s called Paraná. It’s where the big falls are, Iguazu Falls. Pretty wonderful family. I lived close to my grandparents, so pretty happy overall.
Dr. Ivaniuk: And how did the happy kid end up in medical university? What led you there? Were you inspired by anybody? Or did it just happen?
Dr. Nascimento: Yeah, that’s a little bit hopefully interesting. My mum is a dentist, and my dad and my uncle are physicians, so I always kind of had that dream to become a physician. But then I really liked math, too. So I actually did engineering for a year. Which I loved, and had a great time, but I always thought, there was something in the back of my mind that always drove me to medicine. I would see medical students hanging out on campus and in the anatomy labs and something made me think maybe I should switch, maybe my calling is to be a physician.
So after a year of engineering, I switched over, took the test—we have a big test in Brazil, it’s different than in the States, and luckily, I was accepted and started medical school.
Dr. Ivaniuk: That’s quite a turn, your first turn, from engineering to medical university. That’s a dramatic one. Did your engineering background help you somehow through medical school and did it influence your future career decisions?
Dr. Nascimento: I think it did. I did less than a year of engineering, so I didn’t learn a whole lot, but I think the process of logical thinking is something they valued and taught during engineering school, and I think I try to bring that to our field as well. That’s important as well as the non-logic of patient care. A little bit of both, or a lot of both, is important to what we do. And then needless to say, the EEG world is all about engineering and physics and stuff like that, so I think it did help somewhat.
Dr. Ivaniuk: Absolutely. Now we’re at the point where you’re in medical university in Brazil. Along the way in medical school, when did you decide that your future pathway would be linked with neurology? What inspired you to take that track?
Dr. Nascimento: In Brazil, it’s six years of medical school, because we go directly from high school, so it’s a bit different than here in the States. During medical school I really liked cardiology at the beginning, and pediatrics, so I didn’t really think about neurology until later on, about the third or fourth year of medical school. I actually fell in love with neurology through epilepsy. It’s kind of interesting – I decided to be a neurologist because I wanted to be an epileptologist, which I guess is a bit atypical.
I remember during medical school I had this peds neuro lecture which was all about epilepsy, and the lecturer mentioned one of our former graduates from our university was practicing in Canada as an epileptologist and she was going to come give a lecture to us. That’s Dr. Danielle Andrade, and we’ll talk more about her in a bit. She did come to give that lecture and unfortunately, for some reason, I wasn’t able to attend, but I did get her email and I sent her an email kind of introducing myself and asking for an opportunity to work with her and shadow her.
I think that’s when things really – that was a tipping point in my career, I think. I did join her for a month at the University of Toronto, at Toronto Western Hospital, and was there during a month in the summer – our summer, but American and Canadian winter. It opened up a completely new world and I really fell in love with epilepsy before neurology.
When I came back, it was interesting. I’m flying back home from Toronto and somehow, I knew I wanted to train in North America for residency. At that moment I decided I need to take these steps, get ready, and do a neurology residency in the States.
Dr. Ivaniuk: You mentioned Dr. Andrade – I imagine she was your mentor during your fellowship in Toronto?
Dr. Nascimento: Correct.
Dr. Ivaniuk: Her research is centered more around genetics, and you somehow became interested in electrophysiology, right? How did that occur and was it during your fellowship there, or later, and overall, what was your focus during your fellowship in Canada?
Dr. Nascimento: Yeah, so when I did come back from that one-month observership during medical school, I continued medical school and graduated, and I applied, and she gave me the opportunity to come back to Toronto as a research fellow for two years. And she does epilepsy genetics, so I got to learn a lot with her about that particular field in epilepsy and it was fantastic and awesome. I don’t think I got as interested in EEG until residency – that took a little bit longer.
When I did go do my research fellowship, I knew I wanted to do epilepsy, but I wasn’t sure if I wanted to do clinical epilepsy as a neurologist, or epilepsy surgery. Seeing patients in clinic and getting a sense of how Dr. Andrade practiced and the type of research she was doing, it was really easy to make that call once I got to hang out with all of the multidisciplinary teams involved in the care of patients with epilepsy. It fit in really well with what I wanted and my personality, so it was easy to decide.
So that time, in addition to learning a million different things that shaped who I am today as a physician, as a researcher, as a person, I think that the confirmation that I wanted to do clinical epilepsy was really huge for me.
Dr. Ivaniuk: And the influence of Dr. Andrade is very strong as far as I can imagine, and still at the end of the day you decided to move to the United States for training. Could you recall the time and share with us some challenges you encountered on your way to the US for residency and overall the change of countries, change of setting, from clinical slash research to fully clinical?
Dr. Nascimento: Like you mentioned, you’re right: I started taking these further steps during medical school, right after that one-month summer experience in Canada, when I came back, I decided to read the USMLE [U.S. Medical Licensing Exam] books and get ready for that. That was the first challenge – it wasn’t that long ago, I’m not that old, but things are different, I feel like there weren’t as many forums and YouTube channels to teach you stuff, so I had to research on my own and I hadn’t known anyone else who had done it. So I think that was a little hard in the beginning, to get to know, first aid and what to read and what not to read. That was the first challenge.
Second is the language. I had to learn more and be more fluent, you know the technical language for medical stuff, so that was a challenge as well. And then the third point – most of my challenges I think are common to every international medical graduate, I think we take the same path. The third one was making connections and getting to know people from the States that can support you and write letters and help you make decisions, where to go, and give you mentoring guidance. I was really lucky to meet so many wonderful people along the way who helped me a lot, including some Brazilians that were here who I met afterwards. That made it a lot easier.
Dr. Ivaniuk: Despite all the challenges, you were able to get a pretty prestigious, nice place, in Texas for your training and overall get into the system pretty successfully. There was a transition from a quite narrow field of epilepsy into the huge vast field of neurology, that sea of different diseases: stroke, multiple sclerosis, neuroinflammatory diseases, headache, et cetera. How did you feel with all of that? Did you feel uncomfortable with the transition from the narrow field to the vast field of general neurology?
Dr. Nascimento: M-hm. I don’t think so. It was more fun because I really liked epilepsy and I already knew some, a little bit, so it was fun to hit the ground running if you will, and know some stuff at the very beginning of residency. But it was also fun to learn from scratch all the other subspecialities. I don’t think that was a challenge – it was fun – I had a great time, great teachers, great mentors. And it was probably because like you said, Baylor is an outstanding place, it’s got a lot of very smart people and my residency experience was fantastic – I made very good friends there. One of my mentors who became my friend and is still at Baylor, Dr. Jay Gavvala – we’ll talk about him later on. So no, overall I knew what I wanted to do but I was really happy to learn about everything else and get good at other specialties. We had every specialty at Baylor – a lot of different patients, so I think that was a good experience overall.
Dr. Ivaniuk: You mentioned that you became interested in neurophysiology in residency, or rather that you were not interested in electrophysiology beforehand. What was that exposure that made you feel or think about turning toward that side, toward neurophysiology?
Dr. Nascimento: Every week during fellowship, Dr. Martin del Campo, who is still I think at Toronto Western Hospital, he used to staff routine EEGs with a fellow. And I used to go with them and check it out. It was fascinating but I didn’t really understand anything. It was a completely different world. So I had that not-knowing feeling from fellowship, so I really wanted to learn and be able to read EEG.
So then during residency, I had a lot of difficulties as my peers and everybody, really, there’s a lot of challenges in learning EEG in residency, which is something that we’re studying and trying to improve. But around halfway through residency I met Dr. Jay Gavvala that I mentioned awhile back, and I approached him for guidance overall, to think about fellowships and research projects and things like that. We met on day for the first time at the cafeteria, I hadn’t gone through the EEG rotation yet, at the cafeteria at St Luke’s Hospital, it’s a private hospital affiliated with Baylor that we rotate at.
We just had a chat, just the two of us. He was super kind to take an hour out of his schedule to talk to me and give advice. I asked if there was any research project he thought I could be involved in. That was the spark that made me really interested and passionate about EEG. Because he’s a fantastic teacher and he had an interest as well. Then we worked together throughout residency studying how much we knew, how lectures were effective or not effective, getting the ball rolling from a research standpoint. And at the same time, I learned some EEG during residency from him and other mentors down there, Dr. Mishra, another very good epileptologist. So I guess halfway through residency is when I started to learn and also be more interested from a research standpoint.
Dr. Ivaniuk: And here we have also mentors that guide you that could spur some interest in your, in your eyes, toward a specific subfield. And was it your experience that drew you into this field of epilepsy and neurophysiology education or was it something else? How did you decide you wanted to study some more and something to change the way neurophysiology is delivered to trainees?
I think that’s one of the most important parts of my career because it was my experience that I saw that was other residents’ experience that made me think about it and highly consider it and ultimately take this path of improving how we teach. Back to being a resident, I really loved EEG, the idea of it, but it was hard to learn it in residency. My co-residents had the same difficulties.
So I found that gap in education at that moment, that gap where on one side there are residents that wanted to learn but it was hard, for multiple reasons. And on the other side, the huge knowledge that EEGers have to share. There was something in between that wasn’t working right. It wasn’t matching in the way the education was being delivered and received from the trainee standpoint.
That’s when I started to try to understand why that was happening—why was that the case, what was going wrong and how we could improve it. And we’re going to get to that in a little bit – the point where I myself learned more about EEG, I could retrospectively look back and say, “Huh – I wish that would have happened earlier, I wish I would have had that resource earlier, I wish somebody would have told me that earlier, and that would have made the process for me a lot easier.”
So really from anecdotal evidence of my own experience and my buddies from residency, I learned a lot and try to implement that and that’s what we’re doing right now.
Dr. Ivaniuk: Of all your research so far, what is the most important issue in neurophysiology education in the US?
Dr. Nascimento: We still need to adapt the way we teach to the adult learning theories. So we need to use what’s been learned from a medical education standpoint in the field of epilepsy and apply those concepts and use those when you’re teaching trainees. It’s relatively simple stuff.
For example, something we learned from EEG Talk and just from talking to people, and if you look for papers on medical education there’s actually evidence about that, pretty well established: Our attention span is not an hour. If you have a lecture that lasts for an hour, especially about EEG, you really can’t maintain the level of mental power to follow everything and learn every single thing.
That’s one simple concept – maybe if you shorten the lecture, highlight the major points, you match with how much people, the background knowledge of that trainee, you can get so much more done in a shortened period of time. It’s not like out of this world. It’s not easy, but it’s definitely doable.
Dr. Ivaniuk: There are many people who are involved in medical education who do research on that or try to come up with policies, local or global, but not everybody starts a YouTube channel. Can you recall the moment and circumstances when you decided yes, we should start the channel and get some stuff produced?
Dr. Nascimento: That’s a good memory of mine. I’ll summarize it. After I joined fellowship for the first year, the EEG clinical neurophysiology year, as we know, the learning curve for learning EEG is really steep in the beginning. So the first couple of months is really tough. Then maybe by three months, four months in, you feel comfortable like, “No, I can do it.” Of course, I need mentorship, guidance, supervision, but you feel a little bit more comfortable in coming up with your own interpretation and identification of at least major findings.
When I reached that point in my fellowship, going back to what I mentioned, I was like no, this is what we need to do but we need to make sure that at least part of this training is migrated into residency. Because it’s possible, it’s doable.
So that was the idea – how can we make it digestible, and then that’s the other important part—fun, and entertaining enough so people will actually sit down and watch it. And try to get pieces of information about EEG in different topics, different videos, and kind of bring this knowledge back to their training and they can apply that when they’re going through EEG rotations and trying to read EEG on their own. That’s the insight.
And it would have been just an insight if it weren’t for Dr. Brandon Westover. I brought that idea with me to him and we went out that night for dinner at this pretty cool place on the corner here, this tavern with a grill, so we had a hamburger and I shared that with him. I said look, I learned a lot over the past few months, and I feel like we can do this – we can create some resource that’s free, that’s available, really high quality but entertaining at the same time, that can be shared with all trainees out there and they can take advantage of it. He was super enthusiastic about it, he was like, “Yeah, that’s great let’s do it.”
So that night over a hamburger or two we shaped the idea and he started talking about it and the idea came out.
Dr. Ivaniuk: I would just like to bring up the quote that I found that mentions that EEG Talk is dedicated to its cause and will not stop until all neurologists can read EEGs. What do you mean by “all neurologists” – do you aim at every neurologist in the US? In the world? What is your target and what do you expect should happen for you to stop producing EEG Talk?
Dr. Nascimento: Those are very relevant questions. I think the idea behind “We’re not going to stop until all neurologists can read EEGs” is mostly focused on the trainee, the neurology resident and fellow, mostly neurology residents.
Of course, there are some people who know they’re going to do movement and they’re not going to be private practice and not going to be reading EEGs, so it’s a generalization that all residents really need to be able to read EEG – that’s a little exaggerated.
But aside from that subpopulation within the trainee population, I think that depending on the country you’re in, and that’s a study that Dr. [Sándor] Beniczky and I are kind of doing right now, if the country where you live, such as the US, there’s a lot of general neurologists without EEG training or clinical neurophysiology training who read EEGs in clinical practice, I think it’s imperative that at the point of graduation they’re able to accurately and consistently interpret EEGs. That’s where the idea came from. If you’re going to do it in clinical practice, let’s make sure you have the competency and the skills required to read EEGs accurately by the time you finish up your training.
Dr. Ivaniuk: Who’s behind the scenes – do you do everything on your own? By everything I mean not only recording but also processing, script writing, and which additional skills did you have to learn to be able to produce the series?
Dr. Nascimento: Yeah. So the episodes themselves, it’s Dr. Westover and I getting together either live or on Zoom and coming up with topics and guests and the major points we want to cover in an episode, the major take-home teaching points of that episodes.
Our jokes are very well scripted – some of them. Some are pretty natural, but we do script the jokes a little bit and we script the educational structure. We’re going to talk about this topic, then ask the expert, have some follow-up questions and then make sure a second point is addressed. He and I take care of that.
From the production standpoint, it was pretty much just me – I had to learn everything about YouTube. I had no particular training. I did have one mentoring session with my mom’s marketing person in Brazil, who’s great, and she taught me the basics, and after I learned that, I YouTubed a bunch of videos that taught me other things that I needed. It’s improved – if you look at Episode 1, it’s very different from what we’re doing now and I’m sure it’s going to continue to get better, as I learn more tricks here and there.
Dr. Ivaniuk: It’s just amazing how the whole series probably made you reflect on what you know and what you could learn from the professionals but also you could learn some additional skills, unrelated to medicine, to produce the series. That’s amazing.
Now let’s talk a bit about other things besides the clinical field you’re involved in. You also have a lot of editorial experience. Can you recall how you got into the editorial world? What was the first journal where you were assigned as any kind of editor, and what are your outtakes from this experience?
Dr. Nascimento: I was really lucky, and that really changed my entire life, really, not just professional and my career but really my life as a whole was getting into the Neurology Resident Fellow Section led by Dr. Roy Strowd, who became my friend and current mentor.
When I entered it was Dr. [John] Millichap who was the editor and Dr Strowd was the deputy editor, and then during my three-year term, Dr. Strowd became the editor. So that was my first exposure to reviewing manuscripts and getting a sense of how the editorial aspect of a journal, in that case the Neurology Resident Fellow Section, really works from the backstage side of things. And that was during residency.
Dr. Ivaniuk: And afterwards, you also assumed a couple of other positions, among them editorial positions, right? And probably the most visible one is your involvement with Epileptic Disorders journal.
Dr. Nascimento: Yeah. So initially – that was a long time ago. That was before residency, I believe. I had reached out to Dr. [Alexis] Arzimanoglou, and I just asked him for an opportunity to review for Epileptic Disorders, and he welcomed me and I became part of the editorial board at that point as a reviewer.
So I did that for a few years throughout residency. A couple of years ago, I had an idea about tuning up or kind of launching a social media initiative for Epileptic Disorders. So I emailed Dr. Sandor Beniczky, I’d never met him, I just got his email online and emailed him. And that really changed everything. Fast forwarding two years, we talk every day, we work on a lot of projects together and I learn so much from him. He’s an outstanding mentor and such a kind, generous person. That really changed and shaped me for sure into what I am now and what I’m learning from him.
Dr. Ivaniuk: Yeah. I think it is phrased pretty well how having initiatives and telling the world about your initiatives, reaching out to people, proposing something, can make a difference in your career, and again, allow you to meet certain mentors that can teach you something.
Can we go back to residency – you mentioned you started peer reviewing during residency. This is something that young people usually hesitate doing – they are not sure whether they’re competent enough to give a commentary on an article. Did you feel comfortable taking your first peer review? Do you remember the first article – was it on epilepsy, or not?
Dr. Nascimento: It was epilepsy. But with the Neurology Resident Fellow Section, we reviewed everything, not just epilepsy. But that’s a great point. It is a little intimidating at first, for two reasons. One, you just don’t really know too well the process of what to write, what to recommend, what not to recommend, how to pinpoint potential issues, minor issues, what not. That’s one thing you have to learn through the process.
There are some mentorship programs for peer reviewing out there that are excellent. The Publons website of the [American Academy of Neurology], they have a pretty good one, and I know Dr. Strowd, through the Resident Fellow Section, they launched one as well. Then the second is you not knowing, not being an expert in the field, just by the nature of being a trainee.
I guess I didn’t have that perspective at that point but now looking back, I like to invite residents and trainees and fellows to review articles for the Epileptic Disorders journal and for other journals I’m involved with from an editorial standpoint. Because they’re really good! And I think trainees, maybe they have a little more time, or maybe because they’re not as familiar with the literature, they actually go and look, and they read. So the reviews, the recommendations from trainees, I think they’re excellent.
I don’t think trainees need to try to avoid it. It may be a little bit more work because you need to familiarize yourself with the literature out there. But then you read some papers and you get really good at it. Because not all of the reviewers will know all the papers out there, so if you take the extra step especially at the beginning to kind of pick the articles that are relevant and read them and compare and see positive and negative points in the manuscript you’re reviewing at the time, it’s super valuable in helping the editor and associate editor make a decision. So I would agree with you – I highly recommend trainees to start that really early, to get the ball rolling and exercise in that way.
Dr. Ivaniuk: You are involved in neurophysiology related task forces in different societies. Can you remember when you accepted your first position in a task force, and what is your experience interacting with senior members? Is it easy for you as a young specialist to find common ground with more senior people?
Dr. Nascimento: Thanks for asking that. I think task forces happened at around the same time; they’re relatively recent. They came from different societies at around the same time. ILAE, ACNS [American Clinical Neurophysiology Society] and AES [American Epilepsy Society]. There wasn’t a particular sequence for them.
Having the opportunity to work with seniors – I think honestly, it’s the best aspect of it. I learn a lot, I have a lot of fun, and you asked if I felt confident. I think because you have the mentorship of the senior people teaching you how to think, what to recommend, and kind of guide you through the whole process, I don’t think there’s any issues and I felt pretty confident doing it under their mentorship.
So yeah, it’s been a really outstanding experience. And getting to know people from different countries that have very different opinions sometimes, different outlooks on certain topics, you grow so much as a junior trainee and epileptologist. I think it’s great.
Dr. Ivaniuk: Do you think you’ve had a good work-life balance during your training, during your residency and fellowship, and can you compare that life in Canada during your research fellowship with your life during your training in the US? Are they different and do you think you’ve reached that balance or not yet? And if not yet, what is lacking?
Dr. Nascimento: Yeah, that’s a really good point. You might not agree with me, but I think the work-life balance is very different from person to person. I think it’s a pretty generic term we use and it’s a good term, and we need to prioritize. I was talking to one of my co-fellows and best friends, Irfan Sheikh, here at MGH and we just learned that well-being is one of the milestones for ACGME [Accreditation Council for Graduate Medical Education] for a fellowship. So it’s really important to think about that and prioritize that and make sure trainees have a good well-being and good work life balance.
But in my view, I’m fortunate to take a lot of what I do as really fun, and so I like to edit for EEG Talk on the weekend – I think it’s amazing! I jam to music, have some coffee, edit some episodes and learn and add some sound effects – and just laugh, by myself. And writing – writing stuff is something I really like, writing manuscripts and looking at data and analyzing in SPSS and things like that—I just have a lot of fun doing it.
So at the end of the day, it all just merges together, and it might not be correct, but sometimes I don’t make the distinction that much between “this is work” and “this is my life” – I just kind of put it all together and I do work in my life and life in my work, if that makes any sense.
Dr. Ivaniuk: Probably if you make your work your home, you will never go to work, so it’s a very nice approach to your occupation and your professional life absolutely. This is amazing that you have joy for what you do and what you do is rewarding for you. That’s awesome. So I want to ask a cliché question that people usually ask during interviews with physicians: Where do you envision yourself in five years and what are you involved with?
Dr. Nascimento: I think I’ve identified the areas that I really love and I want to spend more time developing and trying to make a difference in our field. I think the first one is the one we talked about a lot, which is EEG education, and clinical EEG research, which I’m doing with Dr. Brandon Westover, Dr. Sandor Beniczky and Dr. Jin Jing here at MGH, that’s our Spike Team here at MGH. And in addition to my previous and current mentor Dr. Gavvala. So that’s the one portion of it.
The second is really the hard-core education aspect of EEG education. Forgetting about EEG for a second and learning about the foundation of education and then make that bridge again and try to bring those concepts to EEG. My mentor on that aspect is Dr. Roy Strowd, with whom I mentored for that Neurology Resident Fellowship Section. I’m actually doing a Master’s in Medical Education starting in a couple of months, so I’ve planned to get better at that and then be able to close that gap of ensuring that neurology trainees are able to read EEGs pretty well by the time they graduate.
And then the third, not in any order of importance, but the other point I want to focus on in my career is the epilepsy genetics part that dates back to the fellowship. In that realm of things, Dravet Syndrome is my clinical passion, somewhere where I really want to make a difference and improve care and discover things to help those patients.
I have an outstanding relationship with Mary Ann Meskis and Dr. Veronica Hood from the Dravet Syndrome Foundation. We’ve been brainstorming and working together and doing some projects to help me set up a transition clinic at my future institution, so that’s part of what I want to focus on.
And then the epilepsy genetics in the epilepsy patients – I think it’s a field that’s growing. And in that third aspect of interest, I met Dr. Elizabeth Thiele here at MGH. I’m really lucky to have a lot of phenomenal mentors. She’s a pediatric epileptologist and I started working with her when I came to the fellowship.
So that’s a lot to be accomplished in five years – hopefully I’ll be able to make some steps in that direction.
Dr. Ivaniuk: Fabio, thank you so much for being here, for sharing your insights, your experience, and your pathway. Probably—not probably, I am sure that it will inspire lots of young people along their way to make decisions and not be afraid of taking turns. Thank you so much!
Dr. Nascimento: Thank you. I’m really honored to be invited. Thank you, great questions and it was awesome talking about a bit of my past, present, and future. And then lastly, if there’s anybody out there that wants to chat for whatever reason, I’m super available and reachable out there on social media and my email’s online, so I’m happy to talk to whoever.
Find Dr. Nascimento on Twitter (@fabnascimen) and visit the EEG Talk YouTube channel.
