When Zaeem Siddiqi MD, PhD, joined the neurology program at the University of Alberta after completing his residency and fellowship at Duke, he had just one other colleague specializing in neuromuscular disease. Now that team has expanded to five, with more on the way. For this week’s “Spotlight” interview, Siddiqi talks to us about his current work treating patients from Edmonton to Kagluktuk near the arctic circle while training neurologists and conducting research on myasthenia gravis. He also reflects on his time at Duke and the unexpected joys of being a new grandfather.
What are your current responsibilities at the University of Alberta? What does a typical workday look like for you?
Tuesday, Wednesdays and Thursdays are typically clinic days for Myasthenia Gravis (MG)/neuromuscular, EMG and autonomic patients. Mondays and Fridays are the days where I "plug in the holes" in research, teaching and administration activities. I take seven weeks of call a year, typically on the general neurology/consult services. We serve a large area that extends way up north and I have MG patients all the way up to Kagluktuk (check it out on the map!). I field calls from family/ER physicians and nurse practitioners from these far out locations. The clinical practice can be very different and may require improvisations. For example, since Rituximab has annual or semi-annual dosing and does not require regular blood monitoring I use it often for MG patients in remote areas. We do not have home infusions, which led me to develop a large program in subcutaneous immunoglobulin for patients on maintenance immunoglobulin therapy.
When I joined University of Alberta after completing my residency/fellowship at Duke, there was a single neuromuscular specialist at my institution. We now have five with few more in the “pipeline.” During this period, I developed the MG program from grassroots, and started a multidisciplinary muscular dystrophy (MD) clinic. We have a unique model of multidisciplinary care for MD with each clinic staffed by a neurologist, cardiologist, physiatrist and respirologist along with a neuromuscular nurse, dietitian, social worker, and other support staff. Though it took some doing to assemble this team, the patient love this “one-stop shopping” model. Through a national award, I established the autonomic laboratory/clinic, the only one in Western Canada. For this, I spent some time with Dr. Low at the Mayo Clinic to emulate his battery of autonomic tests in my lab.
Our MG program is one of the few in Canada dedicated to research in MG. We have been part of several major clinical trials and international collaborative research projects in the last 20 years. In addition, I have an ongoing project in biomarker discovery in MG. On the clinical side, I have fostered collaborations with provincial health and the industry as MG can be an expensive disease with only a few drugs covered by governmental health plans. A large number of my patients on immunotherapies, including novel agents (i.e. Eculizumab), are able to get them free of cost due to these collaborations.
So with all the ongoing activities no day is typical. There are always new things propping up and life is never dull!
How and when did you first get interested in neurology? How did you decide to focus on myasthenia gravis in particular?
Choosing an academic career in neurology was both fortuitous and pragmatic as I was a cardiology buff for many years. It was during my doctoral research at Boston University that I had the privilege of working with one of the most eminent neurobiologists, Dr. Alan Peters. He was the inspiration that led me to follow the academic path and pursue excellence. Being a foreign medical graduate with a strong background in neurobiology, I perceived that Neurology would provide me with the best chance to match in a top tier training program and subsequently, pursue an academic career. With that in mind I interviewed at >25 Neurology programs (still have my match list!), drove about 10,000 miles in 6 weeks to end in Duke. I still remember it was the 4th ranked program in the country at the time. Dr. Peters was overjoyed and announced it to the whole department. Those were some unforgettable moments!
The satisfaction of managing patients with MG and Dr. Sanders’ mentorship are the key reasons I ended up focusing on MG. I was inclined towards neuromuscular medicine and electromyography ever since my EMG rotation. In fact, once during my rotation I bet on a muscle’s action with Dr. Morganlander and won a quarter from him. Not an easy feat by any means! There was this inpatient with an unusual presentation who had previously been assessed in the EMG lab and the diagnosis had remained unclear. On a follow-up visit I did the assessment and suspected MG. It actually turned out to be anti-MuSK MG, a novelty in those days. I ended up getting a “virtual” gold medal from Dr. Sanders and we still sometimes talk about her! Incidents like these cemented my interest in MG.
MG is fun to manage, with no two patients being the same (“snowflake disease”). Treatments have to be individualized based on a number of factors. About 85% of MG respond well to treatment, which must rank among the highest response rates in neurological diseases. Most neuromuscular folks, regardless of their primary interests, enjoy treating a myasthenic as there is so much to offer.
What’s one experience from your time as a resident that stands out as being especially memorable or useful to you?
There are many but I consider the first (PGY II) year at Duke to be especially memorable and productive. We spent 10 months on the inpatient services (2 months each on three services at Duke Hospital, VA service and the Neuro ICU). Stroke volume was high and there were no fellows to help administer TPA. The high volume and variety of patients, the teaching rounds with almost all attendings during the year, supplemented with morning teaching sessions, noon conferences and weekly interesting case conferences set an exceptionally strong clinical foundation. The grand rounds were of top quality and it was mandatory for the residents to present every year. I still reap the benefit from the rigorous all round training at Duke despite my focus in MG and neuromuscular diseases. Sound clinical methods are always a plus in our field!
The other unique aspect of the Duke residency program was the superb staff. I could always count on getting support from Drs. Janice Massey and Graffagnino, to name a few. There were several outstanding clinicians like Drs. Hurwitz, Rozear, and Wayne Massey who had a major role in my training. Some were season ticket holders for the Blue Devils and would offer me a game ticket (once in blue moon!), which is a huge deal in that part of the world.
What advice or words of wisdom do you have for current residents or medical students interested in neurology?
To the medical students who are considering a career in neurology, I would highly endorse the specialty for multiple reasons. First and foremost, it is one of the most rapidly advancing medical specialty with extremely diverse content. Within neurology I can count 12 (or maybe more) accredited subspecialty fellowships to choose from. There is no shortage of jobs, both in academics and community, and the work/life balance is quite decent. The diseases have become much more treatable, which wasn’t the case in the past. Both my kids have chosen neurology as their careers…. which does say something!
To the current neurology residents my advice is practical. Decide on academic versus community practice early as the paths for two are different. For academic medicine find an area of interest by the end of PGY III year and a mentor who can provide you opportunities to flourish. Cement that interest in PGY IV and look out for a "niche" in that arena during your fellowship year. If you follow an untrodden path, there will be tons of opportunities. Develop and maintain collaborations, which highly augment one’s productivity. I have maintained my ties with Duke and we continue to collaborate in multiple projects.
Finally, to both students and residents, nothing is more important than the family. I couldn’t have made it without my parents and family’s support and sacrifices. Be there “mentally and physically” when you’re around them. I tried to attend all my children’s parent-teacher meetings or baseball games during my training years. They still remember some of the bedtime stories I told them. Still, I feel I missed a chunk of time while building a career. These golden years go by very very fast, faster than one can imagine. Make sure that you get the most out them.
What’s the biggest change you’ve observed in how we treat or understand neurological conditions since you were a resident? What potential change(s) are you most excited about in the next 5-10 years?
There have been enormous advancements all around. In genetics, we now have the molecular diagnosis for 95% of our MD patients. We have gene therapies for diseases, like spinal muscular atrophy, which were untreatable just a few years ago. Advances in imaging have completely changed the paradigm of acute stroke management. Now, we have door-to-needle time of minutes, administer TPA in stroke ambulances, and perform intra-arterial thrombolysis routinely. In neuromuscular/inflammatory diseases, novel targeted therapies are completely changing the treatment protocols. Migraine treatment has gone beyond triptans with several new treatments on the horizon, including monoclonal antibodies.
I see a plethora of novel medications coming in many areas in neurology including MG, which is very exciting. Mycophenolate mofetil usage in MG dates back to the late 1990s with no new medication for the next 15 years. Conversely, just in the last 5 to 7 years, multiple novel targeted therapies have shown promising results, including complement inhibitors, antibody depleting therapies, B cell inhibitors etc. I expect that several of these will find usage in MG with other new ones following.
Unfortunately, there has not been a breakthrough in the treatment of neurodegenerative diseases and MD. Good news is that we are close in some i.e. motor neuron disease and Alzheimer’s. I am optimistic that we will have some effective therapies in the near future that can slow or even halt the progression of these conditions.
What do you enjoy most about your work?
Diversity of clinical practice. No field in medicine has such an amazing range of possibilities. We neurologists see some of the most diverse symptomatology and it is fun and challenging to diagnose and manage them. I have realized this more as I conduct discovery learning sessions for medical students in other specialties.
I am passionate about managing MG patients. I love the continuity of care and developing personal rapport with my patients and their families over the years. It is highly satisfying to see a myasthenic with a severe disease onset doing well after months of uncertainty and turbulence.
I used to be an ardent mentor for student/residents early in my career and was quite involved with teaching and received several awards. With the expansion in responsibilities it is hard to maintain that tempo but I regularly mentor trainees in my clinics, particularly if they are interested in neuromuscular medicine. I enjoy helping residents and medical students in academic writing and have numerous published manuscripts with my trainees as first authors. Publishing always gets them excited and lays foundations for academic careers!
What’s the hardest part of your job?
To keep up with the rapidly evolving knowledge in other specialties in neurology. Advances in genetics and imaging modalities, and numerous new therapies in multiple sclerosis, epilepsy, headaches etc. are hard to keep track of. I find this knowledge explosion very exciting but has been a challenge to remain afloat!
Our center has recently switched to electronic medical records (Connect Care). Ordering an infusion electronically is a nightmare!
I find it hard to manage time and keep a balance between the clinical, research, teaching, and administrative duties. I struggle to find that 25th hour in my days.
What passions or hobbies do you have outside of work?
Family of course! Recently, my wife Lubna and I have been blessed with a cute and vivacious granddaughter. My mornings usually start with a video chat with her and spend most evenings playing with her. After several years, I had to “refurbish” my rusty skills in changing diapers and keeping a neonate/toddler engaged. It is an amazing déjà vu and I am enjoying it even more this time around.
We enjoy traveling and visiting art/history museums and traveled quite a bit in Europe and North America. Not being able to pursue these leisure activities during the pandemic has been hard. These days, Lubna and I head to the Rockies whenever we get a chance. On the plus side, we are getting a lot of time with our granddaughter….
Siddiqi poses with his wife Lubna and granddaughter in front of the Canadian Rockies.