Resa E. Lewiss ’92: Teena, why don't you take us through and tell us about yourself, whatever you'd like to share regarding education and where you are currently?
Teena Shetty ’95 MD’00: Sure. So I am a physician and a neurologist at the Hospital for Special Surgery in Manhattan. I earned my bachelor's degree in English literature and comparative literature at Brown. I studied at Oxford and Cambridge in between my Brown education and I did the Program in Liberal Medical Education at Brown. So I earned my MD at Brown as well.
Lewiss: So you heard it right, audience. Dr. Shetty did the eight-year program at Brown University, both undergrad and medical school, and in between, she took some time in the U.K. Do you want to tell us a little bit more about that?
Shetty: Yes, so I absolutely loved every year at Brown. In particular, what was enjoyable for me was that I was in this PLME, or Program in Liberal Medical Education, which strongly encourages students to take a liberal, humanistic approach to their medical education and with the knowledge that they will end up in medical school. One is encouraged to pursue other sources of knowledge and, to that end, I was an English literature concentrator as well as comparative literature and French, and I found that incredibly beneficial both at that time and later on in my future career.
Lewiss: And then you took some time to pursue that in a little further depth when you did your time in the U.K., is that correct?
Shetty: I did, yes. I ended up studying literature for a full year intensely at the year that I spent in Oxford, and my second year in the U.K. was actually the University of Cambridge on a Fulbright scholarship, and I was doing a study in medicine and research.
Lewiss: So you and I had a little bit of a pre-meeting. We got to know each other and we talked about the importance of voice. Voice, not just because we're doing a podcast, but voice in terms of the human voice, the physician's voice and the women's voice. And you actually did a bit of a deep dive when you were an undergraduate in studying that. Is that true?
Shetty: I did, yes. Part of my concentration in English allowed me to do a senior thesis, which I actually did in creative writing, and I wrote stories about women's voices in India, which is where I was born. And I particularly enjoyed writing about the stories of women whose voices were not heard for many years, due to gender issues and otherwise, and so I found that very rewarding. I wrote stories that I heard from my grandmother and great-grandmother about women, and ended up writing that into sort of a collection of short stories, which became my senior thesis at Brown.
Lewiss: And I'm smiling because this is exactly what we love about Brown and a Brown education. Listeners may wonder, how can a physician how can a physician do a concentration in a non-science, but you and I both know that if anything, it made you even more prepared to be a physician and deliver the care to patients that you do today. In India, was there a specific region that you focused on?
Shetty: Yes, I focused on the South because that is where I'm from originally.
Lewiss: Mm-hmm. And now let's fast forward a little bit. So you completed your concentration, you completed undergraduate, you did some work in the U.K., you found yourself in medical school. Tell us about the Teena of medical school.
Shetty: Well, I loved medical school at Brown. I began with anatomy. I had some amazing professors, Sharon Schwartz and Ted Gaslo, and I remember so much of that class, the dissection of the cadaver, learning about the different organs. I particularly was struck when we got to the brain and started uncovering the cranial nerves. As one unraveled after another, I realized that there was this incredible aspect to medicine, which is that understanding of the human body with a depth that is hard to have if you haven't actually had the opportunity or that exposure.
So I think it was dramatically different to my undergraduate experience, since that was very humanities-focused. But it complimented that beautifully. And I found that same kind of humanism in terms of the structure of the Program in Liberal Medical Education in undergraduate as I did in the medical school. And I particularly loved the clinical rotations, because sort of one month you're an internist and next month you’re a surgeon, the next month you're an OB-GYN. And getting that exposure for me was tremendous.
Every day, I felt like it was full of these new stories of patients' lives and the way that I learned how to take care of them and learned the art and the science of medicine was very compelling. I was struck at how much I enjoyed it. I mean, there was obviously a lot of work, but I really, really enjoyed the actual experience of learning in medical school.
Lewiss: Yeah, and I think some people may be surprised that medical school is actually fun, but I agree with you. It's actually fun and it's amazing the privilege that we're afforded and that we appreciate by having access to all these different rotations, all these different exposures, all these different specialties, and then we ultimately select. So tell us a bit about your selection of specialty.
Shetty: I think it's a challenge for every third-year medical student, and it's something I really enjoy discussing with my own medical students at Cornell when I do some teaching. For me, it was a bit of a process of elimination. I think you really, in choosing a specialty, what I encourage my mentees to really think about is to also really understand themselves and how they function best, because that will give them the best experience as a physician in terms of what they can offer to their patients and to their career.
So I began to eliminate things for various reasons. And then I increasingly was drew more and more compellingly to the study of the brain. And I realized that about myself, that as I tried to understand each organ of the human body, each one was so interesting in its own right. In terms of the GI organs, and the cardiovascular pathophysiology of the heart I found fascinating, as well as the kidneys and all the science that goes into that. But I realized that if I looked at all the organs of the human body, I just could not ignore the draw of the brain. I found the neuroanatomy fascinating and I found the possibilities of understanding the brain to be endless, in terms of the fact that even for neuroscientists, neurologists and neurosurgeons, there's so much about it that we don't understand. There's neuroanatomy that we don't understand, and the interplay of chemicals in the brain, neurotransmitters in the brain, and the function of different anatomical parts of the brain is something that I found to be an incredible puzzle for doctors and scientists alike.
And I thought, well, if this is something one can spend one's career trying to understand, that has to be rewarding. I also found it very compelling that the brain is really, in some ways, as I understood it, who we are or our soul, and it really defines so much of our desires and our personalities and our being and our experience, as well as our memories. And I thought, well, this has to be something that will be really interesting. And knowing myself, I wanted something that would continue to engage me for many years. And I found that in neurology.
Lewiss: Listeners that were paying attention, they may think, wow, wait a minute. You said Hospital for Special Surgery in New York City. Isn't that an orthopedic hospital? So why don't you bridge some gaps and fill in some of the holes about how you are the founder and director of the concussion clinic at the Hospital for Special Surgery as a neurologist at an otherwise orthopedic surgery hospital?
Shetty: Yes, so I work at a tertiary care orthopedic hospital. Hospital for Special Surgery is highly specialized. What's unique is that it does have many services, which cater to the active patient and, of course, the athlete. And as a result, there came to be a need for neurologists, of which I am one of a number of neurologists who practice here. For two reasons, one because as an orthopedic hospital we actually do a fair amount of spine. So there's a lot of nerve and muscle issues, which are relevant to the spine, for which a neuromuscular-trained neurologist such as myself could be useful.
And then also in the arena of sports, many people are aware that head injuries are an issue that is problematic in sports and with athletics today for patients of all ages. And so there is where my interest and the beginning of my kind of commitment to the world of concussion began.
Lewiss: So that makes perfect sense. And it's amazing to know that you're there working and that you're leading this comprehensive, intersectional, inter-specialty clinic. Who hired you? How did you get there?
Shetty: I was hired by Tom Sculco actually, who is a Brown graduate.
Lewiss: That was a planted question, of course, audience. So it actually, as we all know, it all goes back to Brown. Brown, Brown, Brown, Brown, Brown. So Tom Sculco, who was, I think, physician-in-chief at the time of Hospital for Special Surgery, hired you. And I think that's just a great little connection to highlight on the podcast.
Shetty: Yes, that was a fascinating connection for myself. I had always admired Dr. Sculco's work and he was kind enough to engage me in becoming a physician on staff. And it was absolutely wonderful when we realized the strength of our Brown connection.
Lewiss: Let's do a little bit of a deep dive into concussions in sports injuries. Make believe the audience members know very little about it. Give us some highlights of prevention treatment and what we need to know in terms of what the research is showing us.
Shetty: Concussion is unique as a scientific field in that we're still in the very early stages of understanding both the pathophysiologic basis of concussion and the injury itself of mild traumatic brain injury, as well as a lack of evidence-based guidelines for structuring a patient's recovery. So there is a general consensus on how to diagnose concussion. The definition of concussion continues to evolve, but most people do understand it as a constellation of neurologic symptoms chronologically following a blow to the head.
I think concussion is a big problem. Epidemiologically, it's fascinating because it's something that when I was in high school, nobody really was aware of anyone having a concussion, and now in many schools they actually have nursing staff and athletic trainers and athletic directors who are very conscious, and are implementing concussion policies, and are very involved in taking care of students with concussions. So the awareness has risen exponentially, actually in the last 10 years. And that's been a wonderful thing, which has also helped to prevent concussions and detect concussions. So going back to your original question, in terms of diagnosing concussions, I do feel very comfortable diagnosing them because I see them so often. In terms of managing them, I founded a clinic at the Hospital for Special Surgery, which is a multidisciplinary clinic. And we have a number of healthcare providers, led by myself, who work together to holistically provide a comprehensive concussion recovery for every patient of every age. We function almost like an urgent care, so we try to see patients as soon as possible after their concussion, if we can, and then triage them to a series of multidisciplinary therapists, including a vestibular therapist for issues of dizziness and lightheadedness that can happen when the posterior fossa, or the back of the brain, is affected and issues of vision as well and convergence of the eyes together.
We also work on neck physical therapy, so this can be very, very helpful and instrumental in patients with refractory headache and cervicogenic headache or with any kind of neck pain after a concussion. And also to actually prevent concussion, because when we build up their neck, it serves as prevention in some manner to help prevent future concussions when they hopefully, if they do sustain another blow to the head, they may not have a concussion if the neck is strong enough to absorb some of that force of that blow.
In addition, we also exercise patients. So I found it very challenging to give patients a prescription and say, "Go home and do this amount of exercise." That, although fine in the context of somebody who's just trying to exercise to become healthy, does not work, unfortunately I found, for a concussion patient who's really struggling with headache and dizziness and balance difficulties and vision problems and cognitive difficulties. So we found that when we held the patient's hand and said, "Let's come and exercise together," in the HSS concussion program, and measured their heart rate, and their heart rate variability, and their blood pressure, and actually watched them exercise, that it was a very, very different experience for the patient and it actually allowed a much swifter and smoother recovery. So those are sort of some of the elements. I think going back to my intrigue with the brain, I think all of us realize that the brain is so important for so many things, but very obviously, neurologically, it's responsible for things like our motor and sensory function, as well as our reflexes and our coordination and our balance. But on top of that, of course, it is sort of our mood, and who we are, and this very complex, intricate interplay between neurotransmitters in the brain that is at play with every kind of emotion and mood and response that we have. And, of course, a lot of environmental and genetic influence on that as well. And one realization that I had from treating so many concussion patients is that we couldn't do this in isolation. At the same time, I am a neurologist and not a psychiatrist, but mood, anxiety, and somatic symptoms are very much a part of almost every concussion patient’s experience. So to that end, we hired a neuropsychiatrist in the program to help us.
Lewiss: No, actually Teena, I'm glad you brought that up, because that as you're speaking and sharing this information, I'm thinking depression, there has to be high rates of depression and anxiety. So what role does psychiatry and therapy play in the treatment of your patients?
Shetty: I would say that it's essential and there's many patients who cannot recover from their concussion, especially if the symptoms linger indefinitely, without the assistance and collaboration of a neurologist and a psychiatrist because there is so much anxiety, mood disorders, somatic symptoms that can prolong a concussion and, in fact, impede its recovery. So I think it's myopic in a way to not recognize how important the psychiatric and psychologic element of concussion recovery is. So to that end, we hired a neuropsychiatrist to collaborate with in the care of these patients, and we also refer many patients for cognitive behavioral therapy and psychological services, because we find that many patients cannot recover without that teamwork.
Lewiss: There's the athlete who, in middle school, high school, gets a head injury, say gets hit in the head by a soccer ball, gets hit in the head by a baseball bat or a field hockey stick. The football player that is wearing a helmet and has a head injury, is there any difference in the approach to that age and stage of a patient as compared to the older patient—50s, 60s, 70s —slips on the sidewalk on the ice and hits their head.
Shetty: I think it is quite different. And I see all ages. I see many children, adolescents, and adults, and also elderly patients. And I think it is very different because developmentally, the adolescent brain or the pediatric brain is facing a different set of environmental factors, and also hormonal factors. And what we see is that children and adolescents are really more vulnerable than adults. Having said that, it's not to say that if you were concussed as an adult that you will have less symptoms. It really depends on the individual and the circumstances of the injury.
So this is one of the problems or one of the challenges in concussion care, which is that it is very individual. Because each of our brains is so different and functions so differently. So to answer your question, I think, the youthful concussions are very different to older concussions. I think with people of a certain age that concussion can be very troubling because sometimes they can kind of unmask a difficulty with memory that they may have already been struggling with to some extent. And I think with children and adolescents, it's extremely challenging because, unlike us, they're actually learning new material every day and processing and memorizing and doing homework, and so that often really unmasks concussion symptoms very quickly. And it creates a lot of problems when they're at that stage in their life and they really need to be learning new materials and being students in school, et cetera.
Lewiss: What has been found in the research regarding the role of diet and food, and what do you advise patients or people that use marijuana?
Shetty: I get asked that question a lot. So there's a lot of studies that need to be done and that have not been done. I think there's a tremendous interest in cannabidiols and CBD and a lot of these therapies that don't have the active THC ingredient. Unfortunately, I think that the science is not there yet. And as a concussion specialist, it's troubling to consider use of a substance that influences the CNS without fully understanding it. When I say CNS, I mean central nervous system. So we have to do the work to try to understand that because there's obviously tremendous potential in some of these substances, but we have to make sure that they're safe for patients, understand the long-term side effects, make sure that they're not addictive in any way, and then move forward.
But I think we're right in that era, and that time, and I think it's happening, and it's going to happen. So it'll be interesting to understand that as time goes on. But right now it's not something that I am comfortable utilizing in the care of my patients.
Lewiss: And I was thinking even the adolescent brain with the rise of marijuana and using marijuana that in the non-concussed adolescent brain doesn't do too well. So I would imagine that the same thing follows in a cumulative or additive effect. And what about diet?
Shetty: Diet is very important. So many of our concussion patients struggle with headaches and head pressure. So with regard to nutrition, I often counsel patients on lifestyle modifications. So I first try to understand what they are eating at baseline, and it's very interesting what you find out when you engage someone on their dietary habits. Especially younger people, because sometimes I find out that they don't have breakfast, or they skip lunch, or they don't eat very much at school when they have lunch because they don't like the food. So it's very important to really understand what we're working with and whether they're actually consuming sufficient protein, because we do find that there's a relationship between inadequate protein and refractory headaches or head pressure. And we also often try to understand what vitamins they're taking. We often check vitamin levels. Vitamin B12, of course, is very relevant to both the central and the peripheral nervous system.
So it can be useful to have some depth of understanding of this and also check blood work, for example, and get some more evidence-based knowledge about this. I think in terms of specific foods, there is a lot of word out there that Omega could be helpful, but we don't have the science to back that up, but I think there's no harm in eating foods with Omega. So it is fine. I usually encourage my patients to do so if they would like to.
Lewiss: Medicine is chock-full of research. Research is often on a standard white male, 70 kilograms. And increasingly we're aware that unless you actually study, for example, women or people from different racial/ethnic backgrounds, different cultures, treatment therapies may be different. How much of a sex and gender health lens do you take when you're doing your research and when you're treating your patients?
Shetty: In my experience and in literature, females recover very differently from concussion to males. So it's something that one has to really pay attention to and really understand what stage of their life they're at, what they're experiencing. I see a lot of adolescents, so I think many people underestimate the role of the hypothalamus and the pituitary on the concussion. I see a lot of sleep irregularities, temperature irregularities, and autonomic issues, which are probably all interrelated and have to do with the influence of the concussion on that part of the brain.
So I think it's very, very relevant to understand this. And I agree with you, the templates that we have are very much for one kind of person. And I think that continues to evolve, but it's something that we need to pay attention to.
Lewiss: So for the listeners in the podcast, for you, for me, if we have children in our life, if we have young adults in our life — what activities would you steer them away from, if you feel comfortable sort of committing, or what would you just advise regarding prevention of concussions?
Shetty: I would advise toward awareness and knowledge and education rather than forbidding children or saying, "This sport is dangerous, it's off-limits." I don't think that's a, kind of, a good way to raise them. But that's, of course, very personal. So I think it's better to educate them and let them make their choices. I think we are now in an era where people are very cognizant of the risks of head injuries. As scientists and physicians, we acknowledge that there is so much that we don't know. Can I tell you that if you have 10 sub-concussive blows that it won't leave you with any neurocognitive changes or problems in midlife? I can't, and no one can.
So we have to work with what we have and I think the best approach is early diagnosis, early detection. Refer to an appropriate healthcare provider, get the mild traumatic brain injury cared for appropriately, and hopefully the patient will heal and recover as quickly as possible, and then return to activity in full.
Now we do run into issues with people who have many concussions, but those issues are very individual and we have to really look at that in context. I'd like to back everything up with science and evidence-based medicine, and a lot of this we can’t back up with those things. So we have to just give our best judgment and oftentimes it's a family decision where we talk about, like we do with many things in medicine that I know you're very familiar with, Resa, in terms of risk, benefit, alternatives.
Lewiss: So our listeners are wondering, “Wow, if I have a concussion, I would love a Dr. Teena Shetty.” The wonder is what if I don't live in New York City? What if I don't have access to a comprehensive concussion clinic, what would you advise to listeners that wonder what is accessible to them and maybe with limited resources financially and/or in terms of health insurance?
Shetty: I would definitely recommend first trying to seek out a specialized health care provider—whether sports medicine, or neurology, or physiatry—who has experience in the care of concussion patients. If access to that is impossible, there are wonderful websites and literature on the web. The first example I can think of is the CDC website, which is an excellent resource for youth and adults with concussion, and explains the typical symptoms of concussion, what the typical management of concussion is, what one needs to watch out for, and what kind of therapies may be helpful.
So I think educating oneself about mild TBI can be enormously valuable for someone who's struggling in isolation with a concussion. I think it's very helpful to be seen in a comprehensive, multidisciplinary clinic. But, of course, that's not always possible. But I have seen many patients from other states and other places who've actually found those resources individually. Just through talking to people and doing research and getting connected with, say for example, a private vestibular therapist who they can access, or learning vestibular exercises online to help them with some of the symptoms, or learning about the options for their headache management. And although it's challenging, I think it can be done. And fortunately, because there is so much more awareness now about mild TBI, the resources are out there.
Lewiss: I think that's great. And to your point, so much is available online. People can read, people can access resources, they can access support groups, et cetera. So we started out the program talking and focusing on you. Then we moved more generally to your field of practice, your field of inquiry. I'm going to bring the lens back, bring the spotlight back on to you. And this is regarding you in the Hospital for Special Surgery. So, orthopedics, as we talked about, is male-dominated and 2019, listeners you may not be aware, but it's been many, many, many years that we have the American Board of Orthopedic Surgery. And 2019 marks the first year that they actually elected a woman as president of that American board. What has your experience been like as a woman physician in general, and also speak a little bit to who’s mentored you, and who you mentor, and your overall approach to mentorship?
Shetty: I've felt enormously welcomed in a male-dominated orthopedic culture at the Hospital for Special Surgery. So I feel very fortunate in that when I came here to work on staff as an attending, from the beginning, I felt that I was respected, encouraged, and supported. So that's been tremendously rewarding. Having said that, I think, I was one of a few women in the field at the time, and I think that from that one can also draw a certain strength. I did not find it discouraging at all because I felt very validated by my peers and encouraged, and also welcomed. I was very fortunate to have been mentored early on in my career by Dr. Russell Wharton, the physician emeritus for the New York Giants, who guided me in my initial role working as a neurologist for the Giants, and also exposed me to sports medicine and encouraged me in that direction.
So I think that was enormously helpful. It's now a tremendous part of what I do. And I think one of the things that I recognize in my own work is that there has been a dearth of female mentors to date for women in my type of career in medicine at my stage. And I've really tried to take that on with younger female physicians. So, for example, I teach in the Cornell Medical School and it's been very, very rewarding to work with first and second and third-year female medical students who are looking for a female mentor. And I think that's wonderful that they now have that structure and that they're encouraged to seek out a mentor. And there's programs that we have at Cornell, which actually enable that mentorship and encourage and guide the direction of that relationship. That's something that we didn't have when I was in medical school, or in my early years as an attending, and I think it's tremendously beneficial.
Lewiss: I couldn't agree with you more. And you and I both had similar experiences as we were navigating medical school, residency, fellowship training, early career, mid-career. Often the people that are mentoring and sponsoring may not be women. They are often men. They're often what we call “he for shes,” who believe in equity, believe in safe, equitable, and dignified work environments, and we are absolutely thankful for individuals such as these.
A final question: Had someone filled you in 10 years ago or had someone given you the rule book or the shortcut — are there things that you would have done any differently?
Shetty: No, I feel very fortunate, and I think it's funny that we're on the Brown Podcast, but I feel that Brown actually had a lot to do with that. Because I felt, as a PLME student and at Brown for undergraduate and medical school, I felt that the opportunities were limitless and it was so wonderful to be encouraged and praised for pursuing non-scientific pursuits as an undergraduate. You just feel like the world is your oyster and you can do anything. And I think that is really the message that I would leave people with, which is that, pursue your vision and really the sky is the limit. There's anything you can do with this if you have the tools and the education to do it with.
And I feel very, very fortunate that I felt those limitless possibilities from Brown, because it was such a broad education. That spirit of openness, I think, stayed with me throughout undergraduate and medical school and in my career, where I continued to try to figure out, “How is it that I can make this better?” Now it's for my patients or for my concussion program, whatever it is, “What can I bring to this that is out of the box?”
Lewiss: Fantastic. The beauty of a Brown education.
Lewiss: Teena, thank you so much. Listeners, we appreciate your feedback. We welcome comments in the show notes and until we speak again.
Shetty: Thank you so much, Resa. It's been such a pleasure.
The views expressed in this interview do not necessarily represent those of Brown University.