Facing MS: From First Symptoms to First Steps

Facing MS: From First Symptoms to First Steps

Episode 186 – Podcast Transcript

Stephanie Buxhoeveden: [Music] Welcome to the Can Do MS Podcast. I’m your host Stephanie Buxhoeveden. I live with MS, and I’m also a clinician and MS researcher. Today we’re joined by Dr. Leorah Freeman who’s a neurologist and the medical director of the MS and Neuroimmunology Center at University of Texas, Austin. She’s not only dedicated to caring for people with MS, but also leads innovative research to better understand and treat the disease. Hi, thank you so much for being here today.

[(0:48)] Dr. Leorah Freeman: Uh, thank you for having me, Stephanie.

[(0:51)] Stephanie: We had the pleasure of meeting recently in person for the first time, and I feel like we hit it off. So I’m really excited that we get to chat here today about newly diagnosed.

[(1:02)] Dr. Leorah: We truly hit it off, and yes, it’s absolutely an honor to be here and just talk about this important topic and-and the, you know, great-great discussions can be had around, you know, diagnosis of MS and how can we make it more timely and more accurate for our patients.

[(1:16)] Stephanie: Definitely. And I feel like an old timer now, right? Because compared to [giggles] 15 years ago-ish when I was diagnosed, it feels like the whole process of being newly diagnosed has really changed. Is that how you see things?

[(1:29)] Dr. Leorah: Yeah. I mean, I feel like an old timer as well. I’ve been in practice now over 15 years and-and, uh, as an MS specialist, and-and I agree with you, I think things have changed. And-and, you know, the reason why things have changed is because our diagnostic criteria have changed over time. And those diagnostic criteria are the guidelines that we as neurologists follow to, uh, diagnose MS. And every few years we, you know, think again about those criteria and how we can make the process better, faster, more accurate for-for patients. And-and, uh, I think that this has led to a-a lot of changes. I mean, I remember when I started in practice, you know, again, f-, you know, 15, so years ago, um, where, you know, people with MS had to wait for another event, you know, to be diagnosed with MS.

Let’s say they had their first relapse, then that was not enough to make a diagnosis. They had to wait to have another relapse or new lesions on a subsequent MRI. And that led to, for some people, two years, uh, of-of delay in the diagnosis. So I think this is something that, you know, we-we’ve been able to achieve with the nuclear diagnostic criteria is now really being able to diagnose people sometimes here and there at their first event, uh, of MS. And-and, uh, and that has changed our practice tremendously because now we have opened the door to, uh, treating people earlier with effective therapies.

[(2:59)] Stephanie: Yes, that’s so true and so important. When I was diagnosed, it was my first event that triggered me to actually seek medical attention, but then in retrospect, I had symptoms that let us establish that dissemination in time, right? This, those two attacks. But it was incredibly frustrating as a provider to have to wait and watch people get worse before, after offering them treatment, which is crazy because now we know the sooner you treat the better you’ll look down the line.

[(3:29)] Dr. Leorah: Yeah, absolutely. And I think what’s fascinating is that now even with our-our last iteration of the diagnostic criteria, we may be able to even diagnose people with MS without any symptoms, you know, highlighting the importance of all these other tests like MRI, in particular, in making a diagnosis so that even people who never had symptoms but had an MRI for other reasons and show, you know, lesions typical of MS, may come to a diagnosis. Meaning that we could even prevent them from even having this first episode or prevent them from occurring disability.

[(4:04)] Stephanie: Yes. That’s so exciting. I mean, literally goosebumps being able to catch it early and treat it early. Um, but it really goes to show how far technology and how far our understanding of-of MS have, has happened [noise] in a relatively short period of time. But as you said, although we can catch MS earlier, that’s not the case for everyone. And so how have things changed for those of us who are either initially diagnosed with a more aggressive form of relapsing MS or even [noise] primary progressive MS?

[(4:34)] Dr. Leorah: Yeah, uh, you know, I think that’s, you know, even though we’ve made tremendous, you know, progress in diagnosing MS earlier, we still have not reached the holy grail of having a single test, like a blood test that says, boom, you have MS, we know you have MS, we don’t have that. So MS remains a diagnosis of elimination. We can, you know, certainly do the process faster now, but there’s still some clinical situations where it’s more difficult to make a diagnosis. So you mentioned two different contexts. People with initially more aggressive disease, people with progressive disease, vastly different situations, but both challenging, you know. So to kind of explain to our listeners, you know, what is aggressive MS. So there are usually folks that tend to have a lot of relapses or sometimes accrue disability very quickly and can have a lot of activity on their MRIs with lots of new lesions, lots of active lesions on their scans.

And, uh, and sometimes, you know, these cases can be surprisingly difficult to diagnose because we may look for other causes, infections, tumors, other things that can cause these really kind of sometimes very impressive, uh, MRI presentations. Um, but these cases are-are the ones for which we have to fight for an early diagnosis because our treatments really matter in preventing the next attack that can be extremely debilitating. Um, on the other end of the spectrum is people with primary progressive disease where we don’t have these typical episodes of relapse and remission, where instead we kind of have this slow progression of symptoms sometimes so slow that people don’t even notice. It’s just very subtle over time. And, um, and these patients tend to be very quickly dismissed or misdiagnosed as having, you know, sciatica or other, you know, problems because they drag their foot, for example. And it’s rare that, you know, doctors immediately go to looking at their brain or spine MRI to move towards a diagnosis of MS. But you know, these days we have treatments for people with progressive disease with more that are in trials right now. So, uh, I think that it’s important now to be able to recognize these cases faster.

[(6:58)] Stephanie: Yeah. All very wonderful insights. And like you mentioned, it’s complicated sometimes, and as much as we want an answer in a diagnosis, sometimes it still takes a little bit more evidence gathering, and it’s not necessarily the goal to move quickly, but you have, also have to make sure that you’re diagnosing the right thing and picking the right treatment.

[(7:22)] Dr. Leorah: Yeah, no, absolutely. I think, I think that’s in, the other side of the coin that-that we don’t necessarily talk about a lot is that yes, there are some people who have significant diagnostic delays, but we also see and not insignificant number of people who are misdiagnosed as having MS. And I think you’ll talk to any MS specialist and they can tell you their situations where they had to undiagnosed MS. Uh, you know, and-and that’s really highlights the importance of striking that right balance between timely and accurate diagnosis. Um, and that can be challenging. Again, we have, we don’t have the holy grail, you know, the blood marker that tells us you have MS. So we have to use our-our clinical judgment, look at the clinical presentation, look at, you know, exactly what the MRI looks like. We spend a lot of time inspecting, you know, the-the, those lesions, how, where they are located, what is their shape, um, um, you know, and to-to really help differentiate running other tests, sometimes to rule out other causes, uh, to really make sure, because there is a risk of morbidity associated with starting an immunosuppressive treatment when it is not indicated.

So we wanna make sure that we treat the right people at the right time. Uh, I would say that the-the, you know, the, or the new diagnostic criteria, the new revision of the diagnostic criteria that have been proposed this year, this past year, um, are really looking to, um, help us in making a more specific diagnostic of MS. So we’re seeing some exciting things come out of the MS community with these new biomarkers, uh, particularly on MRI, looking at the central vein sign, which is a very specific sign, uh, that we can see within MS lesions that we don’t see in other conditions that can mimic MS on MRI. And so I think these new biomarkers are kind of gonna help us, uh, as they become implemented in clinical practice in trying to, again, not only diagnose people quickly, but also make an accurate diagnosis.

[(9:33)] Stephanie: Yes. And we’ve alluded to the new McDonald criteria a few times in the…

[(9:37)] Dr. Leorah: We have.

[(9:37)] Stephanie: … in conversation. The new diagnostic criteria. So maybe I’ll-I’ll pause for a second and ask you to tell us a little bit more about that. Um, and also interject with how participating in clinical research actually helped me. Um, so I go to the NIH every year. I get MRI scans of my brain, and I have very, uh, spinal MS, so I have a lot of disease in my spinal cord and optic nerves. Not a lot of brain lesions, not a lot of new brain activity. So this was always, you know, you mentioned there’s a lot of mimics, right? There’s almost 100 diseases that mimic MS. And so that was always sort of an uncertainty. I went on MS treatment, that’s what we landed on eventually, but there’s always been this sort of question in the back of our minds, could it be something else? And so I actually participated in MRI studies on central vein sign, and what they did was they looked at my lesions and they looked to see whether they had vessels, blood vessels running through them. And we now know, thanks to that clinical research, that, uh, most MS lesions do have a central vein, and-and it has been incorporated into the diagnostic criteria. So that to me was one of… I participated in a lot of clinical research, and I always tell people it’s not just about helping researchers. It actually helps you [giggles] learn more about your disease and manage it better. But, um, but yeah, I’d love for you to just tell us a little bit more about the diagnostic criteria updates.

[(11:04)] Dr. Leorah: Yeah. I mean, first I wanna commend you for, you know, accepting to participate in research. I mean, interestingly, me and my team have been on the other side of that research as we’re a clinical sites that has enrolled patients into, uh, research on the central vein sign as well. And, uh, so it’s been fascinating seeing the journey from the very first studies that research started, you know, eight years ago to, uh, now really seeing this incorporated in the diagnostic criteria. So, uh, to tell our-our listeners, you know, more about the MS diagnostic criteria. So as I mentioned, ver-, you know, earlier on, uh, you know, these diagnostic criteria are, you know, the guidelines that help us make the diagnosis of MS every few years, they tend to be, um, revised. So we have now a new iteration of the, um, you know, the revisions to the diagnostic criteria, which we call the McDonald’s criteria. And, uh, over time it has changed to help us diagnose MS earlier.

Um, I think that there’s some, you know, I-I-I think that this new revision, uh, that, um, is, uh, you know, coming out of-of the new criteria is-is it’s a big shift, uh, in many ways and a very interesting shift. And there are several things with the-these new revisions that have caught my-my interest. The first one is that, um, as I’m, I think I mentioned earlier as well, you know, with these new diagnostic criteria, we put the emphasis on the MRI and not just the clinical presentation, and that’s allowing us to diagnose MS even without symptoms really getting as early as we can in, uh, the diagnosis of this condition and its treatment. Um, the other aspect is that we are looking at the MRI a little bit differently.

First we’re, you know, you mentioned you had lesions, you had lesions in the optic nerve, it involved your optic nerve. That was something that interestingly, even though optic neuritis or inflammation of the optic nerve is a leading presentation of MS, right? Very frequent, very common, you know, first symptoms, surprisingly enough, the optic nerve was not counted as-as a localization for MS lesions. So that has been rectified with the new, uh, diagnostic criteria. And then, you know, in these new revisions, we now have, um, uh, we now have the introduction of new MRI biomarkers such as a central vein sign. You gave us a great, you know, uh, summary of what the central vein sign is, you know, like looking at MS lesions as being different from other conditions that cause lesions in the brain, as you know, in the fact that they have this central vein that runs through them, giving them a special shape, uh, and aspect.

Um, and then looking also at as, a different kind of lesions, which we call paramagnetic rim lesions, using other sequences where we see kind of like a-a halo of a different kind of inflammation around the lesions, which is also quite specific of multiple sclerosis. So we’re really trying with this new diagnostic criteria to expand, you know, ho-, in whom we can diagnose MS at the same time as we’re trying to ins-, increase the specificity, uh, of the diagnosis, making sure that we’re not misdiagnosing people as having MS when really they have something else. Um, to add a quick word on, you know, your particular situation. It’s one that has always fascinated me. Uh, people who tend to have lesions in their spinal cord, but no lesion in their brains. Uh, and, um, that was always very, very difficult to diagnose very long di-diagnostic delays, uh, particularly if people had, you know, sometimes progressive forms of the disease. They tended to have more frequently lesions in their spinal cord. And-and, uh, I think that’s also something that’s being addressed with a new diagnostic criteria, being able to diagnose people even when they have just lesions in their spinal cord. Uh, and, uh, so I think, again, we’re, it-it’s-it’s opening up a lot of opportunities for us to-to make, uh, make good diagnoses at the right time.

[(15:09)] Stephanie: Yeah. Thank you. That’s so fascinating. And so, speaking of me being a little bit of an oddball, tell us a little bit about, with the diagnostic criteria in mind and the fact that you mentioned optic neuritis is one of the most common presenting symptoms of MS. Is there something that you see initially, although we can’t predict who’s gonna progress worst in most cases, is there something you use clinically to tell you that this is a person who needs high efficacy therapy right off the bat, or something that puts your mind at ease a little bit?

[(15:46)] Dr. Leorah: So I would say that, you know, f-first you kind of maybe take a step back and talk about how do we approach treatment in general. I think because this has changed really tremendously as well. You know, we used to put people on the lowest efficacy possible and then escalate as they failed and had new relapses, new attacks and disability. Uh, and now we’ve kind of flipped this pyramid on its head, and we’re more and more, you know, comfortable and proactive in treating people with high efficacy early, uh, and, uh, we, you know, but it’s always trying to navigate the benefit risk of these high efficacy treatment with a, versus potential complications and risk that, you know, may affect our patients. And I think that they are, we-we have some knowledge from research about, um, specific, you know, presentations that can be associated with the risk of, you know, poor outcomes.

So we know, for instance, that, um, you know, people who tend to have a lot of lesions in the, in their spinal cord or in the bottom part of their brain called the brainstem, may have, you know, more difficulty because this area has a lot of motor fibers and, you know, things that can impact patients’, you know, ability to-to walk over time. Um, we know that, you know, something that I look especially about, you know, regardless of where the lesions are, is-is how do people recover? You know, I think that also gives us a lot of information. Let’s say somebody has an, has an attack and-and then they recover poorly and slowly. That would be for me, like also a great scenario in which I absolutely wanna start a high efficacy early, because-because any relapse can cause, you know, the accrual of disability. So, uh, looking at, you know, where the lesions are, looking at how people recover after their attack, we also look at, you know, sometime there are some ethnic differences we believe, you know, um, and, um, some patients from, you know, minoritized backgrounds may have a higher risk of recurring disability. So this is something that in practice, we can be sensitive to as well. But I would say that overall, you know, even without these findings of severity, we tend more and more to treat patients with high efficacy treatment early.

[(18:07)] Stephanie: Thank you. We’re gonna take a brief break for a message from our partner on this episode, and when we come back, we’re gonna talk about what that conversation about picking treatment looks like and more. [Music]

[(18:23)] Female Speaker 3: The following message is brought to you by Novartis. Since partnering with Novartis, I have been thinking a lot about when I was first diagnosed with relapsing MS, and to be honest, I was overwhelmed and in denial, and I didn’t wanna accept it. Eventually, I had to be real with myself, reflect on what was important, reframe how my diagnosis was impacting my life, and focus on how I was feeling. And I wish I’d started thinking about my needs sooner. It helped me get to a place of acceptance and find the right treatment choice for me. And I really hope others don’t wait as long as I did. That’s why I partnered with Novartis to create a three-step guide, hoping it can help people speak up and voice their needs. Get the guide@reframingms.com. [Music]

[(19:13)] Stephanie: Welcome back. So when we left off, we were talking about the complexities of diagnosing MS early and accurately. Now I wanna focus on what happens in the room with-with you and your patients. So, as we alluded to, choosing a first treatment is overwhelming. So how do you help people navigate that decision?

[(19:34)] Dr. Leorah: Well, I think that the key is to really understand for the patients, and you know, myself as-as a clinician, to really understand that we’re in this together, we’re a team, you know, we’re working this path together. And that’s both people. The, you know, the-the clinician and the patient have to share information freely and both understand each other very well. And that’s what we call shared decision making. It’s very important, you know, for patients to understand their options, what’s available to them to be, you know, educated on what MS treatment looks like, what are the goals of treatment, uh, what we hope to achieve in the short term, in the long term. Um, and so that’s something that I spend a lot of time, you know, talking about, you know, just going from the higher level to the deeper level of like, what is treatment? What is the goal of our treatment and-and what-what are we hoping to achieve?

And at the same time, it’s important for me as a clinician to understand who my patients are and what their priorities, what their goals truly are. And because every person is different, every person has their fears, their concerns, their background, uh, their experiences, and being able to communicate that with one another ensures that, you know, we pick a treatment that’s not just right for their disease, but right for them as individuals. So, you know, I usually, um, choosing a treatment takes sometimes, and as I said, I want, I want my patients to have the time to reflect and have the time to learn. Uh, often I-I try to not, I try to give people some time by having two visits back to back, one visit where we talk about the diagnosis, we talk about what MS is, we talk about, you know, whether our treatment options and goals of treatment.

And we talk a little bit about what treatments I-I envision for them, you know, I-I explain what a high efficacy treatment is versus lower moderate efficacy. What are the risk benefits of these different treatments? I answer their initial question. Then I-I let my-my patients go home with their families and loved ones and with some information, you know, usually send them home with some information packets and things to read. And then we come back again, you know, say a few days later or a week later after, you-you know, we run some initial tests to be able to, you know, really make a decision. That’s when I listen to their questions, that’s when, you know, we-we really talk again about their preferences and goals and-and we’re able to make a treatment decisions.

[(22:15)] Stephanie: Yeah, I think that’s such an important point. I was, like I said earlier, diagnosed in a time where we had, you know, three options and at that time, getting a MS diagnosis was terrifying. And the side effects of the medications that were available at the time were almost equally terrifying. Right? So now that we have over 25 options, I really empathize with people who are newly diagnosed and-and understand what a daunting, overwhelming decision can be. ’cause it’s almost as though your mind’s wrestling with what am I more afraid of, my MS or the medicine that I need to treat it? [Inaudible] help people with that.

[(22:55)] Dr. Leorah: Yeah. It’s-it’s, you know, it-it’s… that’s why, you know, aligning on the goals of treatment is so key, you know, because sometimes we’re, you know, people are like, well, I had this relapse where I had a little bit of numbness or weakness in my leg. I can live with that. I cannot live with the side effects of the treatment. So, I mean, I think now we have a lot more option for the side effects and not what they used to be with all these injectable. But also I think we-we look at treatment differently. You know, you talk to any MS specialist, we’re really looking at treatment as a way to protect the brain in the long term. The analogy I give my patients is-is like investing in your 401k, you know, your MS treatment is-is a 401k. You are, you are investing in your brain, you know, not, not to prevent a-a mild relapse in the next year, but to prevent disability when you’re 50, 60, 65, so that you can live a long life without, you know, hopefully accruing, you know, as much disability.

And so, you know, treating, that’s why treating early with high efficacy treatment has become really a mantra for us. Um, because we, those treatments can really reduce disease activity very significantly. And when we choose the right treatment, we’re able to do this with minimal, you know, uh, side effects or complications and navigate then the path with our patients. So I think it’s really important for, you know, to-to weigh things equally. You know, when-when we treat MS, we don’t, it’s not just-just a matter of preventing a relapse or two, it’s really protecting the brain from further damage and from disability that can, you know, um, not maybe occur immediately, but can certainly occur in the future if you accrue brain damage because you’re undertreated.

[(24:52)] Stephanie: Yes. Thank you. We had another podcast on this issue, um, last year, and the doctor that we interviewed said that he hadn’t prescribed a wheelchair in several years. Do you think now you’re seeing less relapses, less disease progression than compared to in the past before we had all these high efficacy therapies?

[(25:14)] Dr. Leorah: One hundred percent. I mean, this is, this is a huge change that I have seen in my own lifetime as an MS clinician. You know, 15 years ago when, you know, all we could use as a first line were injectable therapies. You know, many patients would come to my clinic, uh, using wheelchairs or even sometimes on a gurney. I mean, it’s-it’s-it’s a-an entirely different level of-of, you know, disability that we used to TC at that time. Now with the advance of high efficacy, early, uh, and not just that, but also our more active monitoring of the disease. You know, MRIs regularly, you know, in our clinic, we also do biomarkers. Um, you know, we are really trying to see not just, you know, who we need to treat with high efficacy early, but when is a good time to change a treatment before our patients have to suffer devastating consequences. So, yeah, it’s-it’s just changed dramatically. So many of my patients, you know, report, like people would not believe I have MS because I look so good. And, uh, and this is a testimony to, you know, how things have changed and-and the-the good work that has been done in-in, you know, treating-treating MS earlier, treating her more effectively, and monitoring it, um, you know, very aggressively as well.

[(26:32)] Stephanie: Yes. I think there’s a lot of hope out there…

[(26:35)] Dr. Leorah: [Inaudible]

[(26:35)] Stephanie: … for the newly diagnosed.

[(26:37)] Dr. Leorah: Yeah.

[(26:37)] Stephanie: Yeah.

[(26:37)] Dr. Leorah: Totally.

[(26:38)] Stephanie: So, we’ve talked a lot about medicine, but in addition to medicine, most newly diagnosed people also wanna know whether they need to change their diet or do a certain type of exercise. And there’s so much advice out there about how to live a healthy lifestyle with MS, but what does this actually look like in real life without it being completely overwhelming or riddling you with guilt? [laughter]

[(27:01)] Dr. Leorah: [Laughter] Yes, we do not want that. You know, uh, you know, forming healthy habits is, you know, really a-a-a change that happens over time. Uh, it’s not, you know, something that you just wake up and change everything all at once. It’s-it’s a journey in and of itself, and it’s something that should bring joy rather than bring resentment and bring guilt. Um, so I’ve learned a great deal about lifestyle modification. It’s always something that has, you know, you know, that I have been passionate about. Uh, but, um, I, um, about a year and a half ago, I started working with my colleague, Dr. Lisa Doggett, who is a lifestyle medicine specialist, and she works with her, with us in, at our center. She works with our patients. And, uh, and, uh, she, uh, is, uh, a family medicine doctor who’s board certified in lifestyle medicine.

And the way that at our clinic, you know, we approach lifestyle changes is again, really as this, it’s a marathon, not a, not a sprint, but we try to take into account all the different aspects of-of lifestyle. So looking at diet, looking at exercise and movement, looking at, um, you know, use of co-, toxic substances, alcohol use, tobacco, all of this. But also looking at things like, you know, stress and mental health, looking at, uh, connectedness, um, and how, you know, our-our social lives, how rich our social lives are, because all of this is part of-of our, of our lifestyle. So there’s a lot of adv-, you know, advice out there sometimes claims that we can reverse MS with diet. I personally think that lifestyle modification is-is a tool in addition to disease modifying therapy, and that’s how we obtain the best outcomes.

Sometimes have patients who arrive and they are, their lifestyles are great, but they don’t wanna do disease modifying therapy. And I’m like, you know, you’re already doing the hard parts. You know, why not do that? Uh, but, uh, most of the time people wanna take a treatment and want everything to just look great afterwards but we have to do the hard work too. And-and again, as I said, it’s a journey. So, um, you know, so a lot of, you know, looking at-at lifestyle, not just as being like a-a magic diet, we are gonna do, uh, or a magic exercise we’re going to do. But again, it’s like a-a-a thorough and holistic change in how we approach life or relationships or relationship with food or relationship with movement and try to, you know, start at a small, at, you know, at our level, you know, see, uh, uh, see what we can do.

So, uh, Dr. Doggett who works in our clinic, she starts her visits with our patients by doing a-a, uh, a lifestyle, um, she uses a lifestyle questionnaire, um, to, uh, evaluate where people are along these different axes of lifestyle medicine and, uh, then kind of talk about goals, you know. Um, in terms of diet, we, uh, we are big proponents of, uh, of, um, plant centric Mediterranean diet for, uh, our patients. Um, and I think that’s where we have the most data, not just in MS, but also in, you know, brain health in general, uh, prevention of dementia, and also in heart disease. Um, and then with movement, we have guidelines, you know, that’s, that, uh, encourage people with MS to exercise more. But the key is finding what type of exercise works for each individual, you know, patient and not, again, not just try to do massive amount of change at one time, but incrementally, you know, walk more, start lifting weights, do a little bit more cardio, but find what’s enjoyable.

Your neighbor might love to swim, and you might love to be at the gym lifting weights. It’s, you, you know, we each have to find what works for us and what works with our, you know, other aspects of our lives and our other responsibilities. So this is what I encourage my patients to do, is to just have an open mind and, you know, meet with a lifestyle medicine specialists, listen to the great podcast, they are on MS and lifestyle, and just make one change at a time that-that aligns, you know, with-with their values and-and what they like. And, uh, especially that just brings joy and connection.

[(31:09)] Stephanie: Yes. And your patients are so lucky to have you…

[(31:13)] Dr. Leorah: They are.

[(31:13)] Stephanie: … in that [laughter] in that resource. So what can people expect from a healthy relationship? Clearly, you have a very healthy relationship with your patients and-and a holistic a-approach with your MS team, but how can somebody tell if they have a good relationship or maybe if it’s time to get a second opinion?

[(31:33)] Dr. Leorah: Yeah. And that’s, you know, I-I think that’s a tough one. I think, you know, they-they’re, you know, sometimes, and I hear this from-from patients who’ve transferred care sometimes to me because they couldn’t really find that relationship. Um, you know, I think, you know, as I said, like those first visits are really meant to understand each other. You know, it’s a conversation. People should not feel like they’re talked to or told what to do. They should feel like they’re engaging in a conversation with their, you know, with their care team that, you know, their doctor is interested in what matters to them and what’s, what is a challenge in their lives, what their goals are. And if they don’t have that, you know, impression that their healthcare provider is listening with intent to what matters to them, or not asking their opinions, or, um, sometimes just like, well, if you don’t agree to do this and you don’t need to see me, I-I mean, I’ve heard patients report stories like this, it horrifies me, you know? But again, that’s-that’s [music] to me is a sign of-of, you know, finding the right healthcare provider is somebody who will have a good, you know, eq, somebody who can really kind of walk with you and that makes you feel heard, makes you feel seen, cares about you, is responsive. That’s-that’s when you know, you know, you found the right one. And, uh, and it’s okay, you know, to-to move on. Sometimes, you know? [Music]

[(33:05)] Stephanie: It is a relationship just like any other relationship…

[(33:08)] Dr. Leorah: Any other.

[(33:08)] Stephanie: … in your lives. One of the most important relationships you can have.

[(33:11)] Dr. Leorah: Yeah. [Music]

[(33:12)] Stephanie: I really wanna thank you for your time, your expertise in this great conversation today. Once again, just thanks for being here. [Music]

[(33:19)] Dr. Leorah: Oh, it’s my pleasure to be here. Thank you so much, Stephanie. [Music]

[(33:23)] Stephanie: Thank you for listening to this episode of the Can Do MS Podcast. If you like this episode, please leave us a rating and review on Apple Podcasts or Spotify. We really appreciate your feedback. We’d also like to thank Novartis for collaborating on this episode of the Can Do MS Podcast. Until next time, be well, and have a great day. [Music]

[END]

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