How specialty-spanning brain medicine training is driving better care for patients with complex brain disorders

People living with complex brain disorders — defined by their combined impact on how a patient thinks, feels and behaves — typically require coordinated care from multiple medical specialists. But all too often, these patients can struggle to access and navigate the multilayered care they need.

Long-persisting siloes in medical education and practice are a major contributor to this gap. While the medical specialties that diagnose and treat complex brain disorders (including neurology, psychiatry, neurosurgery, rehabilitation medicine and geriatrics) have made great advances in recent years, they are not designed to collaborate or even share the same language — tending to train and work in isolation from one another.

Since 2020, the University of Toronto’s Temerty Faculty of Medicine has been working to break down these barriers through innovative brain medicine training opportunities that look at symptoms arising from brain dysfunction in a holistic way.

Now, with generous support from the Azrieli Foundation, the Azrieli Brain Medicine Fellowship Program is accelerating efforts even further — building capacity to train new brain medicine practitioners and, ultimately, transforming the way we treat patients with complex brain disorders in Canada and around the world.

“The Azrieli Foundation has long enabled innovative research and care to improve the health of individuals and communities, with a particular focus on brain health,” says Naomi Azrieli, chair and CEO of the Azrieli Foundation. “But at the very core of our mission, is an imperative to harness the power of education. Through the Azrieli Brain Medicine Fellowship Program at Temerty Medicine, we are doing both: supporting the next generation of exceptional clinicians and investing in a future where complex brain disorders can be identified and managed effectively.”

From Specialized to Holistic Care

The training program is being spearheaded by Sara Mitchell, an assistant professor of neurology at Temerty Medicine and a neurologist in the Sunnybrook Health Sciences Centre’s Hurvitz Brain Sciences Program.

“Traditionally in medicine, the longer you train, the more narrow and hyperspecialized your focus gets,” says Mitchell, who is also the director of the Azrieli Brain Medicine Fellowship Program. “With these fellowships, we’re turning that model on its head — broadening trainees’ experiences so they can provide enhanced care for patients with complex brain disorders.”

Mitchell goes on to explain that the unique, competency-based program, which initially launched in 2019 as a pilot in Sunnybrook’s Hurvitz Brain Sciences Program, is helping develop well-rounded brain medicine experts who can help steward people through the health-care system — and find the care they need.

“For example, now a patient with a complex disorder will be able tell their story to a brain medicine fellow who can then hold a single case conference with a psychiatrist and a neurologist and get their different perspectives,” says Mitchell. “This integrated approach takes the burden off the patient and their family — which could help shorten the patient’s journey through the health-care system by months or years, and improve their quality of life while reducing costs.”

She also points to the long-term value of addressing this gap via medical education.

“Training fundamentally shapes health professionals and the work they do throughout their entire careers,” she says. “The goal of the Azrieli Brain Medicine Fellowships is to have an immediate, but also a lasting, impact on patient care and research that will continue to grow for decades to come.”

Building Connections

Sarah Levitt was the program’s inaugural fellow in 2020 and has experienced the difference the fellowship training has made on her psychiatric practice.

“The experience provided me with countless clinical opportunities and research connections across specialties that are now benefitting my patients,” says Levitt, an assistant professor of psychiatry at Temerty Medicine and a general adult psychiatrist with the University Health Network.

“For example, by training alongside neurologists, I’ve gained a much better understanding of how to identify and treat conditions of cognition. I now use this knowledge when caring for patients experiencing severe and persistent mental illness –– many of whom also exhibit cognitive impairment.”

Levitt is also now helping lead the Azrieli Brain Medicine Fellowship Program as its associate director — working to ensure future fellows receive the same value in their training.

“This fellowship mirrors the kind of care we’re trying to provide,” says Levitt. “We’re looking at brain dysfunction and its many symptoms from every angle, and providing the most holistic care possible.”

Learning from Peers and Advancing Science

Current Azrieli Brain Medicine Fellow, Carl Leochico, is also already seeing the training program’s impact on his work.

“A patient’s behavior and affect (i.e., their emotions and moods) can have a huge positive or negative impact on their response to rehabilitation,” says Leochico, who originally trained as a physiatrist in his native Philippines.

“Through the Azrieli Fellowship, I’m being trained by neurologists, psychiatrists and physiatrists and am learning to detect neuropsychological disturbances in my patients – helping them maximize the benefits they gain from physiotherapy, occupational therapy and speech and language therapy.”

While growing his familiarity with neurology and psychiatry as an Azrieli Brain Medicine Fellow, Leochico has had the opportunity to care for patients with acquired brain injuries at in-patient and out-patient units at the Toronto Rehabilitation Institute. He’s also been able to pursue clinical rotations with different institutions across Ontario to learn about general psychiatry, cognitive neurology, sleep medicine, neuropathology, neuromodulation (e.g., transcranial magnetic stimulation, deep brain stimulation), concussion, cognitive behavioral therapy and functional movement disorders.

In addition, Leochico’s experience has included a significant focus on interdisciplinary brain medicine research – a personal interest that the competency-based, specialty-spanning nature of the Azrieli Brain Medicine Fellowship has allowed him to pursue in addition to his clinical work.

“I’m currently working with Dr. Mitchell and her team on a paper on telemedicine care for dementia and how to guide clinicians in performing virtual neurological exams,” says Leochico.

“We are also working on other research projects, such as case reports on novel genetic variations in familial, early-onset dementia and a specific genetic variant’s role in causing a rare neurodegenerative disorder. Contributions to scientific literature like these are vital to the hope of one day seeing improvements in dementia prevention, diagnosis, and treatment.”

Looking Ahead to Impact

Incoming Azrieli Fellow Mike DeDominicis, currently a fifth-year neurology resident, is eager to follow in Levitt and Leochico’s footsteps beginning in 2024 — and is already looking ahead to the impact the training will have in shaping his future contributions to patient care and research.

One area of focus is his work developing a reference guide that combines neurological and psychiatric lenses for clinical assessments to facilitate the diagnosis of brain diseases.

“Symptoms may seem to belong solely to the field of neurology or psychiatry — for example, numbness or depressed mood, respectively — but there is often an interplay between the two,” he says. “Incorporating a holistic brain medicine approach to this work makes a lot of sense.”

DeDominicis also points out that U of T’s size and breadth helped to draw him to the Azrieli Brain Medicine Fellowship Program.

“There's such a high concentration of different experts working at U of T, so if you really want to learn more about a new or specialized area, or explore the intersection between fields, Toronto is an ideal place to do that.”

Ultimately, DeDominicis plans to use the knowledge he gains as an Azrieli Brain Medicine Fellow to contribute to patient education work — with the ultimate goal of addressing the stigma that exists in mental health.

“The Azrieli Brain Medicine Fellowship promises a broadened clinical perspective that will allow me to better explain to patients the relationship between their brain health and their experience of mind,” he says. “I think discussing psychiatric symptoms as a consequence of organ dysfunction — like shortness of breath is a consequence of lung disease — is a critical step in addressing mental health stigma.”

What’s Next

While the Azrieli Brain Medicine Fellowship Program is still officially a pilot, ambitions for the program’s future are high.  

“Our plan is to leverage this successful proof-of-concept so that brain medicine can eventually become a recognized training program in Canada and abroad,” says Mitchell. “We want to build a model that can be replicated and expanded at different institutions across the country and around the world. We’re already seeing the impact here in Toronto and are laying the groundwork to transform how patients with complex brain disorders are treated everywhere.”

Mitchell also notes the central role the Azrieli Foundation’s support is having in enabling this larger vision.

“The foundation’s support has made it possible to accelerate the program’s development significantly,” says Mitchell. “Thanks to their gift, we’ve expanded the number of fellowship opportunities we offer and are building a network of people who've been trained in this unique way. In turn, they will go on to share their newfound expertise with their peers and colleagues. We’re also disseminating what we learn from the program to other institutions through a new Azrieli Brain Medicine Conference — laying the foundation for similar programs, based on our own, to develop elsewhere.”