The Next big thing in MS treatment, a Conversation with John Scagnelli, MD
Episode 86 Recap of the FLATLINING Podcast
This week Matthew and Ron welcome a Dr. John Scagnelli, from Raleigh Neurology Associates, P.A. to the FLATLINING podcast. Dr. Scagnelli shares with us his journey into medicine and neurology. He provides his insight on some often talked about topics on the podcast, like the future of medicine, what to expect from a life in medicine, and how he has seen the treatment of Multiple Sclerosis (MS) change over his career in medicine.
Matthew welcomed Dr. Scagnelli to the program and asked him to provide some insight into what motivated him to pursue a career in medicine. He explained that he had several physicians in his family, his grandfather, and several uncles. Though his parents were not physicians, he explained that they were both successful in their careers, but he felt like he wanted to devote himself to something else. Explaining that he considered psychology, the ministry, and medicine. Reflecting on his practice, he said that sometimes he feels as though he is doing all three. Dr. Scagnelli specializes in Multiple Sclerosis, a debilitating disease that has no known cure and the cause is still uncertain.
Matthew asked our guest what drew him to his specialty and Dr. Scagnelli pointed out that Neurology, unlike some other areas of medicine where there are more ancillary test procedures, historically based more of its diagnosis on clinical findings during examinations. However, he said today, “Now we have MRI and we have come really far with a lot of genetic testing to determine the reasons why people’s bodies are not functioning.” He explained that when he was in medical school in the early 2000s, it was an exciting time. He said MRI had been around for a while, but there was a rapid emergence of a variety of therapies for neurological diseases.
What started his journey, he said, was on his first day of medical school rotations he was selected to do neurology first, partly, he said, because he thought he would never be a neurologist. He said he thought, he might as well do this one and get it out of the way and then find another area that would interest him more. He said that during that rotation he was in the ER and a man came in suffering from what was likely a stroke and could not speak. He was diagnosed and treated, and Dr. Scagnelli said he witnessed over a few hours the patient coming back to a neurological normal state. That, he said, was very exciting and started him on the path he has followed for all these years.
Additionally, he said, with neurology you get to do a lot of hands-on examination and look at a lot of images, reading and interpreting MRIs and CAT scans. He related that counseling is a lot of what he does as well. Explaining that the disorders he sees often are chronic and lifechanging for people and, he said it is important that “if you are doing a good job as a neurologist, that you develop a good relationship with your patients and that you are able to counsel them on the diseases they are facing.”
Ron said he read a survey from 2022 that said more than half of the doctors questioned said they would not encourage their children to pursue a career in medicine. He asked Dr. Scagnelli, if he would recommend the career choice he made and why does he think the survey returned that result? He explained that he felt that going into medicine was more of a calling and less of a job and he said he gets a lot of satisfaction from coming to work each day. Medicine is a “Hard job” he said if one of his kids wanted to pursue this work, he would make sure they understood what the tradeoffs were. Pointing out there is never a moment when he is fully out of the office. He also pointed out that the business of medicine has become more complicated with the bureaucracy surrounding insurance, filling for reimbursements, etc. But he said if his child understood all that and still wanted to pursue this profession, he would make sure they understood the ins and outs of what they were in for and understand that with the changes in reimbursement, being a physician is not the way to make a quick buck.
Matthew shifted the conversation to MS, asking Dr. Scagnelli to provide us with a primer on what MS is and how it affects a patient. He started by explaining that MS is an autoimmune disease of the central nervous system, noting that autoimmune diseases appear in all specialties and occur when your immune system is “confused” thinking that part of your body is not supposed to be there and will try and seek it out and destroy it. It tends to manifest with people in the prime of their life, he said, between their 20s and 50s when they are working on their careers, and raising families. It can cause loss of vision in one eye, tingling, or difficulty using limbs. What results, he said, is patients will need walkers or canes and wheelchairs. “Left untreated MS is a very disabling disorder.” He said.
Dr. Scagnelli shared that what makes treating MS exciting today, is that they have developed some amazing therapeutics to treat a disease like multiple sclerosis. This makes conversations he has with patients today, very different than a conversation he would have had with a patient in the early 90s.
Matthew asked what causes multiple sclerosis and Dr. Scagnelli explained that there is not a clear cause for the disease, but like many autoimmune diseases there is some discussion around it may be a combination of a genetic predisposition and possibly some type of environmental trigger. He said there was an interesting Department of Defense study that looked at the Epstein-Barr virus as a possible link to MS. Matthew asked about advances in treatment and Dr. Scagnelli explained that the “clinical criteria for multiple sclerosis has shifted over time.” These changes, he said, have allowed for earlier diagnoses than in the past. He went on to explain that due to the old criteria, it might have been some time before someone was diagnosed. With the advent of the MRI, he said, once they were able to describe the typical MRI for MS, and connect them with the clinical observations, they were able to start making determinations earlier to get patients on treatment as soon as possible. The early treatments he said, have demonstrated that it saves patients from disability. He shared that there is an increasing interest across his specialty to get people diagnosed and into treatment as soon as possible.
Matthew asked about a few different types of medicines and Dr. Scagnelli pointed out there are several delivery methods for the treatment of MS in regards to drug therapies. There has been a long-time focus on anti-inflammatory drugs, but now there is some promising research looking for a molecule that can help repair the damage done by the disease, he said. Ron stepped in and noted that it is amazing how our medical system, was able, in the course of Dr. Scagnelli’s career, to go from not having a lot of options for treating MS, to now looking at possibly treating people to slow down and even reverse it. He asked if diseases like Parkinson’s are seeing improvements as well. Dr. Scagnelli admitted that diagnoses like MS come with a certain degree of terror for the patient, but points out that there has been a “rapid expansion of drugs that work” over his career of working with MS patients. He said that if you look at the major pharma companies, many have a neurologic wing working on drugs to address diseases such as MS and ALS. He said it has been a “huge call to action” for these companies. He explained there is a new drug on the market to treat Alzheimers and they will be using that soon at Raleigh Neurology. He stated that he is excited about the possibilities in things like gene therapy since many of the neurologic diseases have some basis in genetics. All these factors he said are what makes working in this field interesting and rewarding to help patients.
Ron thanked Dr. Scagnelli for his compassion and his dedication to working with patients who have these diseases and Dr. Scagnelli acknowledged that this is a team effort from the “Bench to the bedside.” He gave a lot of credit to researchers working on these solutions and pointed out that there is a real hunger to fix these diseases. With that he tipped his hat to the U.S. medical system, pointing out that it often gets a bad wrap, but said the level of innovation that we have in the U.S. is second to none. Additionally, he said, we are developing these drugs for the rest of the world and we couldn’t do this without our system. Ron agreed and noted how people often look at the World Health Organization ratings, which some pundits point to, and see us rated below Turkey. He pointed out how laughable that is and the proof was that we are not seeing many people in the U.S. making the trip to Turkey for cancer treatments. He admitted we have some challenges, but quality, innovation, and access are not one of them.
The conversation wrapped up by discussing some of the challenges with treating these diseases, whether it be access to the drugs a patient needs, which is often inhibited by what their insurance will cover, or disagreements in treatment regimens set by the insurance companies. But also Dr. Scagnelli said he thinks that patients are sicker today than in the past. He said now, it’s not uncommon that he is treating other things alongside the multiple sclerosis in the same patient. The point, he said, with these situations is there needs to be good coordination of care between specialties.
He closed by stating “We are in dire need of healthcare workers, and we are going to be facing a severe shortage of physicians in the next 10 to 20 years.” He quoted a statistic often heard in other specialties, that the average age of a practicing neurologist is late 50s or early 60s. This fact he said, is related to the earlier discussion about enticing people to go into medicine. He predicted that we could find ourselves without enough neurologists to see all the patients that need care. Ron agreed, pulling up some data that showed that 60% of the practicing neurologists in the U.S. are over the age of 55. Meaning, he said, that in about 10 years we will need to replace nearly two-thirds of the neurological capacity we enjoy today.
Matthew and Ron thanked Dr. Scagnelli for being on the podcast and Ron expressed his deep appreciation for him and his service to his patients.