Epigraph Vol. 25 Issue 1, Winter 2023

Dr. Andres Kanner: A career in the psychiatric aspects of epilepsy

Reported, edited and produced by Nancy Volkers, ILAE communications officer

He is one of the best known researchers in the behavioral aspects of epilepsy, and has authored more than 250 papers and book chapters. Dr. Kanner sat down with ILAE to talk about his original goal of becoming an artist, his path to epileptology, and what has shaped him into an excellent clinician.

Listen below or download the episode.

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Podcast Transcript

In this episode, we talk with Dr. Andy Kanner, one of the world’s authorities on the behavioral aspects of epilepsy. Dr. Kanner is currently the director of the comprehensive epilepsy center at the University of Miami School of Medicine.

Thank you for joining me.

Dr. Kanner: Thank you for taking the time to talk to me about my life.

Maybe we could start with your, you as a kid, growing up, and making your way to medical school and maybe tell me a little bit about what you were like as a kid and if you were always interested in medicine, or how that happened.

Dr. Kanner: So no, as a kid actually, when I was a kid, up until the age of 11, I was thinking of becoming an artist. When I was a kid, I had painting classes and I became very involved in painting, and I thought I would go to art school and become an artist.

Headshot of Dr. Andy Kanner
Dr. Andy Kanner

And then what changed was an exchange student program that I participated in. I was born and raised in Mexico. I went to Albuquerque, New Mexico (USA), as an exchange student program in the family of a physician. And this physician used to take me on rounds with him on weekends. During the week I would go to school with the kids of the family, and on weekends he would take me to the hospital on rounds with him. And I thought, “Wow, this is cool.”

And he would explain to me different things, and so when I came back to Mexico after three months of being in Albuquerque, I told my parents, “I think I’m going to become a doctor.” Which was, for a Jewish mother, it was a big relief! And that stayed with me for the rest of my junior high school and high school.

In Mexico you don’t go to college – in Mexico, you decide which type of career you’re going to take when you are a sophomore or junior in high school. And so you spend the last two years of high school in courses geared towards biology, chemistry, physics et cetera, in preparation for medical school.

And then I went to medical school at the National University of Mexico. My interest in the brain became very clear from the first year of medical school. During my clerkships, I became convinced that I wanted to go into neurology. Then I did my clerkship in psychiatry, and that also was quite interesting. And for the last year I was toying between neurology and psychiatry, and one of my professors said, “Well, why don’t you do both?”

I decided to do psychiatry first because my professor said, “Think of which is the area that you plan to practice as, and do that at the end.” So I thought, “Well I’ll do psychiatry first and then neurology.”

In Mexico like in many countries in Latin America, we’re talking now about the 1970s, I graduated from medical school in 1977. If you had an opportunity to come and do your residency training in the United States, that’s what you did.  I applied to come to the United States. I chose Long Island Jewish Hillside Medical Center because it was an institution that had a great reputation. At that time it was the beginning of the biological psychiatry era, which had begun at that institution. The big names in biological psychiatry had come from that institution. And it also had a strong, dynamic school of psychiatry. It had a good blend, so that’s what led me to choose that institution.

I almost didn’t come to the United States because it coincided with Senator Ted Kennedy deciding that foreign medical students should not be coming to the United States, and put a ban on any foreign medical students, implying that when foreign medical students leave their country of origin there is a “brain drain” for the countries of origin, and for a while I didn’t know whether I would be able to come.

And then because of the uproar that this caused in many institutions—because many of the institutions in the United States relied on foreign medical graduates, and it would have left these institutions without residents. So they had to waive that legislation.

When I was done with my psychiatry residency, two daughters were born and I thought, “Wow, doing another residency – do I really want to do another residency?” So during my residency in psychiatry I became very interested in psychopharmacology and in pediatric psychopharmacology. So I was accepted to Columbia University to do a fellowship in pediatric psychiatry and then psychopharmacology.

And while I was at Columbia, I was rotating through the pediatric neurology clinic, where my interest in neurology rekindled. One of the things that you see a lot in a pediatric neurology clinic are kids with epilepsy.  I thought well, I think I’d like to reconsider my decision, and at that point decided I’m going to go back to my original plan and decided to apply for neurology, with the idea of doing an epilepsy fellowship.

I found the whole phenomenology of epileptic seizures to be fascinating, and particularly I saw that understanding epileptic seizures was one way of also understanding the neurobiological aspects of the mind, because of the symptoms of seizures, they’re so closely related to psychiatric phenomena.

And that’s what led me to do my residency at Mt. Sinai in New York City. And when I was done with that residency, there were only a few big epilepsy fellowship programs in the country, about four or five big epilepsy programs that also did surgery for epilepsy. And one of them was the Cleveland Clinic. It was interesting because I applied to several programs, one of which was at NIH. They did not accept me, and one of the reasons I later on found out that they were a little concerned about was that I had done a psychiatry residency before, and they were concerned, “Well does this guy really know what he wants to do?” So I was turned down. But I was accepted at the Cleveland Clinic and that was great training.

So I’ve been very lucky – I have been extremely lucky in my trainings, I trained with Hans Luders, who is probably one of the leading epileptologists, one of the persons who’s trained most of the epileptologists in the world. When I finally got a job, which took a while, I was fortunate to join the epilepsy program at Rush Medical College with Frank Morrell. Frank Morrell was one of other big fathers of modern epilepsy. What I like to call the Gustav Mahler of epilepsy because in his time, people did not give him the recognition that he deserved, but he had actually pushed the whole research on kindling, described the mirror focus, and was a big force in the development of epilepsy surgery, with a different strategy than I had learned from Hans Luders. And so I was exposed to both schools of thought, which led me to develop my own approach to epilepsy and I was able to blend both things.

Having had a background in psychiatry, I always maintain a big interest in understanding the psychiatric aspects of epilepsy. I remember my first poster in the American Epilepsy Society was a poster on psychogenic non-epileptic seizures, and my first publication as a fellow was on post-ictal psychosis, the prevalence of post-ictal psychosis. I always from the beginning was interested in seeking out what’s common in the fields of psychiatry and epilepsy. And that has continued up until the present time.

I think those two areas are very closely related and it’s a fascinating field and a field that I think is still in its infancy. It is growing leaps and bounds. I remember when I was in the American Epilepsy Society meetings and this is in the 1980s, early 1990s, the area of psychiatric aspects of epilepsy was very looked down upon. The presentations were left for the last day, and the last session. And they would usually lump them together with a session with the nurses and the social workers. Now, psychiatric aspects of epilepsy has been recognized as an important area in the field of epilepsy, and you have important symposia in every major epilepsy meeting, in the US, Europe, and the ILAE.

This is something I remember having been told by colleagues, more senior colleagues in neurology – “What are you doing, doing this research on psychiatric aspects of epilepsy? It’s not going to lead you anywhere – you’re not going to go anywhere with that.” And I decided to follow my own interests. So if I had a message to give younger colleagues, it’s to follow your own interests, what you think is interesting to you and what you have passion for. Because in the end it’s going to bear fruit, what you’re doing. And we still have a tremendous gap in bringing the two disciplines together but it’s a completely different world today than it was 30 years ago when I started.

Medicine, neurology, psychiatry, is a very fluid field that keeps evolving and keeps changing. And you have to be open to understanding the ways the field is changing and evolving because otherwise you get stuck.

One of the tragedies of psychiatry for example was the division between the dynamic psychiatry field and the biological psychiatry field, which I thought was a tragic phenomenon. It became like a political – you either belonged to one or the other and they didn’t talk to each other. And in reality, there is a lot of biological underpinnings in understanding the dynamic aspects of psychiatry. And this separation in the way you see things actually is idiotic, if you will. (laughs)

Neurologists and psychiatrists didn’t talk to each other. I mean they are two disciplines that deal with the same organ, don’t have much of an interaction. I remember when I was in psychiatry in the psychiatric institute in Columbia, which was right next door to the neurologic institute. I mean it was 20 feet away from each other. No interaction. Nothing. I thought that made no sense whatsoever.

And sadly, there are still many neurologists who are not paying attention to the psychiatric aspects of neurologic disorders, and vice versa, many psychiatrists who don’t pay attention to the neurologic aspects of psychiatric disorders. And the end result is when I hear colleagues in psychiatry evaluate patients and say oh no this is organic, this is not psychiatric. That drives me crazy because there isn’t such a thing as psychiatric disease that’s organic or non-organic. It’s all part of the brain – you can’t separate the two. And this separation is something that is slowing down the learning process of neurologists and psychiatrists and physicians to a significant degree, and to the detriment of care of the patients.

I have published several papers about why neurologists and psychiatrists don’t talk to each other. Part of it is I think the training of neurologists in psychiatric disorders and the training of psychiatrists in neurologic disorders is still poorly conceived. The people who do the curriculum don’t have I think or haven’t grasped the importance of integrating the two fields together and so when residents go into neurology, they’ve had very few exposures in psychiatry, and vice versa. In Europe, for example, in Germany, a neurologist has to spend six months doing a rotation in psychiatry; here, you’re expected to do one month. It’s part of one of the things that I find fascinating and keeps me moving. Keeps me trying to push the field.

So I’ve read a bit about you, including a lot of reviews from patients that are extremely positive and glowing and I’m curious from your point of view - what do you think makes you a good clinician?

Dr. Kanner: Well there are two, well thank you first of all for that kind comment. I think being a clinician is trying to understand the patient as a person, not as a disease.

I always tell my fellows and residents, when you’re evaluating a patient, try to get to know the patient the way you try to get to know a date, a first date. Don’t focus on the symptoms that bring the patient to consultation, but get to know the patient as a whole. And I think that has always helped me in understanding the medical aspects of the patient better.

And the other thing is that I don’t treat patients, I think patients perceive that I’m not treating them as people with symptoms. I treat them as people. And I try to get to know them and I like to know what their hobbies are, what their interests are. Why? Because in the course of treating a condition like epilepsy, which is a chronic condition, the impact of your daily life is going to have direct bearing on the occurrence of your seizures, and all the other comorbid conditions associated with epilepsy.

One major event in my life that also confirmed the way that I practice, is when I had a seizure – I had an epileptic seizure about 15 years ago. It was interesting. I had an epileptic seizure at the Cleveland Clinic when I was about to start grand rounds, neurology grand rounds. So that was a coincidence. And that made me look at things very differently. Because there, I understood what it was to be a patient, what it was to have an epileptic seizure, and the loss of predictability. Not knowing, is it going to happen again, when is it going to happen again.

My seizure was caused by a meningioma, a benign tumor, and I underwent surgery. I remember the neurosurgeon who did the surgery, who actually was the neurosurgeon that I worked with in Chicago, telling me, “Well, Andy, your meningioma has maybe a 10% chance of recurring. But you have a 90% chance that it’s not going to recur.”

And I remember thinking, “Yeah, but 90% is not 100%.” And for the first time, I appreciated what patients go through – this uncertainty of, “Is this going to happen again? Is that tumor going to grow again?” And I remember telling patients in the past, “Oh, you have an 80% chance that you’re going to be seizure free!” And I thought I’m giving them great news. Well, when you’re the patient, 80% is not 100%. And that changed the way I viewed things.

And I tried to teach patients how to cope with that, with that loss of predictability. Which I think is a big obstacle in coming to terms with living with this condition that we don’t unfortunately spend enough time with patients in preparing them for that. I think once you are a patient, you see things in a very different perspective.

The other things that you learn when you are dealing with psychiatric issues in epilepsy is it’s not black or white, there is a lot of nuance. And the communication of what you’re trying to tell patients can sometimes be fraught with difficulty for the patient to understand.

One example is how you communicate the diagnosis of psychogenic non-epileptic seizures. A big error, for example, that I find is that we tell patients, “Okay, this is not epilepsy, it’s a psychogenic process, go and see a psychiatrist, goodbye, have a good life.” And we tell that to patients even when we don’t have any evidence that the patient has a psychological process, that there is a psychogenic process or a psychiatric disorder.

And so I tell my fellows, I say, “Put yourself in the patient’s shoes. If a doctor came and told you that you have a condition and it’s psychological, and you haven’t discussed with the doctor any psychological issue and there’s no evidence in your history of any psychological process. How would you feel if they tell you it’s a psychological process?” Right?

So what I’ve learned to do is to put myself in the shoes of the patient. I talk to the patient and I think, “Well if I were this patient, how would I like things to be presented to me, in a way that I can understand it?”

And obviously you know these things take time, my visits with my patients. I always tell my patients, “If you’re looking for somebody who’s going to see you on time, that’s not me.” Because I will give you as much time as you need when you come, but that means that other people whose appointment is after you may have to wait, and that means that when you are given an appointment that is in the middle of the day or later in the day, you may have to wait. So if you need to be on time, I can refer you to other colleagues who see patients on time, but that’s not me.

So how have you managed to balance the rest of your life with your work and your family. For example, you said you had two daughters. How do you manage that and do you have any advice?

Dr. Kanner: So one thing that I was lucky in my professional career is that my wife,my wife is an occupational therapist and in fact I met my wife when I was a psychiatry resident. In the beginning my wife took care of my kids, but when the kids were in high school, she decided that she didn’t want to go back into occupational therapy and I needed a research assistant, so she came and worked for me as a research assistant. She actually did a lot of the psychiatric research that we’ve published; she actually did a lot of the work, I just took the credit! But if you look at the papers, her name is there. So that I think made life, work and family, to be closer, right. Because we were always together. In fact when I had my epileptic seizure, my wife wouldn’t let me go to different meetings alone—she came with me for the first year and a half.

You know, it’s difficult when you’re in medicine in academic medicine, to separate your obligations at work from family obligations, because you’re very immersed in what you’re doing. But I think that working with my wife made things much more easy. Also I’m somebody who, I can disconnect very easily from what I’m doing and I can go on vacation and do other things that are fun.

But I enjoy what I’m doing. I enjoy teaching fellows, residents, I enjoy working with patients and doing the research that I’m doing, and I think that’s the, that’s the most important thing and this is what I tell my fellows: Are we having fun? That’s my – running the epilepsy division at the University of Miami and when I was in Chicago, what I always looked for is what we’re doing something we’re enjoying. Because if we’re not having fun then there is a problem. And I always try to make sure that even though it’s hard work, and the field that we’re in is very demanding, that at least we’re really enjoying what we’re doing.

When people ask me, “When are you planning to retire?” I at this point I still say well, when one of the following three things will happen first: either I become demented, I get fired, or I die. Whichever happens. Until that happens, I’ll still continue to work. Maybe not as division chief all the way, you know at some point you have to let younger people take over and as division chief I am somebody who’s a strong believer in delegating, in teaching my younger faculty to learn how to take over administrative responsibilities, and the other I think important thing is to recognize what is your role as you go through life. My role right now is not to write more papers. Because if I write another paper it isn’t going to make a difference. My role is to help my faculty write papers, get involved in clinical research, and help them develop their professional careers. And when they’re successful, I’m successful.

How do you have fun outside work? Do you still paint? Are there other things you do?

Dr. Kanner: Actually I have to tell you I have an easel in my living room that I got a couple of years ago, two or three years ago, with the idea of maybe starting to paint again, but I haven’t yet had the time to do it. My wife paints and she’s a very good artist, and she does a lot of fun drawings. But I’d like to get back to doing that.  I love to listen to music, and I love to, I like history and I love politics. And I spend a lot of time listening to the news, and understanding what’s going on in the world, and from the perspective from an historic perspective, and I like to read books that explain what’s going on.

And I love to just relax, lay by the pool and listen to music, go to the beach, and the most important thing also now is that I have become a grandfather. My younger daughter, she’s a pediatric endocrinologist at the University of Iowa, she’s adopted two children, one is 5 years old and the other one is 6 months old and that has transformed our lives.

Any final thoughts, or words of advice?

Dr. Kanner: The only advice I have to my colleagues is whatever you’re doing, make sure you’re having fun. If you’re not having fun, then something is wrong. I mean you’re not going to, obviously when I say “have fun” I’m not saying you always have to have fun there are always going to be hurdles and disappointments. But overall, are you enjoying what you’re doing? And if you are enjoying what you’re doing, that’s what will keep you going.

There is something that would characterize my professional career from the time I was a child is that I always went against the current. When I was a kid, I was going to be an artist, and for a Jewish mother having an artist, it’s not what they wanted. And then I went into a field where I paid a lot of attention to psychiatric aspects of epilepsy, and that’s not what was expected. And at the end I think it worked for me. And I was doing what I found to be very interesting, it was making me passionate. Even though it was not what a lot of the colleagues I worked with found to be interesting, and they even thought, “So what?” But as long as I had fun doing it, that’s what counted. And that’s what I would recommend to my colleagues. Listen to your inner self. Because in the end the only one you’re responsible to is yourself.

Well thank you, Dr Kanner - it’s been a pleasure talking to you.

Dr. Kanner: It’s been fun – thank you so much for taking the time to talk to me.