Two – that's the number of years Dr. Ilia Poliakov has been working as a physician, and in those two years, he's done something no other physician in the province or country has done.
In November 2016, Dr. Poliakov became the first dedicated multiple sclerosis neurologist to work in Saskatchewan. Multiple sclerosis, also commonly known as MS, is a long-lasting disease that can cause a range of symptoms from numbness in the arms and legs to paralysis. It occurs when the immune system attacks and damages nerve cells in the brain, spinal cord or the optic nerves attached to the eyes.
Dr. Ilia Poliakov
As the new Clinical Director of the Saskatoon MS Clinic, Dr. Poliakov says his goal is to transform the clinic into a multi-disciplinary centre dedicated to treating patients with MS throughout the province.
"I'm hoping to build a state-of-the-art MS clinic in Saskatchewan that is as good as anything else in North America," he says, explaining that the difference between today's clinic and the one which opened in the 1980s is that patients can now be seen much earlier in their disease course.
"Up until a year ago, the clinic had a rehabilitative focus on advanced, progressive multiple sclerosis. So, someone who was diagnosed at 30 would see their community neurologist for 10 to 15 years, and when they started developing symptoms that would require a cane or walker, they would go to the MS Clinic," says Dr. Poliakov. "Now, we're treating all MS cases at the clinic, from early onset to the most advanced."
Since arriving at the MS Clinic, Dr. Poliakov has increased the number of patients seen by nearly fourfold, from about 25 per month to an average of 100 (approximately, 1,200 per year). Currently, there is an estimated 3,500 to 3,700 people living with multiple sclerosis in the province.
"Treatment can be done by community neurologists, and is done very well by them, but it means that many MS patients are being followed at various locations within the community," he says.
Ideally – and especially for complicated cases – Dr. Poliakov explains that patients should be treated in a specialized, multi-disciplinary clinic that will give them direct access to a range of healthcare providers from neurologists to registered nurses, occupational therapists, physical therapists, psychologists, psychiatrists and social workers. Currently, the clinic is staffed with a Clinical Director, Dr. Poliakov; a Clinical Research Chair, Dr. Michael Levin; a physiatrist, Dr. Katherine Knox; three registered nurses and administrative staff. The hope is that within the next few years, it will boast a full complement of multi-disciplinary staff.
"Treating all patients in one clinic also makes it possible to accurately collect patient information and aggregate it into an anonymized database for research purposes," he adds.
In February, Dr. Poliakov introduced a new data system to the clinic that displays the disability scores of patients in graph format, providing each patient's healthcare team with a visual timeline that tracks patient outcomes from year to year, from diagnosis to current state (e.g., MS attacks and relapses, medications administered and medication compliance).
"Previously, this information was tracked, but it was in a separate databases and it didn't have that graphical output. We're now collecting the data in a way that's easier to search, process and research," he says, explaining that the goal is to upload this data to national and international registries that will allow him and other MS specialists and researchers around the world to recognize patterns in multiple sclerosis that may lead to breakthroughs and advances in treatment.
One of the questions Dr. Poliakov is hoping the database will answer is whether patients on medication have better long-term outcomes than patients who do not take medication.
"We have very effective treatments for multiple sclerosis that really reign in MS flares, but multiple sclerosis medications are not necessarily pleasant to take as they can have a lot of side effects," he says, adding that because many of the medications for the disease are taken to prevent a flare-up of symptoms, it can be difficult to convince people to take them, especially when they feel fine and don't think they need it.
"The big question is whether decreasing these flare-ups results in a decrease in long-term disability," he continues. "Large databases and patient registry studies will help us answer this question. So far, the bulk of observational studies show that early MS treatment does decrease long-term disability. However, I think we'll need many more years, if not decades, of experience with these databases – and a worldwide approach that converge data from all these systems – before we can affirmatively say that certain treatments are helping in the long term.
"This is one of the benefits of big data," he adds.
Dr. Poliakov's interest in big data, also known as clinical informatics (the search for meaningful patterns in clinical data to inform treatment options), is rooted in his love of computer science and biology.
Prior to being accepted into medical school at the University of Calgary, he completed a bachelor's degree in bioinformatics, an interdisciplinary field (comprised of computer science, statistics, mathematics and engineering) that develops methods and software tools for understanding biological data.
"Apart from informatics, I was interested in artificial intelligence as an undergraduate, so it seemed like a natural progression to go from that to the real brain," he says of his decision to specialize in neurology as a medical student and then a resident at the University of Saskatchewan.
"Neurology is about mysteries," he says of his reason for choosing this field. "I really like being able to take a list of disparate symptoms and come up with a diagnosis. With some patients, we have to sort through up to 50 or more possibilities, and then whittle it down to one or two. I often tell medical students that on a per capita basis, there are more interesting cases in neurology than anything else. When the heart, liver or lungs break down, they tend to follow a set series of events, but with the brain it can be almost anything because the brain does everything – our entire life is experienced within our brain. So, even though the brain doesn't usually break on very clean fault lines, there can be all sorts of unique presentations with brain dysfunction.
"One of the reasons I went into neurology is because of an elderly patient who I saw as a medical student," he continues. "According to her chart, she had decreased vision. When I went to see her, she was staring straight ahead, holding her yogurt an inch away from her mouth, seemingly frozen. When I went up to her and said hello, she snapped out of it and started talking to me, but the whole time it looked like she was staring at something.
"As I talked to her, it became clear that she was not having decreased vision – rather, she was seeing things that weren't there, but not in your usual run-of-the-mill hallucinations. While looking at the clock, she would describe how it was sliding down the wall, almost like a Salvador Dali painting. I then showed her a series of colours to see if she could identify them, and she called one of them a frilly skirt. It turns out that she had a rare variant (Heidenhain variant) of Creutzfeldt-Jakob disease, which is similar to mad cow disease. We discovered that she was showing an incredibly rare presentation of what is already a rare disease that occurs in only one in a million people.
"That sleuthing and detective work is really manifest in treating multiple sclerosis," he adds, explaining that he thinks the disease is interesting for a number of reasons.
"First, there have been huge breakthroughs in terms of treatment," he says. "There are descriptions of multiple sclerosis going back hundreds of years, but we've only been able to treat it in the last few decades. Before 1993, there were zero treatments that were FDA approved for the disease, and now there are at least 10 unique therapies – up to 16 if you include variations of some of the medications – and there are going to be more treatment options coming out in the future. When we look at the trajectory of treatment for MS, we're getting better and better at preventing inflammatory attacks in patients. The current hope is that by preventing these attacks we can also prevent long-term disability. So, what used to be a disease of, 'I'm really sorry you have this, there's not much we can do,' is now one with many options.
"Second, multiple sclerosis is really diverse. Sclerosis means hardening or scarring, so multiple sclerosis is numerous points of scarring that occur in the brain and spinal tissue as a result of inflammation. It's not a disease that manifests the same way in everyone, so physical symptoms can really vary from person to person. At one extreme, we might see someone in their seventies with MS whose level of disability is equal to other healthy people their age, or at the other extreme, a very young patient who has had a severe attack and is disabled early on. Why two people with the same disease can have widely different levels of disability is still not fully known, but if we can answer this question, we might be able to provide better treatment options down the road.
"Third, MS has a very diverse and dynamic patient population. On average, it strikes at the age of 30, but we see patients from 16 to 80 in the clinic, so we get to see people from all walks of life. It's also longitudinal, so you can see people early in their disease course and then follow them for decades."
Dr. Poliakov says that one of the things which really stand out with MS patients is their perseverance.
"Many have found ways to deal with their disease and disability with such grace and strength – it's inspiring to see," he says.
"Most people think multiple sclerosis is this horrible, debilitating condition that will put them in a wheelchair within five years of diagnosis, but that's not the case," he continues. "The majority of patients recover from their relapses, and for some, MS is little more than a nuisance. The good news is that we're seeing a shift to this end of spectrum, and overall, people are getting better. That's not to say there aren't some people who are severely affected, but we're seeing less disability from multiple sclerosis. The hope is that this shift is a result of better treatment. I also think it's related to healthy lifestyle choices – physical and mental activity, diet and taking Vitamin D."
Dr. Poliakov says his ultimate goal with multiple sclerosis is to have everyone with the disease able to participate in society with no restrictions, through work or play, at the same rates as the general population.
"Right now, only about five to 15 per cent of people with the disease have what we would call benign MS, where we essentially see no long-term disability," he says. "Return to work rates is the litmus test for someone with multiple sclerosis in terms of measuring how well they're doing."
Dr. Poliakov was debating to remain in Calgary following the one-year fellowship he completed at the Calgary MS Clinic prior to joining the Saskatoon clinic, but he chose further east on the prairies because of his love for Saskatoon, which developed while he was doing his five-year residency.
"I like Saskatoon because it's convenient," says the Russian-born physician who moved to Calgary at the age of five with his parents, older sister and identical twin brother. "I don't want to waste time driving or being stuck in traffic. I want to go to work, to the gym and do whatever else I have to do quickly and efficiently so that I have the most hours in a day to put into the things I like. My partner, Jennifer, is really into cross-country skiing and snowshoeing, so we do plenty of that in the winter. We also spend a lot of time with our two dogs – walking, jogging and hiking; or just watching Netflix with our two cats."
