The chief of the Multiple Sclerosis Division at the Perelman School of Medicine explained how an increase in the number of MS neurologists could improve the state of care.
Joseph Berger, MD
Making treatment decisions in multiple sclerosis (MS) has become a challenge for many MS-focused neurologists, adding to an already difficult landscape of treatment that sees the ratio of physicians to patients becoming more disproportionate by the year.
One of the nuances to developing a treatment plan is factoring in the desires of the patient. As a patient ages the disease progresses or slows, so the need for excellent prognostic vision is huge—albeit not that successful, according to Joseph Berger, MD. This is helped by spending time with the patient to develop this understanding and improve individual care.
However, with the increasing complexities of the treatments for MS, the ability for each neurologist to keep up has become more imperative. Berger, a professor of neurology at the Hospital of the University of Pennsylvania and the chief of the Multiple Sclerosis Division at the Perelman School of Medicine, noted that with all that goes into the development of a treatment plan, one thing remains the same: the time with the patient.
He spoke about this with NeurologyLive in an interview, noting that there is an ongoing need for more MS neurologists. If there were more available physicians, the time with each patient—and thus the time to develop a treatment plan—can increase.
Joseph Berger, MD: That that that goes into all of our thinking. There are a number of things that go into our thinking when we're sitting across from the patient. The first and foremost is that we attempt to prognosticate. Even though our prognostic factors aren't great, we attempt to do that.
You see somebody who's a young man, African-American, with large disease burden, spinal cord and cerebellar lesions, active lesions—you're saying to yourself, “This person has lots of high-risk factors for progressive disease, I want to put him on highly-active medication.” There are certain medications that are regarded as highly active. They carry great risks, but that is something that you have to weigh in your mind's eye because you don't want this person to be disabled, or any further disabled than they already are. On the other hand, you may be sitting across the from a patient who is a young woman with a bout of optic neuritis that hasn't had anything else, has very little in the way of disease burden on the MRIs, and you say, “This is somebody that I could safely administer a platform therapy to, one of the injectable drugs.” Maybe she wants to become pregnant, so then you think, “Well I probably glatiramer acetate is the safest choice for her.”
The age is factor, the patient’s anxiety and desires are a factor. There are patients that will tell me, “I don't want to be put on a drug that has any risk whatsoever for progressive multifocal leukoencephalopathy.” Well, the risk is extraordinarily low with the exception of natalizumab, even for those drugs that are associated with it. But there are some people who arm you’d really have to twist to take one of those other drugs. The bottom line is that there are a lot of different things that go into your thinking when you make a drug recommendation.
Historically, in academic settings for certain—I can't speak as knowledgeably about non-academic settings—the MS neurologist has been one of the lower paid neurologists. You find that stroke neurologists, epileptologists, neural intensivists, have salaries that are substantially higher, and this has historically been the case. The reason it was historically the case is because up until the early 1990s, there was really no treatment for MS. Any neurologists could practice MS. Then, when the drugs became available, for the first few years we had these injection therapies that were pretty safe, and any neurologist felt comfortable using them. They didn't make a difference to the institution's bottom line.
Nowadays that's changed tremendously. The drugs have become increasingly complex, they're very expensive, and there are side effects associated with them. The neurologist that practices MS has to be extraordinarily knowledgeable about the drugs, when they're indicated, who they're indicated for, what parameters need to be followed, what the consequences of the drugs are, and he or she functions very much like an oncologist. The oncologists, by the way, have been recognized as contributing substantially to the bottom lines of their institutions, and have been receiving salaries two- and three-times higher than that of the MS neurologists, and getting the resources that they need for their programs. That has not been the case with the MS programs and the MS neurologists, but that is changing.
Now, if you have a specialty pharmacy embedded in your clinic or in your institution, and the drugs are being provided through that specialty clinic—I refer you to a paper I wrote and published in neurology clinical practice last year on the financial contribution of the MS neurologists1—you will see that the downstream revenue that the MS neurologist generates far exceeds that of any other neurologist. More than any other subspecialty in neurology, provided that you have that specialty pharmacy, you're providing the drugs, and that the MRIs are done at your institution because we request more MRIs than any other group.
Having said that, there's this large stream of money now that is coming back to the institutions—this, by the way, is true only for the United States because other countries the health care systems are structured differently—and what I would argue is that if you pay people appropriately, you will increase the number of trainees in MS and the solution will be found for creating a sufficient number of MS specialists to care for this large MS population. I think that is a huge issue, and I think there's a way to deal with it. The way I think it should be dealt with is to compensate people commensurate with their level of expertise and what it is they're providing to the institution.
1. Berger JR. The financial contribution of the multiple sclerosis specialist. Neurol Clin Pract. 2017.