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The “Grave Threat” Posed by the Shortage of Neurologists

NeurologyLive, February 2022, Volume 5, Issue 1

With the physician deficit projected to grow larger within a decade, this global challenge has become a major focus of large organizations and medical societies.

A SHORTAGE OF NEUROLOGISTS IN the US is characterized as a “grave threat” to providing high-quality patient care and to the specialty of neurology in a recently published report from the American Academy of Neurology (AAN).1

The gap between demand for and supply of neurologic services is widening due to several factors, including an aging population increasingly afflicted with neurodegenerative disorders, a volume of referrals that do not warrant neurologist intervention, and in some regions, neurologists choosing to practice subspecialties that are not among those most urgently required.

The report, titled A Shortage of Neurologists—We Must Act Now, was compiled by Jennifer Majersik, MD, MS, chief of the Division of Vascular Neurology and a professor of neurology at the University of Utah School of Medicine in Salt Lake City, and colleagues from AAN’s 2019 Transforming Leaders Program and points to numerous indicators of the shortage, with prolonged patient wait times among the most apparent.

“Pediatric neurology is among the top 3 pediatric subspecialties with the longest wait times, with 30% of clinics reporting new patient wait times of longer than 16 weeks,” Majersik and colleagues noted in the report. “Precise current data in adult neurology are not available, but reports agree that wait times are excessive, reported in 2012 as already at 35 days and rising, and with even longer delays in some markets.”

The disparity between the availability of neurologists and patients in need of treatment is not limited to the US, as described in an article in the Lancet Neurology in 2018.2 In response to regional differences and their needs for neurologists, the Australian and New Zealand Association of Neurologists, for example, has constituted committees to address regional workforce disparities and task forces to recruit to particular patient care needs, such as for additional cognitive specialist neurologists and for subspecialists trained in endovascular clot retrieval in acute stroke.

Considering regional imbalances in Europe, Günther Deuschl, MD, president of the European Academy of Neurology from 2014 to 2018 and a professor of neurology at Christian-Albrechts University of Kiel in Germany, noted that in addition to neurologists often choosing urban over rural settings, there is also a westward “brain drain” from countries that are considered “less attractive” for physicians. “The only way to stop this is for countries that are losing neurologists to pay them more,” Dueschl told the Lancet Neurology.

But addressing such a complex challenge is more complicated than pay scale alone. Majersik told NeurologyLive® that identifying the best strategies to reverse the trend has been difficult because available data on the topic are not only limited but poor in quality.

“We tried to find where there were data in other diseases or other fields or early data that would be useful,” she said. “It makes it hard to settle on something when you don’t really know what’s going to be most effective. And that was our final recommendation: that we need research into these things so we can have a better idea of what will work.”

The working group did reach a consensus after several months through a series of phone calls, in-person meetings, Zoom calls, and emails. “We also had subgroups and then would meet back with the large group. So it was actually a pretty intense process,” she said.

Majersik and colleagues developed a 3-part plan to address the US shortage of neurologists, each part with several strategic components:

  • “Shaping” demand for neurology services
  • Enhancing the neurology workforce
  • Valuing neurologists

Shaping Demand at the Referral Base

In addition to recommending increased adoption of technologies such as telehealth and e-consults to increase capacity to respond to the demand for care, Majersik and colleagues propose a strategy of shaping that demand, principally through educating the referral base. They point out that many referrals to neurology do not warrant neurologist intervention, such as an incidental finding of minimal white matter changes on a brain MRI with a low likelihood of multiple sclerosis.

Taylor Harrison, MD, associate professor and assistant clerkship director in the Department of Neurology at Emory University School of Medicine in Atlanta, Georgia, concurs, attributing the quantity of referrals that may be unnecessary or inappropriate to the lack of adequate education and experiences in neurologic topics across other specialties and practitioners.

“I think one thing that complicates that whole situation is that in many specialties that come across neurological conditions, like family practice, internal medicine, orthopedics, emergency medicine—what have you—many times their residency program does not offer them an educational experience in neurology that helps kind of cement or build their foundation [of] knowledge in that area,” Harrison told NeurologyLive®. “This has been compounded by the large increase in midlevel providers who are practicing in various specialties and may have minimal to no foundational knowledge of neurological disorders, which ultimately results in more referrals to our [neurology] outpatient clinics.”

Majersik and colleagues support a recommendation from a previous AAN work group for a minimum 4-week clinical clerkship in the first 12 months of medical student clinical training directed at the recognition and management of neurologic diseases that a primary care practitioner is most likely to encounter. Such training, they suggest, should mitigate the “neurophobia” that is said to occur among both trainees and experienced practitioners, which they wrote “can lead to both under- and over-referring of patients to neurologists.”

Harrison described how Emory University School of Medicine has incorporated discussion of clinical conditions and neuroanatomical function into early neuroscience curriculum to heighten interest in the details of neuronal structure, transmitters, and pathways.

“Historically, we’ve learned about brain function through the examination of dysfunction,” Harrison observed. “It’s said we’ve learned about the brain, stroke by stroke, seeing how different strokes affect different areas of the brain and observing different deficits in the patient.”

Education to Enhance the Neurology Workforce

Majersik also considered the elements that can attract talented physicians to neurology in a conversation with NeurologyLive®. “Physicians want to work in areas that they can make a difference, and there are so many more therapies now. It’s an exciting time to go into the field. But there will also be more need to see all those patients,” she said.

Speaking at the American Neurological Association’s virtual annual meeting in October 2021 on a panel sponsored by the Association for University Professors of Neurology,3 S. Andrew Josephson, MD, professor and chair of the Department of Neurology at the University California, San Francisco, described how the early neuroscience curricula can also heighten interest in practicing in neurology. He cautioned, however, that preresidency curricula should be broad, pointing out that students at that level are not yet thinking of pursuing neurology subspecialties.

“We’re not trying to get them to be vascular neurologists or tell them about what it’s like to be a neuroimmunologist,” Josephson noted in the session. “Rather, we’re trying to figure out how to get great people to become neurologists. What I do is educate them as to the benefits of our specialty with frank discussions, and we’ll talk about dispelling multiple myths. And then, hopefully, they make some great decisions, and we get more wonderful people to be neurologists.”

Josephson described findings from a 2019 medical graduate questionnaire that ranks the influence of various factors on the choice of specialty, noting the highest ranked was likelihood of personality fit, followed closely by specialty content, role model influence, and work-life balance. He noted that education cost/debt was the lowest-ranked factor and that less than half of those surveyed ranked income expectation as a strong influence.

Cathy Sila, MD, chair of the Department of Neurology at University Hospitals Cleveland Medical Center in Ohio, followed with a presentation on the noncommitted neurology resident and the challenge of better matching care requirements of an aging population with the supply of neurology subspecialists.

“Obviously, there’s a significant proportion of stroke, epilepsy, clinical neurophysiology, neuro critical care, and movement disorder specialists. But this doesn’t quite match with the demand ranking,” Sila told attendees. “The No. 1 demand is for general neurologists, with over 200 active ads for recruitment. No. 2 is a mix of stroke and hospitalists, reflecting inpatients needs for community hospitals and academic medical centers.

“Specialties such as epilepsy, neurophysiology, neurocritical care, and interventional therapies are really in a saturated market, where there’s an excessive number of trainees and it is not the demand.”

Sila offered several strategies for highlighting the areas of need to uncommitted residents, beginning with fostering a desire to serve the targeted community. She proposed developing a specific curriculum to promote the awareness of and skills for addressing the specific needs of the neurologic community.

The curriculum and training should build skill sets that include “cultural humility, cultural competence, understanding their unconscious biases in medical decision-making, [and] being aware of social determinants of health and those health disparities for neurologic conditions and the impacts of language, race, ethnicity, socioeconomic status, religion, sexual orientation, and gender identity,” Sila noted.

"...In many specialties that come across neurological conditions, like family practice, internal medicine, orthopedics, emergency medicine—what have you—many times their residency program does not offer them an educational experience in neurology that helps kind of cement or build their foundation [of] knowledge in that area.”
—TAYLOR HARRISON, MD

For examples of how these considerations can be built into programs, Rebecca Fasano, MD, associate professor of neurology in the Epilepsy Section and director of the Neurology Residency Program at Emory University School of Medicine, told NeurologyLive® that they have recognized that medical students often choose their specialty based on which group of residents they feel they fit in with.

“Our residency program has a specific focus of supporting and increasing diversity in neurology. Forty percent of our residents are underrepresented minorities,” Fasano said.

“Our hope is that by working alongside neurology residents who look like them, more underrepresented minority students will choose this field.”

Fasano also recognizes the increased use of advanced practice clinicians (APCs) in neurology practices and ensures that residents have the opportunity to work with these teams. “Our APCs see follow-up patients, thus allowing the residents and attending physicians to see more new patients and acute consults,” she said. “As APCs are now being utilized nationwide due to the physician shortage, it’s helpful for residents to learn how to work alongside APCs, as they will likely continue to work with them in future practice.”

APCs Enhance the Workforce

Majersik and colleagues called on the AAN to include a postgraduate didactic curriculum for APCs—perhaps as part of the APC conference the AAN recently established—and build upon a recently developed online 12-month neurology course aimed at providing foundational knowledge of 8 categories of common neurologic problems.

“This knowledge content could be enhanced with the development of clinical minifellowships in the most common outpatient and inpatient neurologic disorders,” Majersik and colleagues suggested. “The AAN should acknowledge completion of such education with certification or added qualifications to provide assurances of training.”

In addition, at its Phoenix-based School of Health Sciences, Mayo Clinic now offers a 12-month comprehensive didactic and clinical fellowship program in neurological surgery for physician assistants (PAs), aimed at providing PAs knowledge and skill sets necessary to care for the neurosurgical patients. The program is headed by Orland K. Boucher, PA-C. Mayo Clinic notes that the program is similar to a neurosurgery residency, but is more limited both in training time and depth of content.4

The report also emphasizes the importance for neurology practices to incorporate team-based care formats that are welcoming to and facilitate high productivity of APCs. “The development of team-based neurologic care for patients with complex neurologic diseases could improve patient care and maximize neurologists’ time to work at their highest level, thus reducing the mismatch,” Majersik and colleagues wrote.

The expansion of neurology practices to incorporate APCs is not universally welcomed, however. Recently, Rebekah Bernard, MD, a primary care physician and coauthor of a book concerned with the increased scope of practice of APCs, Patients at Risk, conducted a podcast interview with Carol Nelson, MD, a neurologist at Avera Medical Group in Sioux Falls, South Dakota, and Alyson Maloy, MD, a neurologist and psychiatrist at Portland Cognitive and Behavioral Neurology in Portland, Maine, who emphasized the extensive training required to provide care to patients with neurologic disorders.5

“...Dr Nelson and I had to go through the wringer for over a decade to prove our competency—not only just prove it, but to actually gain it. Neurologic disorders are very complicated, and it takes seeing a lot of patients to see what’s out there and to become competent and [take] care of people,” Maloy said.

Nelson concurred, later commenting, “You can’t just walk in and [provide that level of care]. You’ve got to know the physiology and the anatomy in order to figure out the pathology.

“I think it’s actually been proven that the amount of testing that’s ordered by a physician extender compared to an MD or a DO is astronomical, so it’s certainly not saving the system, or certainly the patient, money,” Nelson added, also expressing concern with an APC training in a neurology practice, only to later move on to another setting. “We fully, fully train them to be our extender, and we teach them some neurology...and they quit and they go to the [Department of Veterans Affairs] where they practice completely independently.”

Bernard noted the additional concern of expectations in referring a patient to a neurologist. “When primary care doctors or other specialists refer our patients to a neurologist, we’re counting [on the fact] that the patient is going be seen by an expert who knows more than we do,” she said.

In a viewpoint column in JAMA Neurology,6 the authors strongly agreed that increased training for advanced practice clinicians (APCs) is essential, as is structuring neurology practices to optimize their function, contribution, and retention. “Exposure to neurology needs to be integrated into APC education by neurologists and neurology APCs, both in the classroom and in clinical experiences,” authors Calli Cook, DNP, APRN, FNP-C, an assistant professor at Nell Hodgson Woodruff School of Nursing at Emory University, and Heidi Schwarz, MD, a professor of clinical neurology at the University of Rochester Medical Center in New York, wrote. The pair encouraged combining onboarding with resident and medical student educational offerings and developing a culture of inclusiveness as possible approaches.

Cook told NeurologyLive® at the time the viewpoint was published that the main advantage APCs bring to the table is their distinct backgrounds. “In a high-functioning effective team, you want people who have different experiences and are exceptional at those different levels of care. When you hire a PA [physician’s assistant], you may be getting someone who has worked as an EMT [emergency medical technician] or in an ambulance and has that experience that another person on the team doesn’t. When you hire an advanced practice nurse, you have those years of nursing experience and those clinical hours that roll into that person who can help with other things,” she explained.

In considering optimal practice structure, Cook and Schwarz proposed a distributed leadership approach, not only to enhance productivity but also to reduce burnout and help avoid the turnover of APC staffing after the investment in their training. They wrote that distributing leadership—delegating a portion of authority and accountability to those who are working most closely with the patients—is an approach to consider.

Majersik reflected on the debate and indicated that it comes down to the individual practitioner and their particular training. “I would argue that one of the best headache providers in [Utah] is a nurse practitioner because she’s been doing it for 25 years or more. It’s certain that one fresh out of school probably doesn’t have that expertise. But I think it can be gained,” Majersik said.

“It’s no different, really, for primary care. There’s a huge amount of work required to become an internist. I wouldn’t consider the issues to be any different for neurology than they are for primary care, where you’re supposed to manage all the body systems. So I think it’s a matter of training and knowing who you’re referring to,” she added.

Valuing Neurology and Neurologists

Majersik and colleagues wrote that they considered their third strategy of valuing neurologists and advocating for them to state and federal policy and lawmakers “in many ways the most important,” urging that “advocacy efforts must frame, highlight, and publicize the danger that the mismatch poses to demonstrate the urgent need and looming public health crisis.”

Their report recognizes initiatives of the AAN to increase community knowledge about the mismatch between demand for and supply of neurologists and supports efforts to publicly acknowledge those who are succeeding at reducing the gap. They note, for example, the hope for an AAN joint award to the chair and neurology course or clerkship directors for the top 5 departments garnering the highest percentage of medical students choosing neurology.

The report points to compensation of neurologists as a critical component of addressing this mismatch. “Regrettably, the increasing demand for neurologists is not driving a corresponding increase in the value of neurologists as measured by compensation,” the authors noted.

Majersik and colleagues are hopeful, however, that advocacy for programs such as the 2021 Medicare Physician Fee Schedule increases to work relative value units for evaluation and management codes will provide some correction. They also anticipate that participation in development of alternative payment models will benefit the field.

Majersik also emphasized to NeurologyLive® this need to advocate for the value of neurologists and neurology. “I think we’re also...victims of our own success,” she said. “We now have amazing treatments for multiple sclerosis, epilepsy, and migraine, and all of those are diseases, not just of persons who are [older] but also of those in their productive years. So it has seemed to me that there is more need because we have more to do.

“You want to showcase what a fantastic field it is, what a difference we can make in people’s lives, so that the younger generation sees it as a viable option for them [as a] field to go into.”

REFERENCES
1. Majersik JJ, Ahmed A, Chen IA, et al. A shortage of neurologists we must act now: a report from the AAN 2019 Transforming Leaders Program. Neurology. 2021;96(24):1122-1134. doi:10.1212/WNL.0000000000012111
2. Burton A. How do we fix the shortage of neurologists? Lancet Neurol. 2018;17(6):502-503. doi:10.1016/S1474-4422(18)30143-1
3. AUPN course 3: supply and demand in neurology subspecialties: how can you match the trajectories of trainees to the needs of the present and future? Presented at: 146th Annual Meeting of the American Neurological Association; October 17-19; virtual. Accessed November 23, 2021. https://vimeo.com/644336052
4. Overview. Physician Assistant Fellowship, Neurosurgery (Arizona). Mayo Clinic website. Accessed February 16, 2022. https://college.mayo.edu/academics/health-sciences-education/physician-assistant-fellowship-neurosurgery-arizona/
5. Transcript of podcast: “JAMA Neurology’s solution to neurologist shortage: just substitute NPs/PAs.” Patients at Risk. July 27, 2021. Accessed December 3, 2021. https://www.patientsatrisk.com/post/transcript-to-podcast-jama-neurology-s-solution-to-neurologist-shortage-just-substitute-nps--pas
6. Cook CL, Schwarz HB. Advanced practice clinicians-neurology’s underused resource. JAMA Neurol. 2021;78(9):903-904. doi:10.1001/jamaneurol.2021.1416