Neurohospitalist medicine constitutes one of the most rapidly growing neurologic subspecialties in recent years. The term “neurohospitalist” was first used in print in a 2005 story in Neurology Today, “Neurohospitalists: A New Term for A New Breed of Neurologist.” Since then, this nascent field has flourished in response to a perfect storm: recessionary financial forces; competing demands for outpatient neurologists' time; the boom in stroke services; the migration of neurologists from private practice to hospital-acquired employment; and the increasing complexity of in-patient medicine in an era of diminished internal medicine training in neurology.
But as with any adolescent growth spurt, the recent intensified expansion of the specialty has given rise to an existential crisis among its practitioners. Engaged in a struggle for definition, validation and consensus, they are making efforts to secure their roles, unify their members, and defend the identity of their profession. Three neurohospitalists — representing different perspectives — spoke with Neurology Today about the challenges they face and the future of their practice.
A PIONEER IN THE FIELD
Liana E. Dawson, MD, a former aerospace engineer for the Johnson Space Center, owned a private neurology practice in Texas between 1999 and 2005 when the death of her husband and business manager, led to its closing and a much-needed hiatus. After an initial stint filling in for neurological coverage in temporary capacities, she discovered that she preferred hospital medicine and she committed to a career as a neurohospitalist. Later, she came to realize that locum life was a good fit, giving her absolute freedom between jobs and providing the answer to her quality of life dilemma.
Dr. Dawson, who is part of a group of self-proclaimed pioneers in the field, and has held a councilor position in the AAN Neurohospitalist Section since its inception in 2009, is also a vocal and interactive member of the section listserv, which is currently focused in a heated debate.
“Community neurologists with both inpatient and outpatient practices often feel they are not properly acknowledged or included in the decisions made by an academic contingent serving in various professional societies,” she said. “Furthermore, the problems of a community neurohospitalist differ from those in academic medicine.”
The community neurohospitalist lacks the support structure typically supplied by the institution for their academic counterpart, has far less (and sometimes no) coverage options, and receives no aid in negotiating demands placed on their performance, Dr. Dawson pointed out. “All too often, each group feels isolated and outcast, and the result is fragmentation, which only diminishes our power as a group,” she said, voicing frustration.
One of the challenges unique to the field is that there is not yet a formal certification or credentialing pathway for neurohospitalists. While there are several specialties that offer training in neurohospitalist medicine, their completion is not a prerequisite to working as a neurohospitalist. Many neurologists pursuing this goal elect to undergo specialty certification in critical care neurology, vascular neurology, or interventional neurology. Likewise, many neurohospitalists elect to affiliate with the organization that governed their training, whereas others also belong to the AAN Section, the Neurohospitalist Society, or the Society of Hospital Medicine.
COMPETENCY IN INPATIENT NEUROLOGIC ISSUES
Joshua P. Klein, MD, PhD, chief of the Division of Hospital Neurology at Brigham and Women's Hospital (BWH) and assistant professor of neurology at Harvard Medical School, completed a fellowship in diagnostic neuroradiology in 2011, and is board certified in neuroimaging by the United Council for Neurologic Subspecialties. Dr. Klein believes that in order for the field of neurohospitalist medicine to evolve and flourish, its practitioners need to continue to carve out their niche. He acknowledges that there has been imprecision in defining the scope of practice of a neurohospitalist; at one end of the spectrum, there are those who believe that a neurohospitalist only sees patients in the hospital, while at the other end, others contend that the designation applies to any neurologist who sees inpatients as part of their practice.
“In my mind, a neurohospitalist is someone who has a clinical focus and sub-specialist level of competency in inpatient-specific neurologic issues, regardless of other clinical activities or total time spent as an inpatient attending per year,” Dr. Klein said. His neurohospitalist team at BWH comprises inpatient specialists who also practice in other outpatient subspecialties — for example, neuro-infectious diseases and neuro-ophthalmology — or inpatient subspecialties such as neurocritical care, and all team members are devoted to resident and student education, clinical process improvement, and patient-centered care redesign. “While I am aware of and sensitive to the many political and economic challenges that our emerging field will face in the coming years,” Dr. Klein said, “I believe that a unified approach to addressing and solving these challenges will be most effective.”
COMBINING IN- AND OUTPATIENT NEUROLOGY
No one knows exactly how many neurohospitalists exist. When the AAN section was formed in 2008 it had 93 members; it currently includes 571 members. John H. Lossing, MD, newly elected section chair has been a practicing neurologist for 41 years. Like many senior neurologists, he has done both ambulatory and hospitalist work at the same time. He estimates — based on his definition of a neurohospitalist as “any neurologist who sees patients in hospitals” — that there are thousands in the field. However, for those who define the role as a neurologist who only sees patients in the hospital, the number may be as low as 100, he said.
“The ultimate exclusion,” he wrote in a post, “is to dictate that ambulatory practice outside the hospital is a disqualification.” That might work at large academic medical centers where they can staff hospitalists in multiple subspecialties like stroke or epilepsy, he continued, “but in Fargo, North Dakota, neurologists need to see outpatients too, including our own follow-up patients we saw in the hospital.” He noted that there are merits to having the one neurologist provide that kind of continuity of care and oversight from the offsite clinic to the hospital: the neurologists know their patients and there is less risk for errors when patients are moved in the handoff from one setting to the other. One wonders why the larger academic medical centers haven't figured this out, he said.
Rather than believing there is a controversy in the field, he likes to think that it is “exploring.” “First, would a neurovascular fellowship followed by a certificate exam improve patient safety? Surely, the answer is yes,” he said. “Should certification require fellowship years (perhaps with a grandfather clause)?” he asked. “For that, the answer might be, good luck finding enough fellows to ever populate this field, particularly as Medicare ratchets down reimbursement every year.” Dr. Lossing believes the solution is to divide the field into two categories: “attending neurohospitalists” and “consulting neurohospitalists,” with respective levels of credentialing.
Meanwhile, the course of neurohospitalist medicine has yet to be written, and much depends of the success of unity over divisiveness. “Existing cliques and groups do us significantly more harm than benefit,” Dr. Dawson cautioned. “Why can't each of us say we are all neurologists and sit down together? When can we see not an academician and not a community neurologist, but a solid group more concerned with working together and effectively addressing all sides of the neurohospitalist future?” she reflected. She pointed to the recent blow to neurologists who perform neurodiagnostic testing as an example and asked, “Are any of us fool enough to think similar threats will not affect us?”
Dr. Avitzur, a neurologist in private practice in Tarrytown, NY, holds academic appointments at Yale University School of Medicine and New York Medical College. She is an associate editor of Neurology Today and chair of the AAN Medical Economics and Management Committee.
WHAT EFFECT DO NEUROHOSPITALISTS HAVE ON PATIENT OUTCOMES AND OTHER QUALITY MEASURES:
Three posters at the 2013 AAN annual meeting focused on the impact of neurohospitalists on patient outcomes:
* The Impact of a Neurohospitalist Service on Patient and Educational Outcomes at an Academic Medical Center: http://bit.ly/ZGlOBi — Investigators found that the introduction of a neurohospitalist service at an academic medical center coincided with a reduction in length of stay and improvement in medical student satisfaction without impacting overall costs, in-hospital mortality, or patient satisfaction.
* The Impact of Neurohospitalist Service on In-Patient Outcomes: An Academic Medical Center Experience: http://bit.ly/11yNVCc — Investigators studied how the neurohospitalist service affects inpatient neurology outcomes with respect to length of stay at a tertiary academic medical center, and concluded that the neurohospitalist service at a tertiary medical center was not associated with a reduction in length of stay.
* The Neurohospitalist. Key Performance Indicators. Experience in The American British Cowdray Medical Center, Centro Neurologico ABC in Mexico City: http://bit.ly/11AGtWb — The researchers applied five key performance indicators to evaluate the effect the neurohospitalist has in preserving standards of quality and safety, and found strong evidence supporting the importance of having a neurohospitalist included as a member of a neurological center; doing so preserved and maximized quality and safety standards.
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