ARTICLE IN BRIEF
New fellowship programs are emerging to address the need for hospital-based emergency neurology care.
Two distinct but sometimes overlapping neurology subspecialties are gearing up to increase their numbers, through new residency opportunities and fellowships. Their goal — to improve care to hospitalized patients — comes in response to a dearth of neurologists who see acutely ill patients in hospitals.
Neurointensivists — a group that gained board certification in neurocritical care in 2007 — almost exclusively treat individuals in an intensive care unit (ICU). Their primary training may have been neurology, neurosurgery, anesthesia, or internal medicine.
Neurohospitalists, a smaller but growing subspecialty, have grown in number in response to increasing demand for neurology care for stroke patients. As hospitals struggle to find neurologists with busy office-based practices willing to come to their emergency departments on a moment's notice, smaller, community hospitals are increasingly relying in neurohospitalists. Neurohospitalists, who can also see patients in ICUs, do not have a mechanism for board certification yet.
“In a medical center without subspecialist resources, a neurohospitalist would be likely to consult on patients in the ER, on the floor, and provide neurological consultation on patients in the ICU,” said Kevin Barrett, MD, a board-certified vascular neurologist and a neurohospitalist who sees patients at Mayo Clinic Hospital in Jacksonville, FL. “In a medical center with subspecialists available, a neurointensivist would manage patients in the neuroICU and a neurohospitalist would provide consultative services to the ER or on the general wards. In hospitals without a dedicated neuroICU, the critically ill neurology patients would be seen by a neurologist, neurohospitalist, or neurointensivist as available.”
Stephan A, Mayer, MD, president of the Neurocritical Care Society (NCS), founded in 2002, said that while the society has approximately 1,000 members, it wants to do more to expand the field. One step was to gain board certification and the next was to develop accredited fellowships, said Dr. Mayer, head of the Division of Critical Care Neurology at Columbia University College of Physicians & Surgeons.
The United Council for Neurologic Subspecialties agreed to accredit neurocritical care fellowship programs for the first time three years ago and now there are 25 such programs. Last year NCS held its first ever fellowship match, and the disappointing results — only 24 applicants were interested in 48 slots — prompted Dr. Mayer, Edward Manno, MD, chair of the AAN Emergency Neurology and Critical Care Section, and other society leaders to think about ways to address this shortage. One idea was to offer elective rotations for residents.
Interest in neurointensive care could be ignited during a residency, Dr. Manno, director of the NICU at the Cleveland Clinic. pointed out, but unless the resident is at an academic medical center or teaching hospital that has a neurointensive care unit, he or she will is unlikely to have chance to learn or practice critical care neurology.
To remedy this, Dr. Manno and others, working in conjunction with the AAN Emergency Neurology and Critical Care Section, are identifying residency programs across the country that are strong in neurocritical care to provide visiting rotations to neurology residents.
“We felt there were probably a lot of neurology residents who would love a career in neurocritical care if they knew about it,” Dr. Mayer said,
The NCS hopes to have rotations established in time for this year's residents in July. (More information is available at neurocriticalcare.org.)
Neurohospitalists also predict growth. While there is no consensus yet on whether board certification should be required, neurohospitalists are working to create and standardize fellowships; the subspecialty now has its own AAN section as well.
“Neurohospitalists are part of an emerging subspecialty that has yet to be fully defined,” Dr. Barrett said. “There are definitely neurohospitalists who spend all their time in the hospital, and many who spend more than 50 percent of their time in the hospital.” But the specialty meets a need, he said.“Many clinic-based neurologists are backing out of hospital coverage; there may be no contractual obligation to provide hospital-based or emergent neurologic care. Some are saying it is not worth their time.”
Dr. Barrett said the Mayo Clinic in Jacksonville recently started a fellowship program and will recruit to fill the first position in 2010; the curriculum “is flexible and learner-based,” he said.
What is still unknown is what financial model will work for neurohospitalists. A hospital with fewer than 300 beds may feel it cannot afford one, and neurology group practices may not either. As a result, innovative arrangements are being developed and in some cases a smaller or community hospital will partially subsidize a neurohospitalist's salary.
Collaboration among neurointensivists and neurohospitalists is often standard practice. “People are beginning to struggle with how are we going to deal with the critical care shortage,” Dr. Manno said. “One of the models is to expand neurohospitalists, who will call an intensivist if they need to.”
Dr. Mayer, who oversees the Columbia's 18-bed neurology ICU (NICU), said the hospital also has four dedicated stroke beds, four step-down and four “close watch” beds, all for neurology patients. In academic medical centers and other hospitals that use residents, restrictions on residents' hours has left a vacuum that others must fill, he said, particularly in seeing patients in the emergency room.
He also sees the need for neurohospitalists in institutions like his that have a NICU but also a step-down unit or beds that need supervision. Laura Lennihan, MD, the neurohospitalist at Columbia, supervises a staff of nurse practitioners who specialize in neurology, but they do not do ER consults, as that remains the purview of residents.
At the Mayo Clinic in Jacksonville, Dr. Barrett is one of five neurohospitalists among a 20-plus-member neurology department that also includes a board-certified neurointensivist, a model that was created four years ago. “Most times, we have two faculty staff in the hospital — a neurohospitalist that can provide consultation to the ER and floor and a neurointensivist to provide care for the critically ill patients in the unit,” Dr. Barrett said.•
A NEUROHOSPITALIST MEETS A DIRE COMMUNITY NEED
In July 2009, Liana Dawson, MD, a board certified vascular neurologist, became the first ever neurohospitalist for Orange Park Medical Center in Jacksonville, Fla, part of a two-community hospital system. Dr. Dawkins, a solo practitioner, fell into the subspecialty after a stint as a locum tenens, during which time she realized she loved hospital work.
Orange Park is her most recent neurohospitalist job, with others in Minnesota, Texas, and most recently, Winter Park Memorial Hospital, also in Florida. In her Winter Park and Orange Park positions, about 25 to 29 percent of her time is devoted to providing critical care in an intensive care unit, with the balance spread between general medical beds and the emergency department. She has never worked with a neurointensivist. Orange County's entire ICU is just two beds shy of the size of Mayer's entire NICU.
At the Winter Park hospital, Dr. Dawson was under contract to a hospital-owned physician administration who oversaw one physician's assistant; here, as well, she was the first neurohospitalist. At Orange Park she has a one-year contract or “revenue guarantee arrangement” through which she is paid certain salary, regardless of how much revenue she receives by billing patients.
Although she said the hospital is satisfied with this arrangement, she believes the financial model needs to remain flexible to the local community, hospital, and medical environment needs. She firmly believes that neurohospitalists should be “independent and autonomous” from hospitals. Regardless of financial arrangement, the need is clear.
“There is not enough call in that size hospital for a neurointensivist,” she said. “It is probably very difficult to staff a neurointensivist in a community hospital — period.” In contrast, there is a “dire” need for neurohospitalists because so few neurologists will come to hospitals, even though some have taken to paying neurologists $500 to $700 per day just to be on-call if needed, Dr. Dawson said.
She does not favor special board certification or accredited residency training, and worries that a push in this direction will eliminate opportunities for neurologists to become hospitalists. “I personally think you could do a split track residency that is part hospital-based and part clinic-based,” she said.•