Just two years after the AAN established a neurohospitalist section, the emerging specialty is growing rapidly.
“I get multiple calls a week from people wondering about how they can become a neurohospitalist or from academic and nonacademic institutions asking, ‘How do we set up this model to work best?’” said S. Andrew Josephson, MD, director of the Neurohospitalist Program at the University of California-San Francisco (UCSF).
More than 300 neurologists have joined the Academy's Neurohospitalist Section, and Dr. Josephson estimates that between 300 and 600 neurologists are practicing as neurohospitalists in a variety of programs around the country.
Three fellowship programs — at UCSF, the University of Washington, and Mayo Clinic in Jacksonville, FL — are training neurohospitalists and many other institutions are beginning new training programs. A new journal, The Neurohospitalist, debuted in January. And members of the Neurohospitalist Society convened for the organization's inaugural meeting earlier this year.
Dr. Josephson compared the new movement to the Society of Hospital Medicine, which has championed the rapid rise of internal medicine hospitalists that have become commonplace across the country.
“We think this is an opportunity to work with the AAN to really advance the field and be an advocate for inpatient neurologic issues,” he said.
One of the goals of the Academy's Neurohospitalist Section is to define exactly what constitutes a neurohospitalist, said Section Chairman David Likosky, MD.
Currently, the term is used to describe any neurologist who practices extensively — although not necessarily exclusively — in the hospital setting.
Dr. Likosky first started practicing inpatient neurology a decade ago and now works as a neurohospitalist and medicine hospitalist at Evergreen Hospital Medical Center in Kirkland, WA. The AAN section includes adult and child neurologists who are interested in the emerging field of hospital-based practice, regardless of their current practice situation.
Dr. Josephson said the neurohospitalist movement is less about focusing on credentials than on improving the inpatient neurology care.
“I'm sure that, just like hospital medicine, there will be a point at which time our subspecialty becomes defined more formally and systematically,” he said. “I think we have a lot to offer because there has been little research nationally, outside of stroke, in caring for patients with neurologic illness in the hospital. If we can advance that goal, we can make a lot of headway to help physicians and their inpatients.”
DEMAND FOR NEUROHOSPITALISTS
Another goal is to validate that the use of neurohospitalists results in better patient care.
“There are a number of projects that have started to look at that, and it makes sense, but it remains to be proven right now,” Dr. Likosky said.
While that issue is being studied, the demand for neurohospitalists is being fueled by several factors. For one thing, many outpatient neurologists are so busy that they would prefer not to make daily hospital rounds or rush to the emergency department on a moment's notice.
“Outpatient neurologists have been so overworked and so squeezed financially that some welcome having more time to be in the office seeing more patients who are knocking at the door after a two-month wait rather than being on call 24-7 for the emergency department,” Dr. Josephson said.
For another, the number of inpatients who need neurological care appears to be greater than previously realized. Because of changes in insurance coverage and medical practice, the bar for inpatient admission is higher and today's inpatients are more ill with more comorbidities than they were a decade ago.
“When you put a neurohospitalist in a hospital, it is remarkable the number of neurologically ill patients that come out of the woodwork,” Dr. Josephson said.
This includes inpatients with known neurological diagnoses as well as patients admitted for other conditions but who have a neurological comorbidity, such as altered mental status or seizures. Thus, internal medicine hospitalists are generally quite happy to see neurohospitalist join their ranks.
“One of the big complaints of medicine hospitalists is that they were not adequately trained to deal with the inpatient neurologic issues that they face in practice, and they are looking for a hand with that,” Dr. Likosky said.
Hospital administrators are also contributing to the demand for neurohospitalists. Many prefer to pay neurohospitalists to treat inpatients and those in the emergency department (ED), rather than pay neurologists only for ED call.
Further, neurohospitalists frequently work on quality improvement initiatives in the hospital, provide electrodiagnostic procedures that internal medicine hospitalists do not perform, and may create a better environment for neurosurgeons and other specialists to work.
“There are several value-added pieces to the neurohospitalist model that appeal to hospital administrators,” Dr. Likosky said.
SPECIALTY TRAINING AND JOURNAL
Vanja Douglas, MD, the editor of the new neurohospitalist journal, said its focus will be on quality and safety for inpatients.
As the number of neurohospitalists increases, they need a place to share new insights into quality improvement and best practices.
Creation of the journal, which will be published quarterly, will also add to the academic credibility of the fledgling specialty, he said. Academic medical centers, however, are already embracing the idea of inpatient neurology as a specialty.
“The best news I have had over the last year are the number of other academic centers who are in various stages of setting up their own neurohospitalist programs and fellowships,” Dr. Josephson said. “Clearly there is a demand for this type of training that existing programs cannot meet. “
That said, leaders of the neurohospitalist movement do not advocate that fellowship training should be required.
Dr. Douglas was the first person to complete a neurohospitalist fellowship at UCSF and he now teaches in the UCSF program. He believes some neurologists are well-prepared for an inpatient career after they complete residency.
Others, meanwhile, may benefit from the additional exposure to inpatient neurologic practice that a fellowship provides — or they may find it helps them prepare for an academic career and leadership positions.
PROS AND CONS OF INPATIENT PRACTICE
A neurohospitalist career appealed to Dr. Douglas because he likes working with acutely ill patients but did not want to limit his practice to critical care or stroke.
“What I really like about being a neurohospitalist is that I get to see a wide variety of patients,” he said.
Other advantages, Dr. Likosky said, are a predictable work schedule and less financial risk than being in private practice.
Downsides to inpatient practice include having less control over their daily work flow than outpatient practitioners and the inability to develop long-term relationships with patients.
Dr. Likosky said neurohospitalists need to be comfortable with the pace of the hospital.
“You have to be able to establish rapport with patients quickly in difficult situations, and you have to be satisfied with the workings of the hospital, which may include electronic medical records and computerized physician order entry,” he said.
Although internal medicine hospitalists frequently receive larger salaries than their outpatient internists, that differential is not yet evident in neurology.
“Ultimately, that is actually a good thing for our field because, unlike the internal medicine model, I think you will find that money is not the big driver for trainees to choose between an inpatient and outpatient-based career,” Dr. Josephson said. “That allows us to keep some of our brightest people in both camps, and people who are neurohospitalists choose that career because they find it stimulating and rewarding.”
TRACKING THE GROWTH OF NEUROHOSPITALISTS
Neurology Today has been covered the burgeoning growth of neurohospitalsts for several years. For more reading on the subject, visit neurotodayonline.com for these articles:
- “Length of Hospital Stay After Stroke Cut More Than a Day by Neurohospitalists, Study Finds,” July 1, 2010, http://bit.ly/ijwMmI
- “Neurology Training Programs Gear Up to Meet Increasing Need for Intensivists and Hospitalists,” April 1, 2010, http://bit.ly/gyKByc
- “Neurohospitalists: A New Term for A New Breed of Neurologist,” October 2005, http://bit.ly/epaaGy