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Are There Enough Neurologists to Address US Patient Population — Now and for the Future?

Butcher, Lola

doi: 10.1097/01.NT.0000406010.37645.42
A 1999 AAN workforce study forecast that the supply of neurologists would fall 20 percent below demand by 2020. In the years since, there has been growing concern about a looming physician shortage in many specialties.

A 1999 AAN workforce study forecast that the supply of neurologists would fall 20 percent below demand by 2020. In the years since, there has been growing concern about a looming physician shortage in many specialties.

The Academy's new study of the neurology workforce is designed to understand the supply and demand for neurologists now and in the future.

The study, to be completed in December 2012, is the first AAN-supported workforce analysis in more than a decade.

When that earlier study was published in 1999, it forecast that the supply of neurologists would fall 20 percent below demand by 2020. In the years since, there has been growing concern about a looming physician shortage in many specialties.

Academy leaders want to confirm whether a neurology shortfall is indeed materializing so they can effectively lobby for increased training opportunities and other changes that would help alleviate the problem, said Chris Keran, chief membership and strategy officer for the Academy.

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The first goal of the study is to identify how many neurologists are currently practicing. The American Medical Association estimate that the United States had 13,330 neurologists in 2010 has been subject to criticism, Keran said.

Some AAN leaders have lost confidence in the AMA's count of neurologists, in part because the AMA membership has dwindled considerably in recent years.

“Some subspecialties have done analyses and have found discrepancies for the AMA numbers,” Keran said.

Indeed, researchers who compared workforce estimates and supply projections using the AMA Physician Masterfile data with those made using the US Census Bureau Current Population Survey data — in a 2009 paper in the Journal of the American Medical Association — found that the physician workforce is — and will be — significantly younger and smaller than what the AMA has estimated.

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“Whether we've got 13,000 neurologists practicing in the country or — more likely — a smaller number, I believe we're going to need more,” said Timothy A. Pedley, MD, professor of neurology at Columbia University and president-elect of the AAN.

That was the conclusion drawn in a 2010 article in the journal Neurology Clinics, which examined the future workforce in the specialty. The lead author of the article — W. David Freeman, MD, a neurologist at Mayo Clinic-Jacksonville — chairs the AAN Workforce Task Force.

Dr. Freeman and his co-author Kenneth Vatz, MD, a private practitioner in Winnetka, IL, said the demand for neurologists in clinical practice is expected to increase within the next five to 10 years in part because of America's aging population, which means ever-increasing numbers of Alzheimer disease and stroke patients.

The healthcare environment is changing rapidly as hospitals want to hire neurohospitalists and neurointensivists and increasingly sophisticated patients seek specialty care more frequently.

“As neurology itself becomes increasingly subspecialized, will we have enough general neurologists to meet the demands for first-line neurological care?” Dr. Pedley said.

He pointed out that neurologists frequently take on primary care responsibilities particularly for patients with chronic illnesses like those such as Alzheimer disease that become increasingly common as the brain ages. In part this is because the supply of primary care physicians is also inadequate to meet demand.

Meanwhile, if the Affordable Care Act is not repealed, it will reduce the number of uninsured Americans by 32 million. That will give patients, who currently rely on emergency rooms for any health care services they receive, coverage for office-based care.

“These are just some of the issues I think that are very, very important for the future of the specialty and for the Academy to meet its mission of being indispensible to its members as we plan for inevitable changes,” he said.

Meanwhile, policymakers and payers are increasingly focusing on the quality and cost of care, and AAN leaders cite studies that suggest neurologists help on both fronts.

For example, a 2003 study in Neurology found that stroke patients treated by a neurologist were significantly less likely to die during their hospital stay than those who were seen by another type of physician.

And a 2010 study in the Journal of Stroke and Cerebrovascular Diseases reported that patients with intracerebral hemorrhage who were treated by neurologists had significantly shorter hospital stays — median stays of 4.5 days versus 7 days — than those treated by internists.

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So many factors potentially influence the supply of and demand for neurologists that the study could be extremely broad.

For that reason, the Academy's Workforce Task Force limited the scope of the analysis. For example, the study will not explore factors, such as reimbursement, that might affect medical students' decisions as to choice of specialty. The study will however assess current demand — whether there is a shortage or oversupply or, as was determined in the previous study, just about the right number of neurologists. It will also consider the percent of time neurologists, in total, are spending on patient care and gender differences in neurology.

The analysis will also derive estimates on the projected future supply of and demand for neurologists through modeling. Factors that will be considered include the number of neurologists in training and the number planning to retire; the growth of teleneurology; the role of international medical graduates; the aging of the US population; the impact of the Affordable Care Act; wait time and other barriers to care that neurology patients experience.

“The focus of the current Workforce Task Force was deliberately kept narrow,” Keran said. “The current iteration is: ‘What are the facts?’”

After the study results are reported, the Board might appoint the Task Force or another group to make recommendations based on the findings, he said.

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The first phase — determining the current supply of neurologists — is being conducted by AAN staff members. Their preliminary findings will be presented to the AAN board of directors later this month.

The second phase — a calculation of the current demand for neurologists — is also being conducted in-house, with a report to the board expected in March 2012.

A consultant will be hired to determine future demand and supply, and its report is scheduled for December 2012.

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  • According to a 2004 demographic report and survey of neurologists in the United States, of 15,831 physicians in the American Medical Association Physician Masterfile, 12,498 neurologist members (7,010 in practice) of the AAN had a primary self-designation of neurology, child neurology, or clinical neurophysiology. Therefore, with a 2008 United States population of approximately 305 million, and assuming approximately the same number of neurologists as in 2003, the population ratio would be at least 5.2 neurologists per 100,000 people.
  • The 2004 AAN survey indicated an uneven geographic distribution of neurologists, ranging from 11.02 per 100,000 in Washington, DC, to 1.7 per 100,000 in Wyoming.
  • Assuming an even distribution of neurologists over a typical 35-year practice career, 400 neurologists would be retiring each year, approximately equal to the number of new neurology certifications per year. However, according to the 2004 AAN survey, 34 percent of all currently practicing neurologists at that time were between 50 and 60 years of age, compared with the expected 28.6 percent each decade, if evenly distributed. Therefore, the attrition rate in neurology (or lack of AAN member neurologists participating in the survey) over the next decade would significantly exceed the rate of neurologists entering into practice.

Source: Freeman WD, Vatz KA. The future of neurology. Neurol Clin 2010;28: 537-561.

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Academy officials believe that demand for neurological care is increasing, so having an adequate number of neurologists is essential. Among the evidence they cite:

  • The Alzheimer's Association projects 16 million Americans will be diagnosed with the disease by 2050, up from 5.4 million today.
  • Migraine-related headaches sent more than 3 million patients to emergency departments in 2008, accounting for 2.4 percent of all ED visits.
  • Nearly 1 million Americans are being treated for Parkinson disease, and 60,000 new cases are diagnosed each year.
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              ©2011 American Academy of Neurology