Article In Brief
The percentage of US members of the AAN who describe general neurology as their primary subspecialty has gradually declined over the past four years. Experts discuss the reasons behind the trend, what the impact could be on patient care, and initiatives around the country to address that trend.
By 2025, we will have a 19-percent workforce shortage in neurology. The anticipated shortfall is due to both an increase in demand from the aging population and a decrease in supply of neurologists in active practice. But potentially masked within this data may be an even more ominous finding: the general neurology workforce is dwindling.
Indeed, the percentage of US neurologist members who describe general neurology as their primary subspecialty has gradually declined over the past four years. According to AAN member profile data, 40.1 percent identified their subspecialty as general neurology in 2015 while only 33 percent did so in 2019. An electronic survey sent to all AAN members graduating from US neurology training programs in the Spring of 2014 indicated that 93 percent of adult neurology residents reported plans to pursue fellowship training, Justin T. Jordan, MD, clinician director for neuro-oncology at the Massachusetts General Hospital, and colleagues reported in a 2016 paper in Neurology.
Three years later, a 2017 paper in Neurology by Abhimanyu Mahajan, MD, MHS, and colleagues, found that 90 percent of respondents reported plans to pursue a fellowship after residency.
“The very high rate of neurology residents going on to do fellowship training both postpones their entry to the workforce and suggests a plan for most to practice within a subspecialty,” said Dr. Jordan, who serves as vice chair of the AAN Workforce Pipeline Subcommittee. “This may have a negative impact on timely access to care, and especially on access to general neurology care,” he added.
The Drift Toward Specialization
The drift toward specialization may be reflected in AAN membership demographics. According to the 2019 AAN Membership Insights Report, the median age of general neurologists is 56, whereas the median age of specialists like those in movement disorders is 47, epilepsy and vascular neurology is 46, and sports neurology is 39.
The increase in specialization within neurology over the past three decades and the advent of new fellowships for autoimmune neurology, neuropalliative care, interventional neurology, and neurohospitalists, among others, is an exciting development which appeals to new trainees. But the unintended consequence of this expansion is that neurologists in academia throughout the United States are finding it quite difficult to identify and recruit general neurologists.
“We are in the process of revising our compensation model, and are trying to make changes that would incentivize and reward general neurology,” said Brett Kissela, MD, MS, chair of the department of neurology and rehabilitation medicine at the University of Cincinnati College of Medicine, who has been actively looking to add neurologists to his department over the past several years.
“We are in a dangerous time in academic neurology,” he said. “General neurologists are essential to our training program because they have the broadest scope of view, but departments have fewer and fewer generalists. In recent years, there has been an increase in the number of specialty fellowships waiting to be filled, and we have created an undersupply of generalists, especially ones who want to join an academic department.”
Like many neurologists, Dr. Kissela is struggling with staffing his outpatient neurology clinics, leading to long wait times. “Specialists in my department are naturally reluctant to take on extra general neurology clinic hours because they prefer to see patients in the specialty clinics for which they are trained.”
“Part of the reason fewer neurologists are going into general neurology is that we are failing to convey its value to our trainees,” said Louise Klebanoff, MD, chief of general neurology and vice chair of operations for the department of neurology at Weill Cornell Medical College. Among the staff of 60 neurologists at Cornell, there are only five general neurologists, and the demand for general neurology services is rising.
When Dr. Klebanoff reviewed patients discharged from the emergency room in need of neurologic follow-up, for example, 75 percent were for general neurologic issues, and when urgent visits were analyzed, 75 percent of those were for general neurology as well.
The Impact on Care
The consequences of this strained workforce, as several neurologists told Neurology Today, is poorer access to care, longer patient wait times, an increased caseload, a rise in care complexity, and greater administrative burden.
Dr. Klebanoff noted that patient access—measured by percentage of new patients seen within seven days—is among the lowest in the institution, when benchmarked nationally. Although administrators have repeatedly asked the subspecialists to assist with general neurologic problems—by adding an hour a week to see urgent referrals, for example—the response has been a widespread lack of interest.
“Further aggravating the backlog,” said Dr. Klebanoff, “subspecialists will not address general neurological concerns that develop within their own patients (i.e. the MS specialists send me patients when they develop neck pain or low back pain).”
The dearth of generalists has a significant impact on the pipeline and is self-perpetuating. “Residents get a limited exposure to the common ambulatory neurologic conditions,” Dr. Klebanoff pointed out. Because training is still very much weighted towards inpatient care, without this experience, they cannot envision a career in general neurology, she explained.
Although the need is recognized by the academic community, the title is neither respected nor valued, Dr. Klebanoff said. “Accordingly, we are regarded as the lower tier of everything: salary, recognition, and promotion,” she explained. Like other general neurologists who spoke to Neurology Today, she noted that although her department has a clinical track for promotion, it is very difficult to prove excellence in regional or national reputation if you are a generalist.
“I know what I do has value, but I don't feel valued,” she said, adding, “I actually love what I do and love taking care of my bread-and-butter neurology patients. There is something very satisfying about reassuring a nervous patient that their muscle twitches are not ALS, fixing their vertigo or improving a patient's migraines so that they can enjoy their life without the fear of a lurking headache.”
“However, there is a general snobbery regarding patients with routine neurologic problems and the physicians who care for them,” Dr. Klebanoff said. “Even in morning report, patients with chronic headaches or dizziness are treated like hot potatoes that no one wants to touch, and those of us who care for them are treated like suckers,” she observed, echoing a sentiment which many fear is influencing trainees.
Creating a New Track, Incentives
For the past several years since Bruce R. Kastin, MD, became chief of the division of comprehensive neurology and the outpatient medical director for neurology at the Massachusetts General Hospital (MGH), he observed that the topic of promotion would evoke feelings of resentment and embarrassment from his clinician-educators as they realized that despite their dedication to the twin missions of patient care and medical education, they had little chance for Harvard Medical School (HMS) research-based promotion and the professional satisfaction it would bring. So, partnering with Steven M. Greenberg, MD, PhD, FAAN, vice-chair of faculty development and promotions, and with the support and guidance of department leaders Merit E. Cudkowicz, MD, MSC, Lee H. Schwamm, MD, and Meghan Kotarski, he worked to create a clinician-educator promotion track at the MGH, which was independent of HMS.
“With the introduction of this program, there is now a value on a career that focuses on caring for patients and educating the next generation of neurologists,” said Dr. Kastin.
“We have been called upon to do more primary care neurology at MGH each year,” Dr. Kastin noted. Among 15,000 new neurology outpatients annually, 5,000 are seen by a general neurologist, he said. Moreover, of 200 patients who require expedited care each month, 60 percent have general neurology problems.
“The referral volume keeps going up because of a growing shortage of community neurologists,” Dr. Kastin said. There are only six general neurologists at the MGH of a department of around 120 faculty members.
“By creating the new track, we hope to be able to attract and recruit more general neurologists who are interested in academia,” he said. “And there is no question that we need to find ways for our high-quality residents to want to become clinicians and generalists,” he added. “That includes finding more exciting incentives to attract our trainees through compensation, acknowledgement of experience and expertise, and by provision of support staff,” he concluded.
Other academic medical centers are also addressing the challenge. Katherine S. Carroll, MD, assistant professor of neurology, and division chief of comprehensive neurology at Northwestern University Feinberg School of Medicine, has developed, along with the residency program director, a formal elective rotation in comprehensive neurology for their residents to rotate through.
Dr. Carroll, like many others, believes the new term “comprehensive” better describes the field than “general.” Her division currently has six comprehensive neurologists in a department of 93 neurologists. “I would love the division to one day sponsor a comprehensive neurology fellowship for residents looking to improve their clinical skills prior to entering into practice,” she said.
Nagagopal Venna, MBBS, FAAN, director of the advanced general and autoimmune neurology fellowship program at MGH, started such a program in 2006 with one fellow, and has four fellows planned for 2020. He is aware of the demands on the comprehensive neurology section, and the staffing needs of that clinic, but stated that his fellowship is not meant to fill that gap.
“Rather, the fellowship is intended for neurologists who are seeking a career in academia,” he said. “Our patients come from referrals from neurologists who have already seen the patient and cannot figure out the diagnosis, and our fellows are trained to solve those ‘mysteriomas.’”
What About Reimbursement?
Given relatively low reimbursement for cognitive services compared to procedural services, a strict relative value unit (RVU) model would place most generalists at the lower end of salary ranges. While some departments like Dr. Kissela's have created salary incentives to attract generalists, others rely on a combination of cognitive and procedural services to balance employee salaries.
A. Gordon Smith, MD, FAAN, professor and chair of neurology at Virginia Commonwealth University, successfully recruited a general neurologist last year and is in the process of recruiting another.
“In each case, they will spend part of their practice in a community setting where they can take advantage of their electroencephalography (EEG) and electromyography (EMG) training, while participating in resident and student education at our main teaching location,” he said. “My past experience is that recruiting faculty to work in a pure general neurology position (i.e., without either a procedural or subspecialty focus) is very difficult,” he said.
“It is extremely challenging to survive in a work RVU-driven model without relying on procedural, neurohospitalist, or other non-outpatient evaluation and management-based activities,” explained Dr. Smith, who also chairs the AAN Education Committee.
“While we have discussed a number of ways we can address the general neurology workforce needs during and after residency at the committee, including redefining what it means to be a ‘general’ neurologist, promoting better exposure to realistic general neurology experiences during residency, and encouraging development of advanced general neurology fellowships post residency, achieving this objective will likely require an evolution in how we practice neurology as a system while addressing neurology compensation models,” he concluded.
The AAN General Neurology Task Force
In order to address the state of general neurology, AAN President James C. Stevens, MD, FAAN, has created the General Neurology Task Force, charged with exploring the needs of the population for general neurology care; the current number and the status/trends of newly trained neurologists entering the field of general neurology; the ability of neurology residency training programs to prepare young physicians for practice in general neurology; the value of establishing a general neurology fellowship, if adequate training is not being accomplished in three-year programs; and threats to the profession if general neurology gives way to subspecialty neurology as a model of care.
Michael E. Markowski, DO, FAAN, one of seven neurologists in a hospital-employed practice in Cape Cod, MA, has worked as a general neurologist for almost 15 years and is chair of the task force, which is comprised of both academic and community general neurologists. “If we don't fix this now, our critical nationwide shortage of neurologists will further exacerbate the shortage of general neurologists, within both our academic centers and communities,” he said.
For further discussion on whether a general neurology fellowship will help solve this problem—or create new ones—read more about the controversy on Synapse, AAN's online communities, under the General Neurology Community section.