Looking Back, Moving Forward to a New Era for the Neurologist
As we celebrate our 70th anniversary this month, the AAN and its members have seen striking changes in the field of neurology. When the Academy was founded in 1948, there were few effective treatments for patients with neurologic disorders. As Dr. Labe Sheinberg said, patient evaluations were often a matter of “diagnose and adios.” Our abilities to diagnose improved with the advent of EEG and CT technology, but—with some remarkable exceptions such as Dilantin and L-dopa—treatments lagged. Nonetheless, our specialty continued to attract medical students, and in the 1970s there were questions as to whether we were turning out too many new neurologists from our academic programs!
The Decade of the Brain during the 1990s—championed by the AAN—brought an influx of federal funding that significantly accelerated research on brain and neurological disorders and the discovery of new treatments. The more recent increases in funding for the BRAIN Initiative and Alzheimer's disease and related dementia research are also providing opportunities for translational discoveries to make dramatic improvements in our ability to treat neurological patients. But as we moved into the 2000s, we began to see declines in the number of medical students entering neurology even as announcements of exciting new treatments picked up pace. For the last decade, only approximately 2.6 percent of US medical students annually chose a career in neurology. Studies conducted by the AAN show a current shortfall of 11 percent in our workforce needed to provide care, and this is projected to grow to 20 percent in a matter of a few years. With the aging of our population, this gap in our neurological workforce could become even greater. In 2018, we now find ourselves in an exciting era with new interventions and opportunities for prevention that did not exist 70 years ago. In fact, in January, the American Heart Association/American Stroke Association published a guideline, affirmed by the AAN, that expands the time window for interventional treatments of stroke to nearly 24 hours, significantly longer than we had presumed from previous research. We also have many other new interventions available for our patients such as deep brain stimulation for Parkinson’s disease and other movement disorders, epilepsy surgery that can be curative, neuro stimulation devices for seizures, and new therapies for multiple sclerosis and spinal muscular atrophy. In the future, we hopefully will have opportunities to regenerate and rehabilitate the brain using stem cells and other approaches such as neuro-modulation.
Not only that, but we are in a remarkable era of preventive neurology. We can prevent stroke with interventions like angioplasty and stenting for carotid stenosis and the use of antiplatelets and statins. We can administer new oral anticoagulants for atrial fibrillation. We can prevent migraine, try to alter cognitive decline via cognitive therapies and vascular risk factor control, and use a variety of approaches to limit falls and head injury. Our ability to image subclinical changes, use biomarkers and risk scores, and identify genetic predictors has refined the opportunities to detect people at risk for neurologic conditions. Neurologists are caring for patients across their lifespan and need to be even more involved with middle age, where we can identify preclinical stages of disease with earlier opportunities to prevent and intervene. We need to delay the transitions from wellness to illness, modify the course of neurological conditions, and compress the timeline of morbidity. Through our earlier engagement and focus on brain health, we can help our patients age successfully and extend their quality of life. At the same time, the AAN has taken major steps to turn around the supply shortage of neurologists and increase our pipeline by getting more students excited about neurology and neuroscience. To help ensure neurologists are providing the best possible quality care to patients, we are advocating for the increasing use of interdisciplinary teams and involvement of advanced practice providers to help ensure an efficient approach to care. The Academy has also strongly advocated for greater access and convenience via teleneurology.
This has led me to believe we are at a crossroads for our profession with an opportunity to reinvent ourselves, to move from neurologists to “newrologists.” I asked the participants in our 2017 Transforming Leaders Program to tackle this as their group project and flesh out this concept from their particular vantage points. The questions put before them: How can the Academy expand the scope of neurologic practice to include a greater emphasis on preventive, interventional, and regenerative care? And how can this help address the workforce shortage, stimulate interest in neurology careers, as well as minimize and mitigate physician burnout?
The Transforming Leaders Program participants envisioned the newrologist as the health care team leader, working with patients on preventive efforts as well as innovating care and embracing new therapies. The newrologist is data-driven, quality- and patient-centered, and business savvy. The newrologist communicates, inspires, and motivates both coworkers and patients. And the newrologist works with and is supported by the greatest professional organization that advocates for patients and its members—the AAN.
The Transforming Leaders Program participants developed an exciting, comprehensive action plan for the AAN to consider:
- Facilitate neurologist-led teams by reframing neurology as a team-based specialty, expanding the use of advanced practice providers (APPs). We’ve welcomed more than 1,000 APPs as members of the AAN, established a consortium, and are helping to define their role and providing clinical education and training to enhance their skills and value within this team. We will harness teleneurology to enhance teams and care coordination. We will develop and promote neurologists as data-driven team leaders and provide education and training in team leadership.
Furthermore, we will seek to create team care pathways for brain health across the lifespan. This can be accomplished by expanding the influence of guidelines and care pathways created by neurologists, and integrating them into primary care and preventive screening. They will specify when to refer a patient to the next level of care and specify diagnostic and preventive measures to improve patient-centered quality care.
- Build tools to implement innovative therapies. While many effective neurology treatments exist in all subspecialty areas of neurology and span prevention and intervention, effective treatments are often poorly utilized. This may be because the neurologist is unaware or has limited understanding of treatments. There may be challenges due to lack of skills and resources, or difficulty navigating reimbursement.
The AAN has made it a strategic priority to centralize and personalize resources for our members, providing one-stop shopping for the newrologist to be able to conduct advanced searches by disorder, resource type, population group, setting, date, etc. The Academy should deliver personalized content through mobile and online tools highlighting new treatments, and create new educational modules to enhance members’ skills.
- Communicate the vision and purpose of the newrologist. Targeted efforts to integrate new initiatives into the AAN’s messages to our members that the AAN is an indispensable source of treatment tools and data. To the public our message will be that the neurologist is the key physician to optimize brain health. And we will affirm to payers and policymakers that neurologists are quality- and value-driven and leaders of the neurology interdisciplinary patient care team.
Our profession has evolved enormously over the past 70 years, not always easily and certainly not always to our liking. The separation of neurology from psychiatry in the mid-20th century was difficult, at times contentious, but necessary for our specialty to stand on its own two feet. New treatments have successfully altered life for our patients, but required neurologists to be up-to-date on the availability and efficacy of these new agents. The support of the federal government for the elderly and poor through Medicare and Medicaid assured access to care while fostering increasing regulatory hassles for the medical community. Health care reform efforts of the past two decades have sought to bring down ever-growing, unsustainable costs while sowing confusion, frustration, and burnout in our ranks. Despite these hurdles, I hope you share my optimism for this forward-thinking view of the “newrologist.” We need to take full advantage of the exciting opportunities to intervene and prevent neurological conditions, expand the future scope of the practice of neurology, and remodel the image of the neurologist. This is a future that we neurologists must—and will—shape.