Has Stroke Care Fundamentally Changed Neurology? What Are the Challenges?

November 2, 2011

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Dr. Bruce Sigsbee

Neurologists are classically characterized as being smart, able to take great histories, and perform elegant exams arriving at a difficult diagnosis. However, the perspective on neurology is that little can be done for patients. In the past decades, our ability to actively intervene has increased substantially. That transition is perhaps the greatest in cerebrovascular disease. While there always have been neurologic emergencies such as status epilepticus or acute CNS infections, the frequency of acute stroke and the need to consider thrombolysis requires immediate availability of the neurologist. No longer can the on-call neurologist suggest acute interventions and see the patient in the morning.

The changing care of stroke patients presents challenges in three areas. The first is training. Care of patients requires substantial knowledge in the mechanisms and treatment of cerebrovascular disease. Expertise is required in endovascular and interventional neurology, critical care, neurohospitalist, neural repair and regeneration, neuroimaging, and vascular neurology. For many of these areas, the training available to neurologists is very limited or uneven. And yet with the growing number of active interventions available and the growth of certified stroke centers, expertise is needed.

Another major challenge is the competition currently surrounding stroke. In the past, there was effectively no interest of other specialties in stroke. However, with the highly remunerated interventions, radiology, cardiology, and neurosurgery are suddenly very interested. In some centers, stroke is admitted to neurosurgery, not neurology. That interest parallels the growing use of endovascular interventions in the treatment of stroke. And yet, often non-neurologists have difficulty recognizing what is and is not a stroke. As a result, inappropriate or even dangerous treatments are employed for seizures, hypoglycemia, conversions reactions, and other mimics of stroke. Some are concerned that we are at risk of "losing" stroke to other specialties.

The greatest challenge is providing for the 24/7 coverage needed for this patient population. For many neurologists in practice, the solution has been to resign hospital staff positions to avoid the practice burden. Where inadequate neurologic coverage exists, hospitals are resorting to teleneurology or to neurohospitalists to fill the gap. These solutions are very expensive. For those still providing the coverage, there are major frustrations surrounding the lack of reimbursement for the service, including the inability to bill for the interpretation of the imaging. That interpretation is typically done by the radiologist well after neurologist has acted on the scan, often the next morning.

The solutions are not easy. First of all, I think that there is little chance that we will lose stroke to other specialties. No other specialty is stepping forward to establish a certified stroke center or provide teleneurology services for acute stroke. Whether neurologists provide endovascular services is up in the air. Given the high remuneration, there is substantial competition and institutional turf wars. Training slots for stroke fellowships and other key skills in the management of stroke are not adequate but growing.

The problem reflects the poor relative reimbursement for evaluation and management services as compared to procedures and the time commitment and responsibility of acute stroke care. Fixing this imbalance will require a change in national health care policy, a change that is likely to happen but not soon. In the interim, there are steps that can be taken. Many neurologists are paid for being on call, particularly on call for stroke. This decision often is made on a local basis, often based on the availability of coverage without payment. Other solutions to call pay such as neurohospitalists or teleneurology are much more expensive. The legitimate use of the critical care codes for the acute assessment and decision about thrombolysis is another short-term solution.

In conclusion, the relatively rapid development of management options in many subspecialties of neurology is a reflection of the exciting and dynamic nature of the specialty. However, the rapid developments present challenges in that training programs must stay abreast of the knowledge base and separate fellowship programs for an ever increasing number of subspecialties, now more than 26. The greatest challenge, as it is with stroke, is establishing compensation systems that fairly recognize the skill and demands of different responsibilities within neurology. A few stopgap measures can provide partial relief but are not effective long-term solutions. While I am convinced that this issue will be solved, we are currently a long way from a meaningful solution. Stroke, in particular, has redefined the role of a neurologist in acute medical care. Compensation models, training, and specialty scope of practice are lagging.

Bruce Sigsbee, MD, FAAN
President, AAN