This week, the journal 'Neurology Live' reported on the publication of A Shortage of Neurologists—We Must Act Now, compiled by Jennifer Majersik, MD, MS, chief of the Division of Vascular Neurology and a professor of neurology at the University of Utah School of Medicine in Salt Lake City. Citing a 'grave threat' to high-quality neurologic patient care, the report called for 1) education of referral bases 2) enhancing the neurology workforce 3) valuing neurologists.
The report noted that 'many referrals to neurology do not warrant neurologist intervention, such as an incidental finding of minimal white matter changes on a brain MRI with a low likelihood of multiple sclerosis,' often due to 'the lack of adequate education and experiences in neurologic topics across other specialties and practitioners.' Majersik attributed this to deficits in non-neurologist physician residency training and a large increase in 'midlevel providers who are practicing in various specialties and may have minimal to no foundational knowledge of neurological disorders, which ultimately results in more referrals to our [neurology] outpatient clinic.'
Interestingly, while the report authors suggest requiring a minimum 4-week clinical clerkship for medical students in neurology (clinical neurology is already a core requirement for most medical schools), they do not address deficits in neurologic training for nurse practitioners and physician assistants. Considering that the quality of referrals by nonphysician practitioners is far inferior to that of physicians, this seems like a missed opportunity.
As usual, rather than emphasizing an increase in neurology residency slots for medical students (a specialty with a 99.6% fill rate and more applicants than slots), the report focused on 'the increased use of advanced practice clinicians (APCs) in neurology practices' and ensuring 'that residents have the opportunity to work with these teams.' They also called for additional neurology training for nonphysician practitioners.
'Neurology Live' referenced the Patients at Risk podcast interview with neurologists Carol Nelson, MD and Alyson Maloy, MD as an example of physicians opposing the incorporation of nonphysician practitioners into neurology practices. While we appreciate the mention, the journal didn't quite get our point. None of the guests on the podcast stated that NPPs should not be a part of team-based practice, but rather, that NPPs should not be permitted to practice neurology independently, without physician supervision.
“...Dr Nelson and I had to go through the wringer for over a decade to prove our competency—not only just prove it, but to actually gain it. Neurologic disorders are very complicated, and it takes seeing a lot of patients to see what’s out there and to become competent and [take] care of people,” Maloy said.
Nelson concurred, later commenting, “You can’t just walk in and [provide that level of care]. You’ve got to know the physiology and the anatomy in order to figure out the pathology.
“I think it’s actually been proven that the amount of testing that’s ordered by a physician extender compared to an MD or a DO is astronomical, so it’s certainly not saving the system, or certainly the patient, money,” Nelson added, also expressing concern with an APC training in a neurology practice, only to later move on to another setting. “We fully, fully train them to be our extender, and we teach them some neurology...and they quit and they go to the [Department of Veterans Affairs] where they practice completely independently.”
Bernard noted the additional concern of expectations in referring a patient to a neurologist. “When primary care doctors or other specialists refer our patients to a neurologist, we’re counting [on the fact] that the patient is going be seen by an expert who knows more than we do,” she said."
The report author, Majersik, asked to reflect on the 'debate,' said that "it comes down to the individual practitioner and their particular training. 'I would argue that one of the best headache providers in [Utah] is a nurse practitioner because she’s been doing it for 25 years or more. It’s certain that one fresh out of school probably doesn’t have that expertise. But I think it can be gained,' Majersik said. 'It’s no different, really, for primary care. There’s a huge amount of work required to become an internist. I wouldn’t consider the issues to be any different for neurology than they are for primary care, where you’re supposed to manage all the body systems. So I think it’s a matter of training and knowing who you’re referring to,' she added."
As physicians and scientists who have come through the Flexner Report of our own profession with an appreciation of the importance of evidence-based medicine and the flaws of an apprentice-based system, we know that an anecdote about an outstanding NP (who was likely trained by an outstanding neurologist) is not enough to validate independent practice by nonphysician practitioners. Medical clinicians must be completely and thoroughly trained to ensure that patients receive optimal care. After all, studies show that more patients die worldwide from poor quality care than from lack of access to care.
On behalf of myself and the Patients at Risk podcast, we maintain our stance in full support of nurse practitioners and physician assistants as critical members of the healthcare team. The science is clear: when NPs and PAs work under the supervision of physicians in a team-based setting, patients receive great care. However, what is not clear is whether NPs or PAs can practice safely and effectively independently, with many reports showing concerns about an increased cost of care, poorer quality of referrals, more missed diagnoses, and more prescription medications by nonphysician practitioners. Until such time the question of patient safety is definitively answered, we must continue to oppose independent practice by NPs and PAs.
Regarding the report's final recommendation of valuing our neurologists, we could not agree more. As the ultimate 'cognitive' discipline, neurologists are often the best and brightest of physicians, dedicating themselves to years of training to care for some of the most complex and challenging medical conditions that exist with compassion and empathy. This type of care takes time, which is certainly undervalued in our current healthcare system. This is yet another reason why my podcast guests and I are so passionate about the replacement of neurologists - the mere idea that someone with a fraction of their training, even with an additional 12-month 'mini-fellowship,' as referenced in the article, can do what they do... well, that is the ultimate disrespect.