Addressing the Neurologist Shortage and Increased Need for Neurologic Care

Jennifer Majersik, MD, MS

A report from the American Academy of Neurology (AAN) 2019 Transforming Leaders Program outlined the “large mismatch” between the number of patients who require neurologic services and the neurologists available to meet this need in the United States.

With an aging population, the amount of those at risk of developing neurologic diseases increases, and additional patients requiring neurologic services further affects patient care and wait times in certain areas. As successful treatments have been identified for conditions such as multiple sclerosis and migraine, referrals to specialists have also increased, as data has shown that patients who see disease-specific specialists often have better outcomes than those who solely see a primary care provider. 

Jennifer Majersik, MD, MS, lead author of the report from the AAN, sat down with NeurologyLive to discuss the driving forces behind the shortage, as well as ongoing strategies being implemented to attract more medical students to fellowships and the field of neurology in general. Majersik, who is chief of the division of vascular neurology and professor of neurology at the University of Utah, discussed suggested strategies developed alongside 9 colleagues, utilizing data and expert opinion to develop a framework for bolstering the workforce and promoting the value of neurology. 

NeurologyLive: What is driving this shortage of neurologists? How it currently affecting patient care, and how will it in the future?

Jennifer Majersik, MD, MS: The shortage of neurologists is multifocal in where it comes from, but a big part of it is the fact that our population is aging. So as patients get older, they are more at risk for stroke, and Parkinson disease and Alzheimer [disease] and other diseases have aged, and so that just by itself will raise the number of patients who need specialty neurologic care. 

However, I think we're also, I guess you could say, victims of our own success—we now have amazing treatments for multiple sclerosis, epilepsy, and migraine, and all of those are diseases, not just of persons who are elderly but also of those in their productive years. So, it has seemed to me that there is more need because we have more to do. There are diseases now that we can treat, and patients are aware of that, and so they and their primary care providers want to refer them. Then the other side of the shortage of neurologists is that even though we do have more neurologists now than we did in the past, we're not keeping up with that demand. The supply is going up, but it's going up more gradually than the demand. 

As far as how the shortage is affecting patient care, now or in the future, it's a little hard to get the numbers on that. We do have numbers on wait times—we know they've been going up in certain areas more than others, so that it takes longer for a patient to be seen as a new patient in a neurology clinic. However, even beyond wait times—which some people may say, “Well, that's just a matter of convenience or demand”—really, there are studies that show that if you see a Parkinson [disease] provider, a neurologist who specializes in Parkinson disease, you're less likely to fall than if you if you see your primary care provider. And in epilepsy, if you see someone who knows what they're doing in epilepsy as a neurologist, you have fewer seizures, which means fewer car crashes and less mortality. Clearly in stroke, again, [patients are] more likely to get tPA [tissue plasminogen activator] or thrombectomy and are more likely to walk out of the hospital. It really does drive patient outcomes in the end, even though this data has been a little hard to get. 

We've seen in some smaller papers that having access to a neurologist does improve patient care. It's one of the things that we've asked the AAN to consider, and whether this happens or not, I don't know, but we think it'd be great to have fellowships with funding in health services research looking at this specifically, so that we can better quantify the value that a neurologist brings to the patient. Because in the end, that's what we think we all do, is bring value to the bedside, but it would be nice to be able to prove that with more rigorous data than what we have available right now.

How imperative is it to attract more individuals to neurology fellowships and the field of neurologic medicine? What are the strategies that might help achieve this goal?

We clearly want more medical students to go into neurology. We want more undergraduates to be interested in medicine, and then go into neurology, because the more providers we have, the more capable we'll be of meeting the demand of our population. My colleagues [and I]—I speak for all 10 of us who wrote this paper—we think it's just really critical for people to understand what the field is. There’s unfortunately still this misperception that neurologists don't have anything to do. There's this old adage—"you diagnose and adios"—nothing makes me madder than hearing that, because it's just not true. You want to showcase what a fantastic field it is, what a difference we can make in people's lives, so that the younger generation sees it as a viable option for them [as a] field to go into. 

One of the things we talk about in the paper is compensation. People don't really like to talk about salary very much, but neurology and other cognitive fields have always suffered behind more procedural fields in terms of their compensation. That’s something that has to change because some medical students do choose their specialties based on how quickly they can get debt relief from their medical school bills; it's really an important part of job choice. The field itself has to be seen as attractive, and then it has to be seen as viable so that you can actually make a living in this field. Both of those are areas that are really important for current neurologists to work on, so that we can generate new neurologists who are as excited about the business of neurology as we are.

Fellowship training in neurology is becoming very common. Even my residents who then go on to practice general neurology are often being fellowship trained, and I think it's because hospitals have specialty needs for someone who can read EKGs, or who can do sleep medicine, or like myself can do stroke medicine. It has struck me that many residents are seeking fellowships for that additional specialty training, but I do think it makes them more hirable as well out in the community. Once they've done their general neurology residency, it allows them to become more specialized, but still to provide even a general role if that's something they're interested in. I think it makes them more marketable as neurologist. Certainly, in my department, we know the areas that we need filling, and so we're looking specifically for people with extra training in that arena.

I think there will always be communities who truly only need a general neurologist, but even within that, here at the University of Utah, I was talking to a neurologist in Rock Springs, Wyoming, and to one in rural Nevada—all of those neurologists have specialty training, and they bring that extra bit to those rural communities that they live in, even though they may primarily practice general neurology. I don't think the shortage makes it less important for people to be fellowship trained, because you want to be able to provide the best care possible to those patients.

Transcript edited for clarity. 

REFERENCE

Majersik JJ, Ahmed A, Chen IA, et al. A shortage of neurologists – we must act now: A report from the AAN 2019 transforming leaders program. Neurology. Published online April 30, 2021. doi:10.1212/WNL.0000000000012111