Neurologist, Internist, or Strokologist?
After all, clinical medicine is above all the study of the difficult aspects and complexities of diseases. When a patient calls on you, he is under no obligation to have a simple disease just to please you.
—J.-M. Charcot, 1887
Stroke is a complex disease involving not only the brain, but many other organ systems. Hence, special skills are required. So who cares for the 20 million strokes that occur each year globally? The reality is that only a small proportion are managed by neurologists, although this varies from country to country. Even so, of all the disease entities treated by neurologists, stroke is by far the largest public health problem. Are the skills required for stroke management unique to neurology? Probably not.
The revolution in imaging and better understanding of cerebrovascular pathology has underpinned a radical change in stroke neurology, from elegant localization and clinical phenomenology to an emphasis on therapy. Neurologists were the quintessential specialists with unique skills linking alterations in brain anatomy with their clinical expression, exemplified by the detailed traditional and hierarchical neurological examination. While they were undoubtedly equipped to service Rolls Royces, they often showed little interest in less prestigious vehicles. Neurology has, therefore, traditionally been a consultant specialty with much less involvement in ongoing management. Even in the era of urgent therapeutic intervention, typified by thrombolysis, many neurologists have been slow to embrace this changing role. Indeed, probably the most important therapeutic advance in stroke medicine, namely coordinated care in stroke units, has often been championed by physicians, rather than neurologists. This does not diminish the seminal contribution of neurologists, from the time of Charcot, to our understanding of the stroke process.
Caplan nicely emphasizes the unique role that can be played by the neurologist in understanding the impact of vascular disease on the brain. We would agree that a neurologist with specific stroke training is perhaps ideally placed to lead a stroke team. However, it does seem unlikely that sufficient neurologists will be trained in time to meet the demands of the impending stroke epidemic and its ever-expanding therapeutic implications. Furthermore, many of our most expert colleagues in stroke medicine are not neurologists. Hence, the view of Lees that there need to be more stroke specialists, regardless of background, makes good sense.
We agree with both protagonists that our patients require a broad-based expertise in all aspects stroke medicine. Neither a “general” physician nor a “general” neurologist is truly qualified to care for all aspects of stroke, without special training. We are attracted to the concept of “strokology” as a discipline with specific accreditation.
What of Rolls Royces and Olympian gods? What better way to ascend to the stars! Strokologists are the Titans of the future.