Stroke Is Best Managed by Neurologists
To the Editor:
We read with great interest the Controversies in Stroke segment published in November, 2003, which discusses whether it is neurologists or internists who are most suited to manage stroke patients.1–3
Caplan, Lees, and Donnan set out the problem so clearly that there is little else we can do, we feel, but agree, on behalf of the Italian Study Group in Cerebrovascular Disease, the Italian Society of Neurology, and the Italian Society of Neurologists, Neurosurgeons, and Neuroradiologists, with all three authors.
We agree with Donnan when he says that “stroke is a complex disease involving not only the brain,” just as we do with Lees when he says that “the deficit in stroke is neurological but the cause is vascular, complications are medical, and treatment should be multidisciplinary.”
It is also true that “stroke care is now managed in and out of dedicated stroke units.” Consequently, how can we deny that “special skills are required” (Donnan), or that “stroke patients require holistic care, expertly delivered” (Lees)?
Assuming that this is the problem, the solution is a highly complex one. We do need a strokologist, though not exclusively for the very early management of patients in a dedicated stroke unit.
We agree with Lees’s view that “secondary prevention is a long-term activity” and that “few neurologists play a direct practical role in the management of blood pressure or atrial fibrillation, use of statins, PFO closure, carotid stenting, or endarterectomy.”
We should add that neither neurologists nor clinicians who are experienced in caring for hospitalized patients necessarily know how best to manage patients at home; such patients need the specific experience of various specialists and, above all, they need someone who does not ‘lose sight of the forest for the trees’, to paraphrase a popular idiom.
Similarly, generalists who treat patients before and after an acute cerebrovascular event might not have the expertise to manage acute stroke patients.
Let us say that we need clinicians with experience in all stroke-related problems who can manage every aspect of a patient’s health, irrespective of the various stroke subtypes and the different phases in the evolution of a stroke, including the psychosocial and economic issues.
A “general” physician, a “general” neurologist, a “general rehabilitation specialist” or a general “physical therapist” are not, it should be said, truly qualified to care for all of these stroke-related aspects.
Reducing the costs of health care is becoming increasingly important, the management of stroke being no exception.4 The high morbidity associated with stroke contributes to the economic burden of this condition worldwide,5,6 with hospital costs accounting for 71% of total stroke care costs.7 In order to reduce these costs without negatively affecting the patients’ outcomes, what is still lacking is the support of a “strokologist” with the expertise in both health service economics and preventive medicine required to set up effective healthcare-dedicated services.
There is an urgent need for stroke specialists who can manage acute stroke units and coordinate both stroke teams who treat outpatients and dedicated rehabilitation personnel.
As Caplan writes, “it would be wonderful if all physicians and personnel” were to “work closely together.”
We substantially agree with Caplan when he says that “among all potential specialists, it is neurologists with an interest, training, and experience in caring for stroke patients that are most likely to possess all the attributes required.”
In our opinion, however, it is Donnan who gets to the root of the matter: stroke is currently by far the largest public health problem. Therefore, “who cares for the 20 million strokes that occur each year globally? The reality is that only a small proportion are,” and we would add ‘can be,’ “managed by neurologists. 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.”
In this regard, Italian neurologists have recently designed a dedicated master’s degree in stroke. The course, which is open to any physician who is interested in gaining specialized, professional experience in stroke management, lasts 2 years. During this period, trainees are expected to attend 1500 hours of learning activities, consisting of both theoretical lessons (265 hours) and clinical training (935 hours). The remaining 300 hours are dedicated to other activities, such as the preparation for and attendance at conferences, the writing of scientific papers, an end-of-course thesis, seminars, and interactive teaching.
The aim of this master’s degree is to impart the scientific and clinical knowledge and experience required to tackle all aspects of stroke: its causes and consequences, the management of adult patients, and the incorporation of evidence-based medicine principles into daily practice. The learning objectives have been divided into 8 areas:
diagnosis, treatment, and general management of acute stroke–18 credits;
neurovascular imaging–4 credits;
cardiac and carotid ultrasound diagnostics–3 credits;
organization, management, and health planning of dedicated services–2 credits;
experimental models of cerebral ischemia–1 credit;
evidence-based medicine and clinimetrics in stroke–1 credit;
stroke rehabilitation–12 credits;
prevention and territorial management of cerebrovascular diseases–7 credits.
In order to achieve the overall aims of this degree, the course ensures that participants follow multidisciplinary training in each of the aforementioned fields of interest.
A written record of training will certify that participants have achieved the aims set out in each of the aforementioned 8 areas.
This second level master’s degree in cerebrovascular diseases was first offered in 2003 as an experimental interuniversity course at the Department of Neurological Sciences, University of Rome “La Sapienza,” and will be soon active also in other Italian universities.
Its curriculum and design will be the object of a separate publication.
The learning objectives in each specific area of this degree, together with other details, are available at the following website: http://w3.uniroma1.it/masterictus/.
Caplan L. Stroke is best managed by neurologists [Controversies in Stroke]. Stroke. 2003; 34: 2763.
Lees KR. Stroke is best managed by a neurologist: battle of the titans [Controversies in Stroke]. Stroke. 2003; 34: 2764–2765.
Donnan GA, Davis SM. Neurologist, internist, or strokologist? [Controversies in Stroke]. Stroke. 2003; 34: 2765.
Samsa GP, Reutter RA, Parmigiani G, Ancukiewicz M, Abrahamse P, Lipscomb J, Matchar DB. Performing cost-effectiveness analysis by integrating randomized trial data with a comprehensive decision model: application to treatment of acute ischemic stroke. J Clin Epidemiol. 1999; 52: 259–271.
Grieve R, Hutton J, Bhalla A, Rastenyte D, Ryglewicz D, Sarti C, Lamassa M, Giroud M, Dundas R, Wolfe CD. A comparison of the costs and survival of hospital-admitted stroke patients across Europe. Stroke. 2001; 32: 1684–1691.
Bergman L, Van der Meulen JH, Limburg M, Habbema JD. Costs of medical care after first-ever stroke in the Netherlands. Stroke. 1995; 26: 1830–1836.
Caro JJ, Huybrechts KF, Duchesne I. Management patterns and costs of acute ischemic stroke: an international study: for the Stroke Economic Analysis Group. Stroke. 2000; 31: 582–590.