Who Will Care for Our Hospitalized Patients?
To the Editor:
Much debate has recently focused on who is best qualified to care for stroke patients.1,2 Arguments have been made for the certification of a neurology subspecialist—the “strokologist.”3 Care for the stroke patient is complicated now and only becoming more so. However, in an era when subspecialty coverage for emergency and inpatient care is scarce, the more appropriate question seems not who should care for these patients but rather, who will shoulder this responsibility. Neurologists have been accused of being “asleep at the wheel” in stroke prevention—the same may be true for stroke treatment.4
Even specialties that have traditionally provided after-hours emergency coverage are demanding payment or refusing to provide this service altogether. Now that stroke treatment involves emergent evaluation and treatment, there has been a significant change in what is expected. Low remuneration for a late night neurologic evaluation is not a great motivator, and neurologists are not used to canceling clinic appointments for emergencies. Neurologists perform few procedures and other sources of funding are few and far between. Cardiologists, nephrologists and gastroenterologists have developed rotations within their groups for 1 physician to perform the inpatient work for a period of time. The inpatient volumes for these specialties tend to be fairly high and are associated with well-reimbursed procedures.
As a result, others have stepped in to care for stroke patients. Hospitalists have come to the assistance of primary care physicians and have helped alleviate some of the workload for specialists. Internal medicine training is obviously an inadequate substitute for a neurology residency. In fact, on a national survey of hospitalists’ perceptions of their residency training needs, many felt that more training in neurology was needed.5 However, hospitalists are frequently called on to provide most, if not all, of the care of the stroke patient. In “straightforward” cases, perhaps this is appropriate. Hospitalists clearly have a different skill set than most neurologists—serving as experts in inpatient care and pathway development.
Neurologists then, are faced with a decision. General neurologists have not been perceived as interested, as a whole, in aggressive stroke care. Strokologists may help to fill some of this gap. Hospitalists, however, are likely to care for the majority of stroke patients in the United States—with or without neurology assistance. Hopefully neurologists will act to either help directly in caring for stroke patients, in the form of “Neurohospitalists,” or help to educate non-neurohospitalists in so doing. Hospitalists are looking for partners in caring for stroke patients—will neurologists be asleep at the wheel?
Caplan L. Stroke is best managed by neurologists. Stroke. 2003; 34: 2763.
Lees KR. Stroke is best managed by a neurologist: battle of the titans. Stroke. 2003; 34: 2764.
Donnan, GA and Davis, SM. Neurologist, Internist, or Strokologist? Stroke. 2003; 34: 2765.
Burton, TM. Two simple tests can prevent stroke, but few get them. The Wall Street Journal;. 2004 Sep 24: A1.