Neurohospitalists: Challenges for the Integration of a New Field: A Neurointensivist's Perspective.

A new field of Neurohospitalist medicine is developing. The roots of this field are firmly in the field of Neurology. The development of the field however, may follow the path of its predecessor hospitalist medicine. It is therefore important to study the history of Internal Medicine and hospitalist medicine in order to understand where the field may be headed. The field of Internal Medicine and medical education has undergone a metamorphosis over the past several decades. Historically, patients would be admitted to a hospital for medical evaluation. During this evaluation teams of residents with the attending physician would admit, evaluate, diagnose, and embark on an extensive treatment strategy. As average life expectancy increased, and newer technologies developed, the cost of caring for patients in an in-patient hospital setting became increasingly burdensome. Nationally, increasing health costs became a serious strain on the economic health of most industrial countries. Subsequently, the inpatient evaluation and treatment of most medical diseases became cost prohibitive and moved toward a more cost effective outpatient setting. The movement of medical evaluations to the outpatient setting provided a challenge to internal medicine education. Residencies needed to mirror practice to appropriately prepare residents for their eventual post training place in internal medicine. Subsequently, internal medicine residencies have increased their outpatient requirements over the past few decades. This, however, has occurred during a time of mandated decreasing residency work hours and increasing in-patient volume and acuity. A solution for many of these residencies was the development and implementation of medical hospitalist programs and fellowship. The development of Neurohospitalist programs appears to be following a similar path as internal medicine. Dr. Meschia has noted similar erosion in the in-patient experience of neurology residencies compared to changes that occurred in internal medicine programs (Meschia, 2010). Practice patterns have also shown parallels to Internal Medicine. Today many neurological diseases are evaluated and managed in the outpatient setting. Neurology inpatient services have also displayed a greater number of medical problems and complications. In addition to these findings, the development and expansion of “acute neurology” and more specifically, the use of intravenous tissue plasminogen activator and the development of interventional procedures has increased the need for immediate neurological expertise. This need has superseded financial models to compensate and accommodate the necessary people and resources to adequately treat this patient population. The development of the field of hospital neurology may provide a solution to this problem. The neurohospitalist can provide timely care for acutely ill neurological patients and can relieve neurology practices the need to cover an emergency room or a sick hospital population. Thus, there is a strong economic incentive for the development of the field. This rosy scenario for the neurohospitalists, however, has many potential pitfalls and questions. How will neurohospitalists be organized? What skills will be needed or required for practice? Dr. Likosky's survey of neurohospitalists found that the majority of these physicians do not see patients in an outpatient setting (Likosky et al., 2010). Who will follow the patient once they have left the hospital? How will neurohospitalists be reimbursed? These are only a few of the questions a young field will need to address as it develops. Each of these questions and issues has potential difficulties. One model for Neurohospitalist development is to have the neurohospitalist hired by a group practice. Reimbursement would be established by the group and patient follow up would be covered by the group. However, what if the neurohospitalists are hired and salaried by the hospital? as is the growing trend in medicine. Coordination with outside practices will take considerable skill. Inevitably “turf issues” will arise. Similarly what will happen when a neurologic emergency occurs when a patient is not covered by the neurohospitalists practice? Who will the emergency room physicians call when an outside neurologist or physician is unavailable or delayed? Most neurologists and physicians may be grateful for this help; however, so may patients who may wish to leave the outpatient neurologists practice to join the practice of the physician who cared for them during their crisis who may or may not have an outpatient practice. A majority of neurohospitalists in Likosky's survey came from either a stroke or neurocritical care background (Likosky et al., 2010). This may represent selection bias of the survey or of individuals who chose to spend their time in the hospital. However, neurohospitalists should be able to provide consultative roles in all areas of the hospital including the intensive care units (ICUs). The neurohospitalists may be able to complement both the general neurologists and neurointensivists by dividing services, procedures, or consultations when necessary. Again a certain level of political skill may be needed to navigate these areas.