How do we fix the shortage of neurologists?
Authors: Adrian Burton
Journal: The Lancet Neurology (2018)

High-income countries have a shortage of neurologists. With continuing deficits predicted, the problem can only worsen as populations age. So what is being done about this? And is anything working? Adrian Burton investigates. The lack of neurologists is a worldwide problem. Even high-income countries are affected. Though Australia has largely dodged the bullet through the immigration of trained personnel, Canada, Ireland, the UK, other European countries, New Zealand, and the USA all report shortages. And as their populations age, and ever more people face the problems of stroke, dementia, and other neurodegenerative disorders, the problem is likely to worsen. A recent report by the USA's National Center for Health Workforce Analysis estimates that while the supply of US neurologists may have grown by 11% between 2013 and 2025, demand will have grown by 16%. So how do we train more neurologists? And are there any alternatives to simply increasing their number? Part of the solution might be to inspire more medical students to follow a career in neurology, but that requires recognition that the discipline may be experiencing an image problem. “The number of US medical graduates [USMG] entering the neurology workforce is not keeping up with demand”, says W. David Freeman, Consultant Neurologist at the Mayo Clinic (Jacksonville, FL, USA). “The proportion of USMG in neurological residency with respect to international graduates has shifted downwards over time. This could be due to numerous factors such as USMG being drawn to specialities with a better lifestyle like radiology and dermatology, the compensation they receive, or other factors. Why neurology is not competing as well historically against other disciplines needs to be examined.” Certainly, the American Academy of Neurology (AAN) is worried this may involve the burnout that neurologists face, partly the consequence of high workloads in large health-care systems. “Long work hours, among [other risk factors] for burnout, could be making neurology undesirable to graduates compared to other specialties”, says Freeman. “The dilemma here is how to make neurology more attractive professionally.” One way might be to make neurology courses more captivating. Faculty at the University of Texas Health Science Center at San Antonio (TX, USA) tried this by designing a novel applied neuroanatomy elective that focused on neurosensory pathways to complement the first year medical neuroscience course. Much more hands-on and interactive (even allowing the use of artistic skills), the students found the course helped them engage more deeply with their traditional neuroscience studies. In addition, “the AAN has made a major investment in developing a pipeline program aimed at stimulating more students to choose a career in neurology”, says Ralph Sacco, Professor of Neurology at the University of Miami (Miami, FL, USA) and AAN President. “We are revitalising our Student Interest Groups in neurology and working to change the image of neurologists to emphasise our abilities to intervene, prevent, and rehabilitate patients.” But wouldn't convincing graduates to become neurologists simply shift the shortage burden onto other disciples? “If we did it well enough, it might”, concedes Sacco. “Ultimately, countries need ongoing workforce requirement studies to figure out how many physicians—including neurologists—they need, and meet the demand through the supply of sufficient places at medical schools.” In Japan, which has an across-the-board shortage of physicians, attempts have been made to increase the number of places available on university medicine courses. And to turn those graduates into neurologists, the Japanese Society of Neurology has embarked on a charm offensive. “We made a 15-minute promotion video for medical students to convince them how rewarding it is to be a neurologist”, explains Ryosuke Takahashi, Professor of Neurology at the Kyoto University Graduate School of Medicine (Kyoto, Japan). “[In it] we interview career models—neurologists working at universities, hospitals, and companies. The video is distributed free to all the neurology training hospitals and used for recruitment. [In addition] we launched a summer camp programme last year, to which about 100 medical students or junior residents were invited for a two-day lecture course on neurology. Since we paid the participants' travel expenses, it cost $70 000. Although that may be big money, we consider this an investment in the future of neurology.” Getting neurologists to go where they are needed can be a problem too: commonly, they are in much lower supply outside of large cities. “The Australian and New Zealand Association of Neurologists [ANZAN], working with the Royal Australasian College of Physicians, undertakes annual surveys of our membership, and the most recent shows Australia has around one neurologist per 50 000 people over most of New South Wales, Victoria, South Australia and the Australian Capital Territory. But [neurologist-to-patient] ratios were lower in regional areas and the Northern Territory”, explains Matthew Kiernan, Bushell Professor of Neurology at the University of Sydney (Sydney, Australia). “So we developed a Regional Neurology Committee to help address regional workforce problems. Separately, ANZAN has developed a focus on societal needs—we need more cognitive neurologists—and recent practicalities, including the rapidly developing field of endovascular clot retrieval for acute stroke. We are training neurologists in this subspecialty, in conjunction with radiology and neurosurgery, and have established ANZAN Fellowships to support this endeavour.” Europe also faces problems of regional imbalances. “This is most dramatic in the less attractive regions of countries”, explains Günther Deuschl, President of the European Academy of Neurology and Professor of Neurology at the Christian Albrechts University (Kiel, Germany). “But it is also true for rural versus metropolitan areas—even in Germany which, overall, has a good number of neurologists. However, a similar pattern also exists between the different countries of Europe. Those in eastern Europe have traditionally paid medical staff less than in western Europe, where working conditions and academic positions have appeared more attractive too. The result has been a westward brain-drain. The only real way to stop this is for countries that are losing neurologists to pay them more. And indeed some are trying. Romania, for example, recently substantially increased the pay of medical staff.” Other solutions proposed to reduce the effects of shortages include the use of telemedicine to reach far-away neurologists (though this is unlikely to reduce workloads), the development of artificial intelligence to help in making diagnoses, and expanding neurological care to include non-neurologist physicians and advanced practitioners (specially trained nurses and physicians' assistants). The last of these options is currently a focus of the AAN. “The Academy has made a major effort to expand our efforts to engage advanced practitioners”, explains Sacco. “They are the fastest growing group in our membership, and now make up almost 1100 of our 34 000 members. We have established a consortium for advanced practitioners to better understand and meet their needs, and we have a number of initiatives focused on them, including educational programs, membership engagement, and involvement in our committees. We are also trying to educate neurologists how best to involve these professionals in helping to meet the increasing demands for high quality neurological care.” And this seems to be working: over the 2013 to 2025 period, during which the supply of neurologists will be in deficit, the supply of advanced practitioners could even outstrip demand. “Having neurologist-led care teams with advanced practitioners trained to perform certain procedures, prescribe medications, and provide ongoing collaborative care of patients, shifts some of the burden off neurologists”, explains Heidi Schwarz, Professor of Clinical Neurology, University of Rochester (Rochester, NY, USA). “This not only reduces burnout, it allows the neurologist to spend time with those patients who require more attention or advanced expertise. Use of team-based care should enhance the quality of care we provide, and allow increased access to care in a timely fashion. [And adding advanced practitioners] to a practice can be done effectively with financial rewards if structured appropriately. Most come with little neurology background, so it is important to have a structured onboarding process as well as incentives to promote retention. Not every neurologist feels comfortable about passing the care of patients to advanced practitioners, but many become comfortable when they see this can work.” The Academy's Advanced Practice Providers Work Group has published a position paper to educate neurologists that this can be a viable care model for the USA. The UK has a different problem, and is therefore seeking a different solution: improving the organisation of its care systems. “UK medical trainees show no lack of enthusiasm for neurology”, explains Mary Reilly, Professor of Clinical Neurology, University College London and President of the Association of British Neurologists, but there are insufficient trainee numbers to meet demand due to historical and on-going under-resourcing. Acute neurology is a crucial and expanding area of practice, and we need to modernise to include 24/7 care and closer working with general medical colleagues. So, we are partnering neurology training with allied specialties and are developing models of integrated care, and using advanced practitioners and nurse specialists to coordinate that care throughout the patient pathway.” Funded projects designed to achieve these ends are currently underway and being evaluated. Time will tell which fixes work best, although given the differences in health-care systems, hospitals, practice types and resources available, a one-size-fits-all solution is unlikely. But solutions we must have, for without them, we could be waiting ever longer to see a neurologist, who might just be burnt out.