Reader Response to: Neurologists wanted!

In the September 2018 issue, there appeared an article, titled Neurologists Wanted by Dr. Rachel Gottlieb-Smith who, in great detail, presented the diagnosis and possible treatments for the shortage of neurologists and the field’s lack of appeal among medical students.¹

As a practicing neurologist for the last 30 years, and former member of the American Academy of Neurology (AAN) Legislative Affairs Committee for a 3-year period, I can attest that this is not a new problem. In the early 1990s, when Roger Rosenberg was President of the AAN, the late Dr. Ken Viste chaired the AAN Legislative Affairs Committee. Dr. Viste and I were the only neurologists in private practice on the committee at that time. We were proud to serve our community and work with colleagues from the academic world.

Although there is nothing wrong with academicians, there is a problem within academia in that it does not train physicians, including neurologists, in business skills for which many have no natural acumen. Real-world business training is essential to the private practice of neurology, including payroll, overhead, billing, collections, and more.

To further the problem, academicians without business training try to address the issue from the academic standpoint, and the business aspects therefore continue to be absent. Whether it is discussed as burnout or a shortage of neurologists, without addressing business skills and economic factors, there can be no solution.

Many neurologists in my area and nationwide have sold their practices to hospitals because they could not make ends meet and pay themselves a proper salary. This is an important cause of burnout and explains much of the lack of appeal for neurology as a field. Survival is in question, in comparison to a lifetime commitment, knowledge, and skills required.

When I was on the Legislative Affairs committee, 30 years ago, I proposed a 2-tier system that would differentiate the field into clinical practice neurology and academic research neurology. This was shut down in favor of a one-size-fits-all approach.

I agree with Dr. Gottlieb-Smith that we don’t need to frighten and overwhelm newcomers with all the amusing anatomy, chemistry, and so on. In the real world of clinical neurology, that is only a scientific voyage for the basic neuroscientist! In clinical practice, patients want to know what is the diagnosis and what can be done about it. Without a focus on that, it is no wonder newcomers find neurology intimidating and economically unappealing!

When it came to economic survival tools such as imaging, nerve conduction studies, EMG, sleep, pain, and now stroke care in the hands of practicing neurologists, the academic neurology community did not advocate for the field. Instead, they advocated teaching these skills to allied health professionals, removing key economic benefits from the practicing neurologist. In that context, the AAN’s advocacy of more research to study burnout among neurologists is not funny but is laughable.

To truly enhance the appeal of neurology and help pay the bills, we still need 2 paths: 1 for clinical neurology and 1 for scientific research neurology. We need to apply knowledge wisely and stop wasting time by putting more stumbling blocks, such as 15 separate board exams, in peoples’ way. Unfortunately, I fear it may be too late and the “Balkanization of Neurology,” as Dr. Steven Ringel called it in the 1990s has already occurred.

1. Gottlieb-Smith R. Neurologists wanted! Practical Neurology. 2018;17(7):65-67, 73.