A national shortage of neurologists is creating “neurology deserts” around the country, forcing patients to wait longer and drive further for care, news that comes as no revelation to Thomas Vidic, MD, clinical associate professor of neurology at the Indiana University School of Medicine-South Bend.
In 2013, Vidic and other members of an American Academy of Neurology (AAN) Workforce Task Force co-authored a report that predicted the demand for neurologists would outstrip supply by 2025. A decade later, it appears the situation is even more dire than anticipated.
While a nationwide physician shortage is affecting all specialties, neurology is facing a particularly difficult confluence of events. Advances in treatments for migraine, epilepsy, multiple sclerosis, and other neurological disorders have created a growing demand for care of pediatric and adult patients.
Over the next 7 to 27 years, as the number of Americans over age 65 increases, the incidences of Parkinson’s and dementia are set to double, and stroke cases are expected to rise by 20%.
At the same time, physician retirement and burnout are siphoning off neurologists from a workforce that isn’t growing fast enough. The American Medical Association reports the number of neurologists who treat patients in the United States grew by only 598 over the last decade, from 12,761 to 13,359.
This perfect storm has created what another AAN report calls a “grave threat” to patient care. The neurologist shortage “reduces access to care, worsens patient outcomes, and erodes career satisfaction and quality of life for neurologists as they face increasingly insurmountable demands,” write the authors of that 2019 report.
“We’re in trouble,” said Vidic. “We have a tremendous need for neurologists that we’re just not supporting.”
How Did We Get Here?
Some of the challenges related to neurologist recruitment and retention are similar to those in other specialties. Compensation is certainly a factor, Vidic said.
Although neurologists’ incomes have increased significantly over the past decade, they still rank in the lower half of all medical specialties. In addition, only 50% of neurologists believe they are fairly compensated.
Burnout is another significant challenge. In 2019, before the pandemic, 53% of neurologists surveyed in Medscape’s National Physician Burnout, Depression and Suicide Report indicated they were burned out. That percentage increased slightly in 2023, to 55%, with most respondents reporting a strong-to-severe impact on their lives.
The most common reason for burnout was administration and paperwork that cuts into neurologists’ time with patients. Charting and completing prior authorization and step therapy forms required by most insurers take an average of 17.6 hours a week for neurologists — much longer than the overall physician average and higher than almost all other specialties.
But perhaps the biggest contributor to the nationwide neurologist shortage is a 26-year cap on Medicare funding for medical residency. Enacted as part of the 1997 Balanced Budget Act, the legislation limits Medicare funding for medical residency training at 1996 levels. Most medical residencies are funded by the federal government and Medicare is the largest participating program.
As a result of the cap, the number of total residents in the United States — which grew by 20.6% between 1987 and 1997 — only increased by 8% from 1997 to 2007.
A new study on patients’ long travel times to neurology clinics, published last week in Neurology, is the latest to illustrate the real-world impact of too few neurologists amid growing caseloads.
Researchers found that 17% of the 563,216 Medicare beneficiaries who visited a neurologist in 2018 had to travel an average of 81 miles one way. Those long distances were endured most often by patients with brain and spinal cord cancers, amyotrophic lateral sclerosis, and multiple sclerosis.
While the neurologist shortage affects every state, a 2020 study suggests rural areas are most affected. This analysis of Medicare recipients showed that just 21% of rural residents with a neurological condition had access to a nearby specialist compared with 27% of urban dwellers. The findings are similar to those of a 2017 report that identified “neurology deserts” in a number of states across the country.
Wait times for new neurology patients are reported to be among the longest of all specialties, with an average of 30 days for adult patients and 5 to 6 months for pediatric patients.
More Neurology Instruction Needed
“It’s really hard knowing there are families out there who need the care but can’t get to it in a timely manner,” said Tyler Allison, MD, associate professor of pediatrics at the University of Missouri-Kansas City School of Medicine.
Working in a rural state means Allison has patients who drive 6 hours or more for an appointment. Although telemedicine has reduced the number of trips for many of his existing pediatric cases, it has had little impact on new patients. This is particularly frustrating, he said, when he sees a new patient with a condition that could have been treated by a primary care physician in their home community.
“One of the biggest problems we have in the child neurology world is that we don’t have enough primary care physicians who feel they are adequately trained to care for these patients,” said Allison, who also is the program director of the Child Neurology Residency Program at Children’s Mercy Kansas City.
“Sometimes I see patients where, frankly, I only need to see them once to provide reassurance to the family and then they go back to their primary care doctor,” he said. “It’s the kind of thing that if we trained people appropriately from the beginning, it would shorten our waitlist.”
Indeed, increasing neurology instruction during medical school is one recommendation offered in a 2019 report that characterized the neurologist shortage as a “grave threat.”
Data from the Association of American Medical Colleges (AAMC) show US medical schools required an average of 4.4 weeks of neurology instruction in 2019-2020. Of the disciplines included in the AAMC report, only radiology and surgical specialties required a shorter clinical course. Many medical schools also require a neurology rotation, usually during the third year.
“There are still medical schools that do not require a neurology rotation,” said Vidic. Indiana University’s medical school requires a 1-month neurology rotation. “Per capita, we turn out more neurologists than any other medical school in the country because we give the exposure.”
General Neurologists Needed
The 2019 AAN report also calls for a renewed focus on general neurology in residency training as a way to ease patient wait times.
“General neurologists in the community can care for 75%-85% of patients with neurological disease,” said Michael Markowski, DO, a general neurologist in Cape Cod, Massachusetts, who chaired the AAN’s general neurology task force from 2019 to 2020.
“Our residency training programs aren’t doing anything wrong, but we have data that show we have to start doing something different if we’re going to care for the one in three Americans with neurological disease who deserve care in their community rather than having to travel to subspecialty centers, which are primarily located in larger cities,” he said.
Based on an AAN survey, only about one third of US neurologists identify as general neurologists; most focus on movement disorders, dementia or Alzheimer’s, epilepsy, or another neurology subspecialty. It’s a sharp contrast from Europe, where the vast majority of neurologists identify as general neurologists.
“It was striking the difference between the neurologists across Europe who identify as general neurologists in comparison to the US,” said Markowski, who was the AAN representative for the European Academy of Neurology General Neurology Task Force. “Close to 28% of US neurologists identify as general neurologists, but across 37 European nations, that [percentage] is 76%.”
In Europe, general neurology rotations make up at least half of the first year of medical residency, Markowski said. In the United States, there is no general neurology rotation.
“If you never see that role model during your training who is a general neurologist, who can see the vast majority of all neurology patients, why would you think you could do that when you graduate?” Markowski said.
A Legislative Solution
While expanding neurology instruction in medical school and increasing exposure to general neurology rotations in residency could help, the clearest path to increasing the number of neurologists in the United States is to lift the decades-old residency cap.
The Resident Physician Shortage Reduction Act of 2023 would do just that, adding 14,000 new medical residency positions over 7 years. The bill has bipartisan support, with hundreds of co-sponsors from both sides of the aisle. Nearly 100 professional societies and medical and hospital groups have submitted testimony in support.
Similar legislation has been introduced at least six times since 2007 and no bill has ever made it out of committee. It’s unclear whether the latest version will meet a similar fate, but its expected price tag of $10-12 billion over 10 years is a large hurdle to overcome.
Congress did take a small step in 2021 to increase residency spots, with legislation that allocated funding for 1000 new positions over 5 years. Congress added another 200 spots to that total in a bill passed last year.
Critics say the slots are tied up in Medicare red tape and it’s a far cry from the 14,000 new positions experts say are needed to address the physician shortage.
“We absolutely want the larger bill, and we think that’s the way to go, but we’ll continue to work and try to add as many positions as we can,” said Leonard Marquez, senior director of government relations and legislative advocacy for AAMC.
Congress is also considering legislation to speed up prior reauthorization for Medicare, something the Centers for Medicare & Medicaid Services is also seeking to do through rule changes. Nearly 30 state legislatures are debating similar legislation at the state level. And another bill in Congress would expand the Conrad State 30 program, which allows states to request J-1 visa waivers for international physicians to work in underserved areas.
“The solutions to this problem are multifactorial, and the answer that worked 10 years ago won’t be the right answer today, and the answer that works today won’t be the right answer 10 years from now,” Vidic said. “All we have to do is keep making changes, keep evolving and the playing field continually changes.”
https://www.medscape.com/
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