November 2004: Guest Editorial -- Treading Water in Clinical Neurology

Orly Avitzur, MD, MBA; Kenneth A. Vatz, MD


November 12, 2004


Clinical neurology is in the throes of an identity crisis. The field was once populated from the top of the medical school classes and revered for its practitioners' seeming ability to divine arcane diagnoses with the aid of a few small instruments. In recent years, it has essentially evolved into an orphaned branch of internal medicine without a clear sense of its future role in the medical world.

Neurologists no longer enjoy the luxury of pure consultantship. We increasingly work in the medical trenches to provide stroke and trauma care in the middle of the night (with their accompanying increased liability risks), whereas during routine office hours we manage patients with headaches, Parkinson's disease, multiple sclerosis, and epilepsy. Many neurologists try to recoup the economic losses resulting from declining reimbursements for these "evaluation and management" codes. Some do this by performing the more remunerative neurodiagnostic studies, but in a competitive market increasingly crowded by nonneurologists and even nonphysicians, others are often available to perform these diagnostics. From both the professional and financial perspectives, many neurologists believe that, at best, they are treading water.

Neurologists are caught in the ever-tightening squeeze between higher overhead and the shrinking reimbursements of cognitive specialists. A number of factors serve to reduce net income: fixed costs, such as rising malpractice premiums and office expenses; ( the increased economic burdens of higher patient volumes but lower payments per patient; and marginal costs, such as the increasing cost of compliance with government regulations and requirements and insurance documentation. Many find themselves in a vicious cycle of longer and less productive hours that results in palpable effects on physician and staff morale (Figure). The pervasive, invisible threat of malpractice exposure, escalated by the loss of neurosurgeons in many regions, has resulted in a growing reluctance to take part in high-risk situations by many practitioners, and in defensive and unnecessary testing by others.

More pain, less gain. Compensation data were attained from the Medical Group Management Association (MGMA) (Physician Compensation and Production Survey reports and the cost data from the MGMA Cost Survey reports).

Remedies that have been attempted include changing practice design and using better practice-management techniques. One common strategy is the incorporation of, or transformation into, boutique practices offering various types of expertise, such as medical-legal services, sleep medicine, pain treatment, headache management, and rehabilitation. There is already competition in these areas, and some neurologists are reluctant to further diversify for fear that such practices may not provide the degree of intellectual satisfaction derived from the practice of traditional neurology.

A large number of practitioners have attempted to establish themselves as experts in electrodiagnostic studies, possibly to attract more referrals from orthopaedic surgeons, hand surgeons, and neurosurgeons, although many of these specialists have already contracted "in-house" or salaried electrodiagnosticians of varying abilities and credentials.

Other neurologists have opted to despecialize and incorporate more general medicine and primary care of patients with neurologic problems, akin to the practices of many endocrinologists, cardiologists, and rheumatologists. Some have also joined multispecialty clinics, where as salaried physicians they are relatively shielded from the risks and costs of malpractice and are able, at a financial sacrifice, to enjoy a somewhat better lifestyle and sense of security.

The need for improved practice-management techniques cannot be overemphasized. Neurologists who do not take the time to understand the business of their practices face real threats to their professional survival. Medical practice today requires business expertise that includes a working knowledge of billing and coding; systematic analysis of payer contracts and fee schedules; evaluation of costs and expenses; and expertise in strategic planning, contract negotiation, marketing, employee management, and more. Unfortunately, medical schools and neurology residency training programs do not provide the tools necessary to meet these challenges. Today's healthcare environment demands that practitioners make an effort to educate themselves in these areas on an ongoing basis.

Technology offers some solutions to those interested in enhancing productivity. Neurologists who invest in an electronic medical records system and related software often find that they are able to work more efficiently, improve their documentation, and code at higher levels. Incorporation of digital tools also allows for a reduction of personnel or re-allocation of staff toward other functions. Many practices are incorporating physicians' assistants and nurse practitioners in order to free physicians to do additional income-producing work, particularly in the more primary care-oriented practices.

Group practice governance and compensation formulas also influence the bottom line. Although most experts recommend that compensation be productivity-based, many practices find themselves caught in the so-called prisoner's dilemma (a non-zero-sum game), in which only mutual trust and cooperation can produce the best results for all prisoners. For example, a 6-person practice may decide to prioritize the scheduling of electromyograms and assign all of them to the 2 most highly skilled electromyographers, which results in consistency and efficiency that make the group more attractive and marketable to outside referral sources. The uneven distribution of time and labor may create some apparent individual inequities in terms of workload and revenues, but it maximizes overall returns and benefits the group as a whole. This structure, therefore, requires long-term planning and strong physician leadership within the group, so that member cooperation can be enlisted and sustained.

Neurology is a specialty that no longer appears to attract sufficient numbers of qualified candidates to its residency programs,[1] and, in fact, it has been receiving increasingly less funding and attention in medical schools and general medicine residency programs. Rizzo and Mobley[2] state the following:

Only rarely are academic departments of neurology able to support the clinical mission of the department on income derived from the clinical services that the department provides....[T]eaching, a key activity in academic programs, is not rewarded to the degree necessary to support the department. Research funding may be the lifeblood of a department but usually covers only its own costs.

As fewer neurologists are trained and the time and resources of those who do the training are further compromised, the specialty faces the threat of eventual extinction. It is unclear whether US clinical neurology truly is in such dire straits, but it is certain that it is moving rapidly away from its former status as a well-remunerated, intellectually satisfying, relatively risk-free cognitive specialty with a reasonable lifestyle. This would, at first, seem to be of little concern to the rest of the medical world, including providers and patients, and perhaps even elicits a kind of "schadenfreude." But these changes inevitably will result in the loss of a pure discipline and of its practitioners.

For neurology, this is the devastating and unintended consequence of the malpractice crisis and medicoeconomic revolution.


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