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The loss of protected time for research and a focus on clinical revenue and relative value units has changed the traditional balance of academic neurology from the traditional triad of research, teaching, and clinical practice. But some of the changes in the last 20 years are for the better, academic neurology chairs told Neurology Today.

With great advances comes greater pressure to deliver clinical care to patients.

Twenty-one years into the 21st century, neurology chairs across the United States say that academic medicine has seen vast changesmany of them exciting, some not so much.

On the plus side, new discoveries and treatments offer neurologists new tools and subspecialties to treat more patients.

When I was a student and resident, I would hear people say, Neurology is diagnose and adios, said Matthew Rizzo, MD, FAAN, professor and chair of the department of neurological sciences at the University of Nebraska. It's not that at all now. So many treatments are available for the acute and chronic diseases we treat. And there are more and more people who seek neurologic care. What I see is opportunity upon opportunity.

At the same time, he and four other chairs who spoke to Neurology Today agreed, demands on academic neurologists to spend more time treating patients and less time on research and teaching have led to increased stress and, for some, burnout.

The emphasis on high throughput has definitely hurt academic neurology, said Clifton Gooch, MD, FAAN, professor and chair of neurology at the University of South Florida's (USF) Morsani College of Medicine. Neurology has more complicated patients than most other areas of medicine to begin with, and the most challenging patients from within this group are referred to academic neurology departments. So when some health systems say, We want you to spend 30 minutes on a new patient with severe Alzheimer's disease and 15 minutes to follow up a complex Parkinson's disease patient, you simply can't provide adequate care, and that puts you under tremendous stress. Department leadership is critical to mitigate demands such as these on faculty, but it can be challenging.

On balance, though, all five chairs said the positives in today's academic neurology far outweigh the negatives.

I finished my fellowship in 1987, when there was more protected time for research and teaching, said Kathleen M. Shannon, MD, FAAN, FANA, professor and chair of neurology at the University of Wisconsin School of Medicine and Public Health. Since then, she said, The pressure for patient care has really, really gone up. That has led to a lot of burnout issues. But don't get me wrong. Academic neurology is a wonderful place. It still attracts the very best people, who are 100 percent committed to taking care of their patients and making their lives better. I really love what I do. It's just hard to know the struggles that my folks are facing.

To help neurologists in every career path better handle the challenges of practicing in an academic setting, the AAN established an Academic Neurology Initiative under its past president, Ralph L. Sacco, MD, FAAN, FAHA, professor and chair of neurology at the University of Miami Leonard Miller School of Medicine.

Many people went into academic medicine to do research and teaching, but the clinical mission is growing more rapidly, Dr. Sacco said. The revenue for academic health systems is much more dependent now on clinical revenues. The AAN felt strongly there was more help needed for neurologists in academic medical centers to deal with the new realities.

Back in the day, Dr. Rizzo said, Neurology departments were basically fiefdoms. Department chairs had a lot of power and leverage over the way money got spent, how the clinic was organized. What I've seen over the course of my career is the corporatization of medicine. You have C-suites and CFOs and CEOs. When I started out, all we had were doctors, nurses, ward clerks, and patients. It was pretty simple.

Dr. Gooch, who in 2017 published a survey of academic neurology departments, described the last couple of decades of the 20th century as a fiscal golden age for neurologists and other physicians.

There was a lot more money in medicine at that time, he said. The baby boomers were younger and healthier, working and paying into the health insurance system while consuming fewer services and clinical reimbursement was good. States provided a much greater portion of most medical school budgets. There was funded time to teach and do research, including small exploratory and/or descriptive clinical research projects. The clinical productivity metric of RVUs [relative value units] were first introduced in 1989, and were not yet an unyielding standard of performance .

Changes accelerated with the advent of managed care, Dr. Gooch said. As we approached the year 2000, the baby boomers started retiring and began consuming health care rather than working and paying into the system. This and other factors, including the development of more expensive technologies and treatments, contributed to rising health care costs, causing Medicare and businesses to look for ways to rein in expenses. Consequently, managed care was born, with a major focus on cutting reimbursement for clinical services, he said. At the same time, state support fell. When I became chair here at USF in 2008, 40 percent of the medical school's budget was from the state. Now it's below 10 percent and continues to fall.

Steven Galetta, MD, FAAN, professor and chair of neurology at NYU Grossman School of Medicine, said that back in the 1990s, Most of us were doing general neurology. As the decade progressed, subspecialty fellowships emerged, particularly for stroke and neurocritical care. We started off with no headache medicine specialists. Now we have six.

As more medicines became available for headaches, multiple sclerosis, stroke, and other disorders, the demand for neurological care became tremendous, Dr. Galetta said. As NYU has taken over smaller health systems in nearby Brooklyn and Long island, he said, We went from seeing 7,000 outpatients in 2012 to nearly 100,000 this year. We've hired over a hundred neurologists in those years.

Even as total US spending on health care has grown vastly in the 21st century, reaching $3.8 trillion in 2019amounting to 17.7 percent of the nation's gross domestic productthe portion going to academic neurologists has hardly kept pace.

The pie has gotten bigger, Dr. Gooch said, but pharma is consuming a much bigger percentage of the pie, and the insurance industry is taking its cut too.

Another irony in the evolution of academic medicine is that while the total amount of research money available from the National Institutes of Health (NIH) has grown, getting an NIH grant for a clinical trial has become increasingly difficult.

While the NIH is the major source of funding for critical basic biomedical researchmouse models of disease, cell cultures, etc., only a very small percentage of the NIH budget is dedicated to human clinical trials, which are very expensive, Dr. Gooch said.

In the past, much of this work, especially exploratory therapeutic studies in humans, was funded by excess clinical revenues, which dried up in the late 90s, Dr. Gooch said. This means a lot of this very important early phase clinical research has been pared back. At the same time, NIH-funded basic research has become the coin of the realm in most academic centers, with broad influence on metrics such as the US News medical school rankings.

As with so many other workers in the 21st century, academic neurologists are now gauged by measures of their productivity.

In the old days, you got a salary and you did your workclinical, teaching, research, and administration, Dr. Sacco said. Now each component is measured. And the measure of clinical productivity is by RVUs. When a clinician sees a patient, or reads an EEG or EMG, they generate a certain amount of RVUs. It's become more metrics-driven. If you're not making your clinical RVUs, your salary could be reduced or you might have to do more clinical time to support your salary.

Despite all the pressures, Dr. Rizzo said, It's crazy to be negative. We have so much opportunity. More and more people need neurological care.

That optimistic view was echoed by Frances E. Jensen, MD, FAAN professor and chair of neurology at the University of Pennsylvania's Perelman School of Medicine.

Academic neurology is in an incredibly dynamic state right now, she said. I am unbelievably excited. I pinch myself every day that I'm actually in the field I'm in. We are moving ahead at a pace that is unprecedented for our field. Twenty-five years ago, neurology was more of a watch and wait and document field. What's happening now, because so many treatments are translating to direct patient care, is we're seeing new opportunities and career paths emerge. We're seeing interactions with industry. There are people looking at population-based studies, public health, operations, safety, and quality.

That's not to say it's all gumdrops and unicorns. Yes, of course, my faculty have to mind their RVUs, Dr. Jensen said. But we also focus on having them participate at the top of their licensure. If you continually ask people to work below their licensure, it becomes demoralizing for them, and you are not tapping their potential for program growth. So we work hard to think about how to use physician assistants and advanced practice nurses. The documentation required in electronic medical records is not going to go away. The question is: How do we automate or find other professionals to handle some of it? We have to be adaptive.

Dr. Gooch said he sees hope for reducing the pressure on academic neurologists to see ever more patients in less time is by moving away from a fee-for-service model.

The movement to population health management changes the whole paradigm, he said. It means each health system gets a set amount of money each year to treat a defined population in their area. So the game becomes here's the money, this is it, use it wisely. Now you want to do fewer expensive procedures. You want to invest in internists, neurologists, and family practitioners to keep your population healthy so that they don't need surgery or emergency medical care. In this model, which is more logical, cost effective, and most importantly, better for the patient, the value of clinical neurology will soar, along with the other cognitive specialties.

The move to population health management is already well underway and is a major strategy of the Affordable Care Act in the form of Accountable Care Organizations ( ACOs). Existing large health maintenance organizationtype health systems are best positioned to transition to the ACO model, and many academic medical centers are actively expanding to enter this space.

For all the changes that have affected academic neurology in the past 20 years and will continue to do so, Dr. Rizzo said, What hasn't changed is the neurologist's diligence, aptitude, and appetite for solving really hard clinical problems and digging into the science to find cures. Neurologists remain a very special group of people.

Dr. Sacco said he, too, remains optimistic. With every challenge comes a new opportunity, he said. We will remain resilient and work collectively together to chart a new course forward.

None of the sources quoted in this stories had conflicts of interest to report.

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20 Years Later, The Pressures and Opportunities Facing... : Neurology Today - LWW Journals