“We’ll get the call on a Friday afternoon because they thought, finally, ‘Well, you know, we need to get neurology involved because we a) haven’t solved the problem and b) there may be some other tests we should be getting,’” he says of common situations. “That has been a problem. If you don’t have a neurohospitalist involved day by day, working with the patient and the general hospitalist, neurology becomes an afterthought.”
He says accurate and early diagnosis is paramount to the patient.
“If the diagnosis is delayed, obviously there’s more insult to the patients, more persistent insult,” he says, noting the timing is particularly important in neurological conditions “because things can get bad in a hurry.”
He strongly urges hospitalists to consult with a neurologist before ordering an entire battery of tests.
At Geisinger, neurologists are encouraging hospitalists to chat informally with neurosurgeons about cases for guidance at the outset rather than after several days.
Hire a neurohospitalist if your institution doesn’t have one already.
At the top of the list of Dr. Kenton’s suggestions on caring for hospitalized neurology patients is this declaration: “Get a neurohospitalist.”
“It’s important to have the neurologist involved from the time the patient’s admitted,” he says. “That’s the value of connecting the general hospitalist with neurologists.”
S. Andrew Josephson, MD, director of the neurohospitalist program at the University of California at San Francisco, says his colleagues are team players and improve patient care.
“Neurology consultations can be called very quickly, and a nice partnership can develop between internal medicine hospitalists and neurohospitalists to care for those patients who have those medical and neurologic problems,” he says.
He also says having a neurohospitalist on board can ease some of the tension.
“No longer if there’s a neurologic condition does a hospitalist have to think about, ‘Well, does this rise to the level of something that I need to get the neurologist to drive across the city to come see?’” he explains. “‘Or is this something we should try to manage ourselves?’”
Tom Collins is a freelance writer in South Florida.
“Neurophobia” a Challenge for Hospitalists, Other Physicians
The unease that many hospitalists, internal-medicine doctors, and other providers feel about treating neurologic conditions is so readily recognized that a term has been coined to describe it: “neurophobia.”
The term has been used in published literature for at least two decades. A 2010 survey found that medical students and residents felt that neurology was the specialty they had the least knowledge about and was the one that was the most difficult.3 And trainees had the least confidence in treating patients with neurological complaints.
S. Andrew Josephson, MD, director of the neurohospitalist program at the University of California at San Francisco, says internal-medicine hospitalists are “increasingly feeling uncomfortable with requests that they have to care for patients with a wide range of primary neurologic conditions in some instances.”
That has helped lead to the emergence of neurohospitalists, he says.
John Vazquez, MD, medical director of the division hospital medicine of Emory University Hospital in Atlanta, says neurophobia is real.
“Every hospitalist has different subspecialty areas that they’re less comfortable with, and I think neurology specifically is one that does scare a lot of hospitalists,” he says. “I think on one side there are hospitalists that might ignore a neurologic problem because they don’t really know what they don’t know. On the other side are the hospitalists who I think are just concerned that they don’t know the field very well and may not feel comfortable.”
Dr. Vazquez did rotations in nephrology, pulmonology, cardiology, and rheumatology but, like many hospitalists, not neurology.
“Neurology is not one that you have to go through,” he says.
He made these suggestions:
- Know what you don’t know and get guidance when necessary.
- Do your own neurologic assessment. Even if a neurologist decides confusion is due to a patient being elderly and having a urinary tract infection, that doesn’t mean that they didn’t actually have a stroke. So if something seems not quite right, be willing to challenge the neurologist.
- Use the resources available to widen your knowledge base.
“You can utilize the consultants for your own education if you have neurologists in your hospital, and many at least have some that rotate in,” Dr. Vazquez says. “You can pick their brain on what they would do with different strokes and what’s the newest thing and ongoing treatment and whatever it is you’re concerned about.”
—Thomas R. Collins
John Vazquez, MD, of Emory University Hospital talks about neurophobia and provides tips for adjusting to the discomfort of working with neurology patients.