John F. Kennedy said “Change is the law of life. And those who look only to the past or present are certain to miss the future.” The article by Ringel1 reflects on the evolution of neurologic practice over several decades, how the profession has tracked changes in neurologists' practice environment, and the enormous, “disruptive” changes the specialty faces looking forward. It is particularly timely given a recent report on the relatively high prevalence of burnout symptoms among neurologists.2
A major change driver facing neurologists is the Affordable Care Act, with its rollout of policies that turn financial incentives for care delivery completely upside-down. The comfortable situation of being paid for care quantity under fee-for-service models is changing to payment for care for a given population and meeting quality targets, putting financial risk on the delivery system and providers. Neurology needs many more evidence-based, team care coordination models,3 experience in implementing them and estimating costs/savings, and active voices in decision-making regarding deployment of these multidisciplinary models within our practice settings.
Envisioning the changes that technology will bring and the radically different skill set it will require is daunting. Facts about the nervous system once diligently memorized can now be retrieved with point-of-care handheld devices. The value neurologists will bring is creating and using tools to optimize clinical judgments—based on evidence that is ever-increasingly individualized with genomic and other predictor data—and effectively eliciting patient preferences through communication of comprehensible risk/benefit information. Electronic medical record systems plaguing us today should become powerful decision support tools with embedded software apps (http://web1.johnshopkins.edu/onemagazine/fall-winter-2014/category/features/rx-disruption/).
Finally, advances in diagnostics and therapeutics should expand neurologists' workforce options, as neurohospitalists, as company-based teleneurologists, and on multidisciplinary quality improvement teams within health care systems, continually incorporating these advances into neurologic practice. Change for neurologists is inevitable and well under way.
Footnotes
Study funding: No targeted funding reported.
Disclosure: B.G. Vickrey receives grant support from NIH/National Institute of Neurological Disorders and Stroke 1U54NS081764 and R37NS031146, the VA Health Services Research and Development Service, California Community Foundation, and UniHealth Foundation; has received consulting income and travel support from Genentech; received travel support from EMD Serono; and received consulting income from Indiana University for participation in Data Safety Monitoring Boards for several NIH trials. Go to Neurology.org for full disclosures.
References
- 1.Ringel SP. The practice of neurology: looking ahead by looking back. Neurology 2015;84:2086–2091. [DOI] [PubMed] [Google Scholar]
- 2.Sigsbee B, Bernat JL. Physician burnout: a neurologic crisis. Neurology 2014;83:2302–2306. [DOI] [PubMed] [Google Scholar]
- 3.Vickrey BG, Mittman BS, Connor KI, et al. The effect of a disease management intervention on quality and outcomes of dementia care: a randomized, controlled trial. Ann Intern Med 2006;145:713–726. [DOI] [PubMed] [Google Scholar]