As a neurologist in private practice for more than 25 years in Ocala, Fla., Gregory Howell, MD, once spent his days shuttling between office and hospital. Emergency calls often forced him to cancel or reschedule outpatient appointments and miss out on potential revenue. By the time he wrapped up his scheduled visits and hospital consults, it was often 9 or 10 p.m.
Much has changed in the three years since Dr. Howell became a self-employed neurohospitalist at Monroe Regional Medical Center in Ocala. Now he works half the year and spends the other half relaxing or traveling. He doesn't write prescriptions or admit patients, and he rarely gets called to the hospital in the middle of the night. With no overhead and few expenses, he earns enough to live comfortably and save for retirement.
“I looked at all the volume of billing, and it turns out that everything I was doing in the office was only paying for overhead, and my salary was coming from hospital work,” said Dr. Howell. “So I thought I could probably just work at the hospital and not have any overhead or employees, and have a lot more time off.”
Neurologists who specialize in inpatient work—i.e., neurohospitalists—like Dr. Howell are finding their skills in high demand. Several forces are driving the trend, including a shortage of community neurologists willing to take call and a rapid expansion in treatments for complex neurological conditions over the past decade, many of which are time-sensitive. Hospitals also need reliable neurological coverage in order to earn or maintain certification as a Joint Commission Primary Stroke Center.
“Neurology has emerged into a subspecialty that has a tremendously diverse set of treatment options and many of those options need to be given quickly or emergently,” said S. Andrew Josephson, MD, director of the neurohospitalist program at the University of California San Francisco (UCSF) and co-author of the first academic paper on neurohospitalist medicine. “That makes it very difficult for a neurologist who is located in a clinic across the street or across town to be able to give good quality rapid care in an inpatient setting.”
One size doesn't fit all
While many hospitals recognize the advantages of neurohospitalists, the model they adopt to use them depends on factors like financial status and access to neurologists. Typically, only academic medical centers with sizable neurology departments can afford to have several full-time neurohospitalists on staff. Smaller community hospitals might employ a single neurohospitalist or contract with individuals or private practices to provide part- or full-time inpatient service.
UCSF and Mayo Clinic in Jacksonville, Fla., for example, both run primary and consultative services with full-time neurohospitalists drawn from their large academic neurology departments. At UCSF, between 10 and 20 neurohospitalists are on staff at any one time, Dr. Josephson said, including some working full-time and others who spend a few weeks at a time on inpatient service.
At Mayo, two of the department's five full-time neurohospitalists are in the hospital at all times, said Kevin Barrett, MD, assistant professor of neurology and one of Mayo's neurohospitalists. One covers the neurological ICU while the other is responsible for primary neurology patients, inpatient consultations and emergency department (ED) coverage.
Columbia University Medical Center in New York City follows a different model, said Laura Lennihan, MD, associate professor of clinical neurology and associate chair for inpatient service and clinical affairs. Four years ago, Dr. Lennihan, the center's only full-time neurohospitalist, was recruited to start a neurological stepdown unit to serve patients coming out of the ICU who require complex medical and neurological management. Dr. Lennihan, working with a team of nurse practitioners, oversees care of the critically ill patients and prepares them for post-acute rehabilitation, usually at rehabilitation hospitals or nursing homes.
The stepdown neurological unit is one of the five prongs of Columbia's neurological service, which each operate independently, said Dr. Lennihan. The center also has separate neurocritical care, a general neurology ward, and stroke and neurology consult services.
At smaller community hospitals, neurohospitalists need to consider the pros and cons of working as an independent contractor versus a hospital employee. Contracting can be lucrative, but it may not be a viable option for less-experienced physicians who aren't ready to handle a high volume of consults per day, noted Dr. Howell. On a typical day, he does up to 14 consults, and on his busiest days he has handled up to 32, Dr. Howell said.
Working independently appealed to Liana Dawson, MD, who discovered a passion for inpatient neurology while employed as a locum tenens at St. Mary's Hospital in Duluth, Minn., in 2006. Dr. Dawson, who previously ran a solo neurology practice, loved inpatient work but wanted to retain the autonomy of a private practitioner.
Her solution was to form her own corporation, Southern Neurological Acute Care Specialists (SNACS), and work as a neurohospitalist under contracts. After declining staff positions at St. Mary's and Winter Park Hospital in Orlando, Fla., she contracted with Orange Park Memorial Hospital, near Jacksonville, Fla., where she currently serves as stroke director and neurohospitalist.
“As a private practice, I skinny everything down,” said Dr. Dawson. “I don't have an office and I outsource the billing.”
By staying autonomous, her practice can be aligned to the needs and goals of the physician and patient without undue influence by external factors, said Dr. Dawson, adding that quality of life “can be addressed while still providing for the needs of hospital patients.”
“Often, hospital-based salaried models are driven by underlying productivity constraints or may be influenced by business factors that should not be considerations in the physician-patient relationship,” Dr. Dawson said. “As a private practitioner, support for indigent patients can still be accommodated through a negotiated relationship with the hospital administration.”
While her daily schedule is quite manageable—she is on call for the hospital from 7 a.m. to 5 p.m. weekdays and takes phone consultations on nights and weekends—being the only neurohospitalist makes it difficult to take time off, she said. Two community neurologists take call one day a month and are willing to cover for her for a few days at a time but “no one is willing to fill in for one or two weeks' vacation,” said Dr. Dawson.
Becoming an employee
Working on staff also can have advantages, said Anthony Munson, MD. He spent four-and-a-half years in a general neurology private practice in Newark, Del., before joining the staff of Christiana Care Health System, which has two hospitals in Delaware. As community neurologists, Dr. Munson and his partners used to alternate taking call and responding to requests for hospital consults but, over time, Dr. Munson found he preferred inpatient work.
Dr. Munson is now director of Christiana Care's stroke program and he and another partner in his former practice are full-time neurohospitalists (the health system hired the remaining partners as outpatient neurologists). The move has been a success both financially and personally, said Dr. Munson. He and his partner see all of the inpatient consultations for the practice during the weekdays, and the call coverage is shared with the outpatient neurologists, which is much more conducive to family life than the unpredictable hours he had in private practice. Dr. Munson also enjoys spending more time with patients and treating stroke, his specialty.
“I can spend as much time as I need to with my patients because there's no schedule,” Dr. Munson said. “I can spend an hour with a patient talking about their new diagnosis of multiple sclerosis, for example, without putting me behind in my schedule. I also like having more face-to-face interaction with physicians in other specialties.”
Another benefit to being on staff, he said, is that a patient's insurance status doesn't impact his income directly, whereas in private practice it was difficult to justify taking on too many uninsured (more often hospital) patients. (Some hospitals address that issue by paying contractors a fee for treating uninsured patients.)
David J. Likosky, ACP Member, a neurohospitalist and internal medicine hospitalist at Evergreen Hospital Medical Center in Kirkland, Wash., started with a collaborative arrangement similar to Dr. Munson's: As a full-time neurohospitalist, he covered regular daytime shifts in the hospital while community neurologists helped with night and weekend call. But staff shortages in the internal medicine hospitalist program forced Evergreen to fold his position into the medical hospitalist group.
“Now we have a hybrid model where I do [inpatient] neurology and internal medicine as a neurohospitalist/hospitalist,” said Dr. Likosky. In addition to regular hospitalist duties, he covers for community neurologists during the days when they need help and is available to administer tissue plasminogen activator (tPA) for stroke.
On the job
The rise of neurohospitalists makes sense given the large number of inpatients on internal medicine services that develop neurological complications, said Dr. Josephson. He and his colleagues authored a 2008 article that noted nearly one million hospital discharges a year are coded as nonsurgical neurological, making neurology (at the time the article was written) “one of the largest inpatient specialties not currently utilizing a hospitalist model” (Annals of Neurology, Feb. 2008).
The overlap with internal medicine makes it critical that neurohospitalists establish solid co-management relationships with medical hospitalists and ED physicians, said Dr. Josephson. Typically, other physicians welcome the addition of a neurohospitalist, he added, because they are often uncomfortable handling complex neurological conditions.
“Over the past decade, as neurologists have abandoned the hospital, internal medicine hospitalists had to care for patients beyond the scope of their practice and comfort level,” Dr. Josephson said. “Working hand-in-hand on a daily basis to care for patients with both neurological and medical problems has been one of the most attractive things about the neurohospitalist model for [medical] hospitalists.”
If there are disputes, they are likely to involve coverage rather than overlapping areas of responsibility, said Dr. Josephson. It's important to get everyone together from the outset—ED physicians, hospitalists and neurohospitalists—to come up with a scheduling model that works so that there's no confusion over who sees a stroke patient in the ED at midnight, for example, he said.
Follow-up to ensure continuity of care is another key element of a neurohospitalist program. “Patients see a community neurologist when they leave, so neurohospitalists have to be aware of providing effective and smooth transitions of care at discharge,” said Dr. Barrett at Mayo.
That follow-up might include calling the treating neurologist and directly communicating what has occurred in the hospital to facilitate the outpatient visit, said Dr. Barrett. “The real key is communication,” he said. “Neurohospitalists should learn from the mistakes made with hospitalists in terms of causing inconsistencies in care.”
Neurohospitalists at smaller hospitals, with fewer resources, typically do not admit patients but handle consultations only. That appeals to many physicians because it frees them from some administrative tasks, such as writing prescriptions and discharge summaries, and allows them to concentrate on the patient.
Consultations require less administrative time than admissions, which “lets you see more patients in the same amount of time without sacrificing quality,” noted Dr. Munson. Neurohospitalists also typically provide interpretations of electroencephalograms and carotid Doppler studies. If they are called to the ED after hours, it is usually to administer tPA to stroke patients.
In most cases, admitting physicians don't call the on-call neurohospitalist after hours unless they have an urgent question or for acute stroke, said Dr. Howell. Patients admitted to the ED at night for syncope, altered mental status or seizure, for example, typically are added to his list of consults for the next day, which he checks every morning from home. The system allows him to have some idea of what the day holds before he arrives, he said.
While maintaining continuous neurological coverage is a challenge for many community hospitals, having even one full or part-time neurohospitalist can make a significant difference to the quality of inpatient care. In large part, that's due to the wide scope of neurohospitalists; according to a January article in Neurology, neurohospitalists evaluate and treat altered mental status, acute stroke, seizure disorders, nervous system cancer, headaches, and neuromuscular respiratory failure, and may also diagnose and co-manage patients with critical illness polyneuropathy/myopathy, coma, complications of solid organ transplantation, or increased intracranial pressure.
“Stroke and the pressure on time treatment has been important in the model, but the side benefit is more neurologic treatment for those other important issues that haven't gotten as much attention,” said Dr. Likosky. “A lot of times those patients either were never seen by a neurologist or referred to one after they left the hospital. Now that there is a neurohospitalist around, they do get evaluated and treated.”