General Neurology Needs Recruits and Respect

Kathrin LaFaver, MD; Louise M. Klebanoff, MD


April 24, 2023

This transcript has been edited for clarity.

Kathrin LaFaver, MD: Hello. Thank you for joining us today. I am Dr Kathrin LaFaver, a neurologist in Saratoga Springs, New York. I will be talking today with Dr Louise Klebanoff on behalf of Medscape Neurology.

Dr Klebanoff is the chief of general neurology and the vice chair of clinical operations at Weill Cornell Medical Center in New York, and we will be talking today about her recent viewpoint, titled, "Modern Neurology Training Is Failing Outpatients," published online for JAMA Neurology.

Dr Klebanoff, welcome.

Louise M. Klebanoff, MD: Thank you so much for having me. I'm really pleased to have this opportunity to expand more on this viewpoint.

LaFaver: Wonderful. To start, tell us a little bit about your background and why you wrote this article.

From Critical Care Neurology to Outpatient Care

Klebanoff: My background is a little bit odd to come to this position of being an outpatient general neurologist. My fellowship training was actually in critical care neurology, and I did critical care neurology almost exclusively for about 10 years.

My mentor always wanted us to have an outpatient practice. He thought it was very important for the critical care physicians to have exposure to their patients after they were discharged from the hospital. He also thought it was important for us to have some exposure to more common neurologic problems, to give us a little bit of a balance with the carnage we saw in the neurocritical care unit.

Over time, I found that the demand was actually more for outpatient neurology, and I found that I really liked it and was quite good at it. Over the years, I became more and more of an outpatient general neurologist. I look at my critical care background as being general neurology to the nth degree, and I think it's comfortable for the patients to know that whatever they come into the office with, I've seen it.

LaFaver: That's wonderful, and that is indeed a very unique perspective. I can totally see how it would be very helpful to not only see patients at their worst day or worst week, but also see the recovery process as well.

You mentioned in your viewpoint about neurology becoming more subspecialized and many residents being steered toward fellowship training. What do you see as the problem that should be addressed with that development?

Klebanoff: I'm a bit older in my career. When I started out, neurology was actually a specialty. I find now that, when we're interviewing resident applicants, the neurology residency is really a stepping point for them to get to a subspecialty training. The problem I see in that is that most patients, on an outpatient basis who need to see a neurologist, actually present with an undifferentiated issue, and they're not sure what subspecialist to see.

In addition, as internal medicine physicians have less exposure to neurology in their training, they're really not sure who to send their patients to. For example, if an internist sees a patient who is having trouble walking, do they send them to movement disorder because it's Parkinson's disease? Does the patient have demyelinating disease? Do they have a peripheral neuropathy? Do they have a brain tumor?

It's very hard for them to know how to direct the patient. With access to neurology being so poor, patients could go to a movement disorder specialist, then a peripheral neuropathy specialist, then a demyelinating specialist and still not have an answer to why they're not walking well.

A general neurologist can take the patient as a whole, do a good history, do a detailed exam, and be able to localize the problem and help out. We might need to refer them to a subspecialist, but then we'll know the correct subspecialist to send them to.

Should Residency Programs Change?

LaFaver: I think these are all very good points. As you said, early in the process, it's probably much more helpful for patients to be seen by a generalist.

How is that affecting the residency programs? What changes should be done to get more people interested in general neurology and also to get the training they need so they feel comfortable practicing in that specialty?

Klebanoff: With residency training, especially in metropolitan areas, the training is really focused on inpatient neurology, in part because the hospital systems, frankly, need the residents to do the clinical work to take care of the patients. Ambulatory care is often added as an afterthought. The real work is in inpatient training.

Then, when the residents graduate from the program, they're not comfortable taking care of outpatients because they haven't done it. They're not excited by taking care of outpatients because they haven't seen the excitement and the satisfaction you get from taking care of a patient globally because that's not what they're exposed to.

LaFaver: Yeah.

Klebanoff: I think it's a failure for the outpatients because, again, most outpatients really have general neurologic problems. They come in with headache, neck pain, back pain, dizziness, difficulty walking, and difficulty thinking. That's what I see day in, day out. That's actually what I like to see. Our residents aren't getting that exposure.

LaFaver: You made an interesting point that, maybe over the years, as we have become more subspecialized as a field, there's been maybe a bit of a prestige question or general neurologists are possibly looked down a bit. That also is reflected in the compensation often being different for those of us who do fewer procedures. Do you have any thoughts on that and possibly how to change this?

Klebanoff: I would say the fastest conversation stopper I have at an academic meeting is when people ask me what I do, and I say I'm a general neurologist. The conversation stops, and they usually ask the next person what they're interested in doing.

I think general neurology is looked down on. I think it's very difficult in an academic setting to get promoted as a general neurologist. You're expected to publish and you're expected to do national, if not international, talks. As a general neurologist, it's kind of hard to get invited to do those things.

In addition, there's less compensation. If you're not doing a procedure, you're going to get less compensation. That's also, I think, a factor when residents are considering choosing a subspecialty.

Is General Care More Satisfying?

LaFaver: I think one of the positive changes we have maybe seen in that realm includes some of the recent compensation changes so we can bill more on time and get more relative value units (RVUs) for longer visits. I hope that we'll see a continued change in that direction so we can actually bill more for our time that we spend with patients. You've already touched on that.

Ending a bit more on a positive note, why don't you tell us more about what excites you about being a general neurologist, and what might be reasons for people graduating in the field now to consider this as a career option.

Klebanoff: I'm excited by every day coming to work. I never know what's going to come into the office, whether it's going to be a headache, neck pain, back pain, something very unusual, or something really common. I love the ability to take care of multiple problems in one patient so that patients don't have to see multiple neurologists for their peripheral neuropathy, their dizziness, or their migraines.

I find it incredibly satisfying to see patients over time. As I get to know them, I'm often seeing family members. I have patients where I started with one, I might see the spouse, I might see a child or two, and I might see a friend of a kid. I like that experience. To me, that's incredibly satisfying and gives me a sense of taking care of a complete patient.

LaFaver: That was a wonderful testament.

I'll add my own story. I was actually a movement specialist in academic medicine for about 10 years. I made a bit of a pivot during the pandemic. Now, I'm practicing in a community-based practice, general neurology.

I'm very happy for my training that I feel did prepare me for this role. Although I still maintain a strong focus in movement disorders, I have been enjoying it for the same reasons that you mentioned.

It's sort of nice when you're not only treating someone's Parkinson's disease but also taking care of their migraines and their peripheral neuropathy, because it's hard to separate it all. People are not excited by seeing two or three specialists just for neurology issues and adding to their time and financial burdens.

I would also like to say that it can be helpful for our own burnout issues, right? Having that comparison of being a subspecialist, seeing many people with very complex problems, and being maybe the third, fourth, or fifth neurologist seeing someone in their disease process, it can be very challenging seeing complex patients time after time for your entire day.

I think the mixture of seeing patients with a variety of disease — some with very serious illness, some with things that we can really help — has also increased my own satisfaction in my work-life balance and in my workday.

I want to say thank you for bringing attention to this very important issue. Yes, there is a need for subspecialization in neurology, but we should not forget our background. I applaud your previous mentor who made a big point of advocating for broad training and broad practice for everyone. I think neurology and our patients can only benefit.

Klebanoff: Absolutely, I agree with you 100%. I think there is a real importance and a real role for the general neurologists to play.

LaFaver: Thank you so much. It was fun talking to you, and I think you've made a number of good points. I hope to see you soon and catch up in person.

Klebanoff: That would be great. Thank you so much.

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