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Neurohospitalist: Demand is growing for this subspecialty

MDlinx Feb 07, 2024

There are just over 11,000 full-time neurologists practicing in the US, which is far fewer than what is needed by our aging populace.

Klebanoff LM, Safdieh JE. Modern neurology training is failing outpatientsJAMA Neurol. 2023;80(4):333–334.

At the same time, general neurologists—specialists who are able to treat patients among a broad spectrum of neurological disease—are becoming less common, with further subspecialization among neurologists limiting which patients they are able to treat.


To address the burgeoning need for inpatient neurology care, neurohospitalists may be the answer. These specialists represent a diverse group of neurologists who manage inpatients with neurological emergencies who require hospitalization for stroke, seizure, and encephalopathy.

Importantly, based on a survey of physicians affiliated with the Neurohospitalist Society, almost 90% reported being pleased with their work.

Probasco JC, Greene J, Harrison A, et al. Neurohospitalist practice, perspectives, and burnout. Neurohospitalist. 2019 Apr;9(2):85–92.



The scope of the field


Neurologists began specializing in inpatient care about 20 years ago, and just under 2,000 are estimated to be practicing today. Once the field emerged, however, hospitals that established neurohospitalist services began to view these specialists as integral in advancing quality care, according to authors of an article in Neurology Today.

Butcher L. Want to become a full-time neurohospitalist? Where the training opportunities are available. Neurology Today. March 7, 2019.



The authors of the survey of neurohospitalists wrote that the fast-growing subspecialty was spurred by the demand for “timely, cost-effective, and high-quality inpatient neurological care.”

“Neurohospitalists are inpatient neurology specialists,” they explained, “caring for patients of increasing complexity in an environment of mounting financial and regulatory pressures.” 


According to results of the survey, neurohospitalists budget about 70% of their clinical activity to inpatient neurology. They also devote time to telemedicine and outpatient postdischarge clinics. Neurohospitalists lead in clinical medicine, administrative duties, education, and research.


Neurohospitalists are uniquely positioned to spearhead patient safety and quality improvement institutionally and nationally, with duties running the gamut from evaluation and treatment, all the way through care transition to the outpatient clinic. 

The activities of neurohospitalists vary based on whether they practice in academic or community settings. Academic neurohospitalists provide dedicated expertise when educating medical students and training residents. They also see more newly admitted inpatients, who are admitted to their primary service, as well as in daily follow-up. Community neurohospitalists see more consults.

The majority of neurohospitalists work with advanced practice providers or residents. Most neurohospitalists participate in a hospital or ED call schedule along with other neurohospitalists or neurologists. Residents are the ones who usually take overnight calls in academic centers, whereas in community centers, a neurohospitalist or neurologist is on night duty. 

Most neurohospitalists serve adults, among whom cerebrovascular disease (eg, TIA, stroke), seizure, and delirium/encephalopathy are the top diagnoses. Community neurohospitalists more often than academic neurohospitalists care for patients with cerebrovascular disease.


Clinical outcomes



Stanford researchers were interested in determining the impact of implementing a neurohospitalist service on clinical outcomes. To this end, they conducted a retrospective, quasi-experimental study comparing length of stay and 30-day readmission rate among patients discharged from the general neurology service before and after implementation of a full-time neurohospitalist service.

Gold CA, Scott BJ, Weng Y, et al. Outcomes of a neurohospitalist program at an academic medical center. Neurohospitalist. 2022 Jul;12(3):453–462.


They compared these results with those from a control group of stroke patients. 

After implementing the neurohospitalist service, there was a significant shift in discharge diagnoses—from headaches to things like CNS infections and neoplasms. “Despite this substantial shift in the patient population cared for by the newly created neurohospitalist service,” the investigators wrote, “hospital complications and inpatient mortality rates remained low, 30-day readmission rate was stable, and mean adjusted LOS decreased by .7 days. Using a quasi-experimental design with a DID analytic approach, implementation of the neurohospitalist program was associated with a marginally significant reduction in 30-day readmission rate compared to the stroke service control group.”


Results of this study are supported by those of another study—as noted by the Stanford researchers—assessing the implementation of a neurohospitalist program, which also demonstrated a decrease in adjusted mean LOS, stable mortality rates, and stable patient satisfaction. 

“Hospital systems may expect reduced length of stay and 30-day readmission rate and an improved capacity to care for more severely ill patients when moving from a traditional model to a neurohospitalist program,” the researchers concluded.


Career satisfaction


Given the nature of their work, there is concern that neurohospitalists might be predisposed to experience higher burnout rates. On the contrary, however, the survey of neurohospitalists demonstrated that these practitioners are actually more satisfied and exhibit lower rates of burnout than neurologists or internal medicine hospitalists. 


Career satisfaction and work-life balance protected against such burnout: Overall, 87% of the neurohospitalists surveyed were pleased with their careers, and only 36% reported burnout. This can be compared with results of a recent AMA survey, which found that, at the end of 2021, nearly 63% of physicians reported symptoms of burnout.

Measuring and addressing physician burnout. AMA. May 3, 2023.




Becoming a neurohospitalist


To date, only a small minority of neurohospitalists are formally trained in the field. Many are fellowship trained in cerebrovascular neurology instead, says Neurology Today. Interest in fellowship has increased recently, with fellowship training offering chances to pursue research, cultivate leadership skills, focus on teaching, and develop protocols for emergency neuro presentations.


Despite the uptick in fellowship opportunities—recent additions include those at Stanford, UCSF, and the University of Colorado Anschutz Medical Center—demand will likely outpace supply of such positions.

“Every year I get more and more emails from residents around the country asking about the fellowship and trying to understand whether it is a good fit,” said Maulik Shah, MD, director of UCSF's neurohospitalist program, in Neurology Today.

Historically, neurohospitalist programs have had tepid receptions. Some never fill the positions or fold outright. To date, the field is not ACGME accredited, although most neurology program directors feel it should be. 

Fellowship programs in the field tend to concentrate on stroke, epilepsy, and consult neurology. Patient safety, patient communication, and professional communication are focal points of these programs.


What this means for you

When medical centers are staffed with neurohospitalists, patients with neurological disease see improved outcomes and better quality care. Although there is increased interest in the field, there is a paucity of fellowship opportunities. Overall, the field is a good option for those so inclined, with neurohospitalists expressing higher rates of career satisfaction and lower rates of burnout among physicians and other specialists. They fill a gap in the acute care of emergency neuro presentations in hospitalized patients and are best trained to deal with complicated presentations that require multidisciplinary care. 


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