- Second opinion
How healthy is UK neurology? A personal perspective
- Correspondence toDr Fred Schon, Croydon (Mayday) University Hospital, London Road, Thornton Heath, Surrey CR7 7YE, UK; Frederick.Schon@mayday.nhs.uk
- Accepted 6 May 2011
I have been a neurologist for over 30 years. Although I remain committed to and mesmerised by the subject, I have doubts about some of the foundations upon which we practise.
Before coming into clinical neurology, I had spent 4 years in Leslie Iversen's laboratory in Cambridge. There, among others neurologists, psychiatrists, neurosurgeons and basic scientists, we studied and discussed widely the neurochemistry and pharmacology of diseases including Huntington's disease, schizophrenia, Alzheimer's disease, Parkinson's disease and gliomas. I naturally assumed that clinical neurologists would likewise be interested in all brain disorders. It was therefore a surprise to find neurologists at that time were not involved in the care of large swathes of brain disease, such as stroke (the most common acute brain disorder), dementia (the most common chronic brain disorder), brain tumours and head injury. They also had only limited participation in three other crucial clinical areas: acute neurology, neurological rehabilitation and psychiatry.
How much has changed?
Stroke medicine has been the shining beacon of progress. It is an emerging integrated subspecialty, shared between neurologists and elderly care physicians, each managing patients irrespective of their age and having a practice backed up by high quality large clinical trials.
By contrast, the management of other important neurological conditions has changed very little. UK neurologists do see younger patients with dementia or those with unusual patterns but are often disconnected from the major dementia care services. They are still rarely responsible for the care of head injured patients and only tangentially involved in the management of patients with brain tumours.
Acute neurology
Acute neurology services have developed, albeit slowly, with more neurologists now working in district general hospitals. However, the least sick patients are still seen in routine outpatient clinics by the most experienced neurologists (consultants) while the sickest emergency admissions meet the least experienced junior doctors: a situation that seems unjustifiable. Consultants should do fewer routine clinics each week but see more emergencies during the day, the night and at weekends. This would improve patient care as well as junior doctor training; it would also reduce patients' length of stay and optimise use of resources, such as MR scans.
Rehabilitation medicine
As most rehabilitation patients have underlying neurological diagnoses, neurologists must shoulder a particular responsibility for its slow development. Rehabilitation medicine should be an area for fantastic advances, with computers and information technology allowing disabled patients far greater control of their environment. Bioengineering should presage more sophisticated prosthetics and electronic stimulating devices. Basic science and knowledge of brain and spinal cord repair mechanisms should have allowed rehabilitation to move forwards by applying basic scientific approaches. Neurologists must be far more involved in helping to advance the evidence basis of rehabilitation medicine.
How can we persuade the body of UK neurologists of the need for an urgent, radical new approach to the total care of neurologically impaired patients and of the need for them to be major partners in the field?
The relationship of neurology to psychiatry
Neuroscience is demonstrating that diseases of the mind are not separate from those of the brain; psychiatric disorders are increasingly found to have underlying brain dysfunction. Likewise, up to 30% of neurology outpatients have predominantly psychiatric conditions.1Breaking down the intellectual and practical divide between neurology and psychiatry presents an enormous challenge. We must work towards such integration if we are to make progress in caring for patients with brain dysfunction in the modern age. However, I fear that developing the subspecialty of ‘neuropsychiatry’ may hinder rather than help progress, as its existence might imply that a neurologist's interest in psychiatry is optional. I see partial integration of neurology and psychiatry training courses as the best hope.
Evidence-based neurology
We have too easily accepted the lack of trial evidence for so much of current practice, for example, idiopathic intracranial hypertension, carotid artery dissection or ulnar neuropathy surgery. This situation may have been acceptable 30 years ago but is now holding back development. We need to collect patients with less common diseases into specialist clinics, setting up longitudinal natural history studies, then small-scale trials and finally comprehensive trials.
There are endless opportunities to develop better evidence for current practice. The recent Scottish Bell's palsy trial2 shows what can and must be done, despite the practical and financial difficulties. Idiopathic intracranial hypertension needs trials of drugs, weight loss and the role of surgery. All chronic neuropathy patients in whom intravenous immunoglobulin is considered (expensive and with limited availability) should be treated only if they are part of regional clinics participating in agreed study protocols with long-term assessments.
Delusions of grandeur
Clinical neurology has traditionally attracted many of the intellectual elite within the profession; this continues to ensure UK neurologists are of the highest calibre. However, I fear it also gives the specialty a prevalent sense of unhelpful superiority. In most branches of medicine, consultants carry out procedures (such as endoscopy), do on-call work, look after inpatients and do outpatient clinics. Yet we have restricted ourselves to small numbers of outpatient clinics and ward referrals. This is despite the dramatically reduced need for neurologists to spend time in regional neuroscience centres, because of MR scanners in district general hospitals and the disappearance of the single-handed specialist. Yet the idea that neurologists need to change the way they practise as patients' needs take centre stage will not be popular.
Conclusion
I see two very different futures for neurology. The first would be as a predominantly outpatient-based specialty—a setting where highly trained and expensive consultants may not be thought of as essential—looking after people with relatively benign diseases such as headaches, blackouts, dizziness and tingling. The second would be to follow stroke medicine's example and become part of a team offering appropriate 24-hour acute care, with practice firmly guided by evidence.
If we are to ensure that neurologists are best equipped to care for all patients with brain disorders, we need a fundamental reappraisal of our role. We must abandon our obsession with rare, unpronounceable and untreatable conditions and concentrate on how we can contribute to managing the total burden of brain dysfunction. We must increase our commitment to clinical trials, take responsibility for the chronic disease management of our patients and move towards a unified approach (with psychiatry) to managing brain dysfunction.
Footnotes
- Competing interests None.
- Provenance and peer review Not commissioned, externally peer reviewed.
