Ongoing Disruptions in Neurology Practice During COVID-19: The Importance of Adaptation

As with most other medical specialties, there were significant disruptions in neurological care during the early stages of the COVID-19 pandemic. Many routine visits and medical procedures have been delayed, and medical staff have had to adapt to a variety of new safety protocols and workflow changes.1 Nearly two years later, while patient care has largely resumed, neurology practices face a shifting set of challenges, including: staff shortages and increasing professional burnout.

Changes in practice and current requirements

“I suspect one of the most important ongoing issues right now is patient access to neurological care,” said Barney J. Stern, MD, professor, medical director of neurological services at the Johns Hopkins Outpatient Center and vice chair of strategic planning for the department in Neurology from Johns Hopkins University School of Medicine in Baltimore. “There is a continuing endemic demand for neurology services,” with previous findings predicting a 19 percent shortage of neurologists in the United States by 2025.2

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Many neurologists are still working on the delayed demand that occurred at the beginning of the pandemic. “There has been a significant shift in care, with some patients avoiding hospitals and emergency rooms, and an increase in patients seeking treatment for their acute concerns [an] outpatient practice setting,” said Andrew Russman, DO, director of the stroke program and medical director of the Comprehensive Stroke Center at the Cleveland Clinic in Ohio. “Patients have harmed themselves by postponing their treatment.”

In addition, there has been an influx of patients with symptoms of “long-range COVID” and symptoms associated with COVID-19 vaccinations.3-5 Although the literature describing neurological symptoms associated with the vaccines is limited, some patients have dr Stern shared that her previous neurological symptoms had significantly worsened since being vaccinated, while others have reported new onset of symptoms such as numbness, headache, fatigue, tingling and brain fog after vaccination.

However, the results of neurological tests are generally unremarkable in these patients. “I don’t think we know how to deal with these cases, other than treating them symptomatically, which may well be the right approach,” says Dr. Star. Most patients appear to improve over weeks or months, although others appear to have persistent symptoms.

Changes in access to telemedicine since the onset of the pandemic represents another recent component of practice disruptions. “Many of us made the switch to telemedicine, and patients for the most part have been very grateful, but now many of the mutual agreements between states have been reversed, themselves in the middle of another climb,” notes Dr. Star. This has further strained patient access to care.

staff challenges

While post-COVID changes in physician employment have been reported, these issues have not materially impacted the Cleveland Clinic.6 “We haven’t had a lot of physician turnover; We’ve actually seen fewer clinicians and hired more staff than before the pandemic,” says Dr. Russman. “Elsewhere, doctors may be near the end of their careers and these new COVID-related demands may accelerate their retirement.”

In their facilities, however, the lack of nursing staff is likely to be the biggest disruption. Nurses enter the labor market in smaller numbers and exit in larger numbers.7

There have been challenges related to staffing issues at the clinic, such as a shortage of nurses and laboratory technicians and computed tomography (CT) scanners, along with staff absences due to illness. “For the most part, we haven’t had to cancel clinics, we’ve been working ‘leaner’, and this has shifted some of the burden onto the doctors,” said Dr. Russman.

address burnout

dr Stern added that interns are also experiencing stress as many are pulled from constituencies to cope with inpatient rushes and are exhausted and at risk of becoming COVID-positive. “This is hitting both residents and medical students, who have experienced major disruptions to their academic year, very hard. Everyone’s expectations have changed.”

In addition, the whole system is under stress as neurologists get sick with COVID and experience burnout and staff shortage causes more demand for medical staff with burnout. Added to this is the general lack of neurologists.

dr Russman and his colleagues work to partially combat burnout by striving for a fair distribution of workload and a reasonable number of days off. “It’s important to understand that people working in high-volume environments require downtime,” he says.

dr Stern emphasized the need for physicians to take care of their mental and physical health for their own well-being and to optimize patient care. This is particularly important as there is currently no end in sight to the pandemic.

Regarding ways to reduce burnout on an individual level, “I think it’s very individual, and different people find relief in different ways — it could be meditation, exercise, spending time with family and friends,” says Dr. Star. “We need to find ways to sign each other off and step back for a day or a week during this time. Every physician group should be proactive in ensuring that every clinician has some free time.”

broader needs

Compared to other specialties, many neurology practices have relatively modest profit margins and lack the capacity to hire midsize vendors. “Having the tools and mechanisms in place to develop a team approach to neurological care coupled with telemedicine would go a long way in improving patient access,” says Dr. Star. “A new patient visit to me is currently booking out 6 months which is inappropriate – and I’m the first to say so.”

While professional organizations like the American Academy of Neurology proactively advocate innovative approaches to team-based care, resources remain limited.

patient education needs

dr Russman encourages colleagues to continue to educate patients at each visit about the importance of not delaying their treatment, as this leads to negative outcomes for patients and puts additional strain on the healthcare system as it responds to eventual demand.

He also stressed the importance of educating patients about the need for vaccinations in a non-confrontational way. “We’re finding that many people aren’t vaccine refusers, they’re vaccine reluctant, and we can use our expertise to dispel myths about vaccination,” notes Dr. Russman, such as the myth about high risk of contracting COVID in hospitals. He adds: “We didn’t see that; What we are seeing is that about 90% of patients hospitalized with COVID are unvaccinated.”

When discussing the benefits of vaccinations with patients, Dr. Russman proposed shifting the focus from infection prevention to milder symptoms and reduced risk of hospitalization. “Don’t be afraid to talk about the importance of vaccination and debunk myths,” he advises.

The Importance of Customization

While COVID-related stressors have certainly taken a toll, says Dr. Stern: “We should be very proud of ourselves for all the adjustments we’ve gone through in the last two years.”

In this sense, Dr. Russman added, “These challenges have taught us to be very efficient in allocating care across facilities and prioritizing resources for the highest-risk patients, so we saw no compromise in the care of acute patients. We have learned to adapt and become more efficient overall.”

references

1. Leira EC, Russman AN, Biller J, et al. Sustaining stroke care during the COVID-19 pandemic: potential problems and solutions. Neurology. Published online May 8, 2020. doi:10.1212/WNL.0000000000009713

2. Dall TM, Storm MV, Chakrabarti R, et al. Supply and demand analysis of the current and future US neurology workforce. Neurology. Published online April 17, 2013. doi:10.1212/WNL.0b013e318294b1cf

3. Patone M, Handunnetthi L, Saatci D, et al. Neurological complications after first dose of COVID-19 vaccines and SARS-CoV-2 infection. Nat Med. Published online October 25, 2021. doi:10.1038/s41591-021-01556-7

4. Garg RK, Paliwal VK. Spectrum of neurological complications after COVID-19 vaccination. Neurol Sci. Published online October 31, 2021. doi:10.1007/s10072-021-05662-9

5. Finsterer J. Neurological side effects of SARS-CoV-2 vaccinations. Acta Neurol Scand. Published online November 8, 2021. doi:10.1111/ane.13550

6. Neprash HT, Chernew ME. Physician practice disruptions in treating Medicare patients during the COVID-19 pandemic. JAMA. September 20, 2021. doi:10.1001/jama.2021.16324

7. Shah MK, Gandrakota N, Cimiotti JP, Ghose N, Moore M, Ali MK. Prevalence and factors associated with burnout among nurses in the US. JAMA network open. Published online February 4, 2021. doi:10.1001/jamanetworkopen.2020.36469