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

As with most other medical specialties, significant disruptions in neurology care occurred during the early part of the COVID-19 pandemic. Many routine visits and medical procedures were delayed, and health care personnel had to adapt to a range of new safety protocols and changes in workflow.¹ Nearly 2 years later, while patient care has largely resumed, neurology practices face a shifting set of challenges including staff shortages and ever-increasing levels of professional burnout.

Practice Changes and Current Demands

“I suspect that one of the main ongoing issues right now is patient access to neurologic care,” says Barney J. Stern, MD, professor, medical director of the neurology services at the Johns Hopkins Outpatient Center, and vice-chair for strategic planning in the department of neurology at Johns Hopkins University School of Medicine in Baltimore. “There is an ongoing endemic demand for neurologic services,” with earlier findings projecting a 19% shortfall of neurologists in the United States by 2025.²

Many neurologists are still working through the delayed demand that occurred early on in the pandemic. “There has been a significant deferral of care, with some patients avoiding hospitals and emergency rooms, and an increase in patients who want their acute issues treated in [an] outpatient office setting,” explains Andrew Russman, DO, head of the Stroke Program and medical director of the Comprehensive Stroke Center at the Cleveland Clinic in Ohio. “Patients have done harm to themselves by deferring their care.”

In addition, there has been an influx of patients with symptoms of “long-haul COVID” and symptoms related to COVID-19 vaccinations.^3-5 Although the literature describing neurologic symptoms associated with the vaccines is limited, some patients have told Dr Stern that their previous neurologic symptoms have substantially worsened since they received the vaccine, while others have reported new-onset symptoms such as numbness, headache, fatigue, tingling, and brain fog after vaccination.

However, results of neurologic testing are generally unremarkable in these patients. “I don’t think we know how to handle these cases other than symptomatic management, which may well be the correct approach,” says Dr Stern. Most patients seem to improve over weeks or months, although others seem to have persistent symptoms.

Changes in access to telemedicine since the early part of the pandemic represent another recent component of practice interruptions. “Many of us pivoted to telemedicine, and patients for the most part were very thankful for that, but now many of the reciprocal agreements between states have been rolled back, even in the middle of another surge,” Dr Stern notes. This has placed further strain on patients’ access to care.

Staffing Challenges

While post-COVID changes in physician employment have been reported, those issues have not significantly affected Cleveland Clinic.⁶ “We haven’t had a lot of physician turnover; we have actually seen less movement of clinicians and we’ve hired more people than before the pandemic,” says Dr Russman. “In other places, there may be physicians nearing the end of their careers, and these new COVID-related demands may hasten their retirement.”

At their facilities, however, the shortage of nursing personnel likely represents the greatest interruption. Nurses are entering the workforce in fewer numbers and leaving in greater numbers.⁷

As such, there have been challenges with staffing issues in the clinic, with a dearth of nurses as well as lab technicians and computed tomography (CT) technicians, for example, along with staff absences due to illness. “For the most part we haven’t had to cancel clinics but are running ‘leaner,’ and this has shifted some of the burden to physicians,” according to Dr Russman.

Addressing Burnout

Dr Stern added that medical residents are also undergoing stress, with many being pulled from elective rotations to help manage the inpatient crush, and they are exhausted and at risk of becoming COVID-positive. “This is falling very hard on residents as well as medical students, who have experienced major interruptions to their academic year. Everyone’s expectations have been altered.”

Additionally, with neurologists contracting COVID and experiencing burnout, and staff shortages placing more demand on medical personnel who are also experiencing burnout, the entire system is under stress. This is on top of the overall shortage of neurologists.

Dr Russman and his colleagues are working to address burnout in part by striving for a fair distribution of the workload and an adequate number of days off. “It’s important to understand that people working in high-volume settings need downtime,” he says.

Dr Stern emphasized the need for physicians to tend to their mental and physical health for their own wellbeing as well as to optimize patient care. This is especially important given that there is currently no end in sight for the pandemic.

Regarding ways to reduce burnout on the individual level, “I think it’s very individualized, and different people find relief in different ways – it could be meditation, exercise, time with family and friends,” says Dr. Stern. “We have to find ways to sign out to one another and step back for a day or a week during this time. Each physician group should be proactive in making sure each clinician has some off time.”

Broader Needs

Compared to other specialties, many neurology practices have a relatively modest margin and lack the capacity to hire midlevel providers. “Having the funds and mechanisms to develop a team approach to neurologic care, coupled with telemedicine, would go a long way to improving patient access,” says Dr Stern. “A new patient visit with me is currently booking out 6 months, which is inappropriate – and I’m the first to say it.”

While professional organizations such as the American Academy of Neurology have been proactive in advocating innovative approaches to team-based care, resources remain limited.

Patient Education Needs

Dr Russman encourages colleagues to continue to educate patients at every visit on the importance of not deferring their care, as this creates negative outcomes for patients and places an additional strain on the health care system as it accommodates the eventual demand.

He also emphasized the importance of educating patients in a non-confrontational way about the need for vaccination. “We are finding that many people are not vaccine rejecters but are vaccine hesitant, and we can use our expertise to dispel myths about vaccination,” Dr Russman notes, such as the myth about a high risk of contracting COVID in hospitals. He adds: “That’s not what we’ve seen; what we’re seeing is that around 90% of patients hospitalized with COVID are unvaccinated.”

In discussing the benefits of vaccination with patients, Dr Russman suggests shifting the emphasis from prevention of infection to a focus on milder symptoms and reduced risk of hospitalization. “Don’t be afraid to discuss the importance of vaccination and dispel myths,” he advises.

The Importance of Adaptation

While COVID-related stressors have certainly taken a toll, Dr Stern says, “We should be very proud of ourselves for all the adaptation we have gone through over the past 2-plus years.”

In that vein, Dr Russman adds that “these challenges have taught us to be very efficient about distribution of care across facilities and prioritizing resources for the highest-risk patients, so we have not seen any compromise in care for acute patients. We’ve learned how to adapt and become more efficient overall.”

References

1. Leira EC, Russman AN, Biller J, et al. Preserving stroke care during the COVID-19 pandemic: potential issues 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 following 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 interruptions in the treatment of 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 of and factors associated with nurse burnout in the US. JAMA Netw Open. Published online February 4, 2021. doi:10.1001/jamanetworkopen.2020.36469