(pasted from original reddit post)
An editorial in JAMA neurology last month promoted using Mid-levels who they concede have no neurology training to deliver neurologic care:
jamanetwork.com
Several colleagues and I responded to this formally. This post is a report of what happened with that response
Understanding that many will not have access, due to a paywall, here are some excerpts from the Editorial: _____________________________ “Currently, the supply of neurology clinicians is inadequate to meet the demands of patients, and the distribution of neurologists in the US highlights inequitable access to care.
From the perspective of APCs, there is little or no exposure to neurology in training, making it less likely they would consider neurology…
Often,APCs express dissatisfaction about not being allowed to operate to the fullest extent of their license as clinicians. A disproportionate amount of their time is relegated to answering emails and calls rather than actually seeing patients. ….
Others report limited opportunities for advancement and leadership roles. Some neurology departments promote APCs on academic tracks, but in many cases, there is no clear path for promotion. ….
In addition to financial concerns, a time commitment of 3 to 6 months is required to integrate and educate an APC in the neurology setting. When supported in their role as a clinician, retention and productivity are improved …
After hiring an APC, onboarding could be combined with resident and medical student educational offerings, encouraging a culture of inclusiveness…”
________________
In response to this editorial, members of the board of Physicians for Patient Protection wrote a letter to the editor. Here is the text of that letter: _______________________________________________ S. Andrew Josephson, MD
Editor, JAMA Neurology
Dear Dr. Josephson,
On behalf of the board of Physicians for Patient Protection, an organization of 12,500 practicing physicians and physicians-in-training, we are writing in response to the recent Viewpoint “Advanced Practice Clinicians—Neurology’s Underused Resource” (JAMA Neurol. published online May 24, 2021. doi:10.1001/jamaneurol.2021.1416).
NP Cook and Dr. Schwarz note that the demand for neurology services outpaces the supply of physicians, pointing out that new patients can expect to wait approximately a month for a neurology appointment. The authors propose increased utilization of non-physician practitioners (NPPs)—namely, nurse practitioners (NPs) and physician assistants (PAs)—to increase patient access.
While the article argues for an increased use of NPs and PAs based on a shortage of board-certified neurologists, it also acknowledges a lack of neurology qualifications of NPs and PAs (“there is little or no exposure to neurology in training”). When primary care or other specialty physicians refer their patients to a neurologist, they are seeking care from an expert with more knowledge and training in the field of neurology, and not from a practitioner with less training than themselves. This begs the question: what is the appropriate extent of neurologic care that can (or should) be provided by non-physician practitioners with little-to-no exposure or training in the field of neurology?
The authors propose ideas to address training deficits, such as including NPs and PAs in resident and medical student educational offerings. The challenge with this suggestion is that many NPPs lack the foundational understanding of medicine and neuroanatomy that is required of physicians and is essential for the development of independent critical thinking and problem solving. NPs and PAs have a fraction of the training of physicians, with many students completing their coursework through online programs with open book exams. In addition, the nursing model on which NPs train is completely different from that of physicians, lacking a comprehensive training of physical examination skills, differential diagnosis formation, and formal neurology training.
The paper suggests that neurologists create templates and onboarding materials to assist NPPs in learning how to care for neurology patients. The time and financial investment required to get an NPP to reach educational milestones appropriate for patient care should not be portrayed as a failure of neurologists to accommodate non-neurologists in the field. For example, although fourth-year medical students have significantly more clinical hours of training than the average new NP/ PA, we doubt that the authors would hire unmatched medical school graduates to independently evaluate new and returning neurology patients. The opportunity for ‘on-the-job training’ would not be offered to unmatched physician graduates, who are expected to continue formal training to obtain adequate expertise. If a physician who has not yet completed training is not expected to be competent to provide patient care, this must be the same expectation for NPs and PAs.
While most NPs and PAs in neurology are currently utilized as physician extenders, the authors note that this leads to “dissatisfaction about not being allowed to operate to the fullest extent of their license as clinicians.” However, helping neurologists care for patients by refilling medications, coordinating care management, and performing routine follow-up visits under a physician’s supervision is an appropriate role for the training of NPPs, and this contribution may help expand access to neurology care while still ensuring that patients receive an accurate diagnosis and treatment plan from a fully trained neurologist.
According to National Residency Match data, there were 1441 applicants for only 701 PGY-1 Neurology positions. If there is a shortage of neurologists, it is obvious where the problem lies. Increasing residency positions would be the effective and responsible way to address a neurology shortage. This is particularly important in preventing health inequities. While the authors note that “the distribution of neurologists in the US highlights inequitable access to care,” they neglect to mention that the approach of replacing neurologists with lesser trained substitutes is likely to contribute to worsening health inequity. Who will determine which patients receive care from fully trained neurologists and who will be forced to see non-physician practitioners?
Ultimately, both physicians and non-physician practitioners share the goal of providing excellent patient care. Our letter is not intended to call into question this shared motivation, merely to clarify that neurology patients deserve to be cared for by neurologists, who can be assisted by other healthcare professionals with tasks suited to their training and skill level.
Sincerely,
Rebekah Bernard MD Alyson Maloy MD Roy Stoller DO
Phillip Shaffer MD Purvi Parikh MD Carmen Kavali, MD
_____________________________________________________
The response to this letter by the JAMA neurology editorial board was:
_________________________________________
RE: Letter to the Editor
Dear Dr Bernard:
Thank you for your recent letter to the editor. Unfortunately, because of the many submissions we receive and our space limitations in the Letters section, we are unable to publish your letter in JAMA Neurology.
After considering the opinions of our editorial staff, we determined your letter did not receive a high enough priority rating for publication in JAMA Neurology.
We do appreciate you taking time to write to us and thank you for the opportunity to look at your letter.
Sincerely yours,
The Associate Editors of JAMA Neurology
and
S. Andrew Josephson, MD Editor-in-Chief JAMA Neurology
_____________________________________
COMMENTS:
Claiming space limitations is odd in an era when many journals have online communications sections. If JAMA Neurology wished to have this, they certainly could
JAMA Neurology published this full-throated endorsement of APC care in Neurology, including ideas for increasing their use in Neurology. This is obviously controversial.
They received a considered letter objecting to this, written by six concerned physicians. A portion of this letter pointed out how weak their claim of needing APCs because of manpower limitations in Neurology was, given they had accepted only 50% of applicants into Neurology Residencies.
The process of science inherently requires controversial positions be given full airing, with opposing viewpoints being presented on equal footing. The refusal of this journal to publish a reasoned response to the original article’s controversial positions and assertions is the antithesis of science. It demonstrates they have a position they wish to promote, and they will not publish information that challenges there preferred position. It further calls into question the ability of the journal to be objective in all aspects of their operation.
The journal has thus told us they have no space for our counter-opinion. Thus – they reveal they have an editorial opinion – a position they are pushing – that is unrelated to science, but is a political statement promoting non-physician care of patients.
This journal has an agenda that will replace physician care with, as they admit, less qualified mid-level care
Ironically and hypocritically, they are supporting a process that is counter to their statements about health equity. Some of the patients of this department will get expert care, others will get care from people who, as they say, have no training in the field. There could be nothing more inequitable.
An editorial in JAMA neurology last month promoted using Mid-levels who they concede have no neurology training to deliver neurologic care:
Advanced Practice Clinicians—Neurology’s Underused Resource
This Viewpoint discusses the benefit of integrating advanced practice clinicians into neurology practices to improve patient access and optimize care.
jamanetwork.com
Understanding that many will not have access, due to a paywall, here are some excerpts from the Editorial: _____________________________ “Currently, the supply of neurology clinicians is inadequate to meet the demands of patients, and the distribution of neurologists in the US highlights inequitable access to care.
From the perspective of APCs, there is little or no exposure to neurology in training, making it less likely they would consider neurology…
Often,APCs express dissatisfaction about not being allowed to operate to the fullest extent of their license as clinicians. A disproportionate amount of their time is relegated to answering emails and calls rather than actually seeing patients. ….
Others report limited opportunities for advancement and leadership roles. Some neurology departments promote APCs on academic tracks, but in many cases, there is no clear path for promotion. ….
In addition to financial concerns, a time commitment of 3 to 6 months is required to integrate and educate an APC in the neurology setting. When supported in their role as a clinician, retention and productivity are improved …
After hiring an APC, onboarding could be combined with resident and medical student educational offerings, encouraging a culture of inclusiveness…”
________________
In response to this editorial, members of the board of Physicians for Patient Protection wrote a letter to the editor. Here is the text of that letter: _______________________________________________ S. Andrew Josephson, MD
Editor, JAMA Neurology
Dear Dr. Josephson,
On behalf of the board of Physicians for Patient Protection, an organization of 12,500 practicing physicians and physicians-in-training, we are writing in response to the recent Viewpoint “Advanced Practice Clinicians—Neurology’s Underused Resource” (JAMA Neurol. published online May 24, 2021. doi:10.1001/jamaneurol.2021.1416).
NP Cook and Dr. Schwarz note that the demand for neurology services outpaces the supply of physicians, pointing out that new patients can expect to wait approximately a month for a neurology appointment. The authors propose increased utilization of non-physician practitioners (NPPs)—namely, nurse practitioners (NPs) and physician assistants (PAs)—to increase patient access.
While the article argues for an increased use of NPs and PAs based on a shortage of board-certified neurologists, it also acknowledges a lack of neurology qualifications of NPs and PAs (“there is little or no exposure to neurology in training”). When primary care or other specialty physicians refer their patients to a neurologist, they are seeking care from an expert with more knowledge and training in the field of neurology, and not from a practitioner with less training than themselves. This begs the question: what is the appropriate extent of neurologic care that can (or should) be provided by non-physician practitioners with little-to-no exposure or training in the field of neurology?
The authors propose ideas to address training deficits, such as including NPs and PAs in resident and medical student educational offerings. The challenge with this suggestion is that many NPPs lack the foundational understanding of medicine and neuroanatomy that is required of physicians and is essential for the development of independent critical thinking and problem solving. NPs and PAs have a fraction of the training of physicians, with many students completing their coursework through online programs with open book exams. In addition, the nursing model on which NPs train is completely different from that of physicians, lacking a comprehensive training of physical examination skills, differential diagnosis formation, and formal neurology training.
The paper suggests that neurologists create templates and onboarding materials to assist NPPs in learning how to care for neurology patients. The time and financial investment required to get an NPP to reach educational milestones appropriate for patient care should not be portrayed as a failure of neurologists to accommodate non-neurologists in the field. For example, although fourth-year medical students have significantly more clinical hours of training than the average new NP/ PA, we doubt that the authors would hire unmatched medical school graduates to independently evaluate new and returning neurology patients. The opportunity for ‘on-the-job training’ would not be offered to unmatched physician graduates, who are expected to continue formal training to obtain adequate expertise. If a physician who has not yet completed training is not expected to be competent to provide patient care, this must be the same expectation for NPs and PAs.
While most NPs and PAs in neurology are currently utilized as physician extenders, the authors note that this leads to “dissatisfaction about not being allowed to operate to the fullest extent of their license as clinicians.” However, helping neurologists care for patients by refilling medications, coordinating care management, and performing routine follow-up visits under a physician’s supervision is an appropriate role for the training of NPPs, and this contribution may help expand access to neurology care while still ensuring that patients receive an accurate diagnosis and treatment plan from a fully trained neurologist.
According to National Residency Match data, there were 1441 applicants for only 701 PGY-1 Neurology positions. If there is a shortage of neurologists, it is obvious where the problem lies. Increasing residency positions would be the effective and responsible way to address a neurology shortage. This is particularly important in preventing health inequities. While the authors note that “the distribution of neurologists in the US highlights inequitable access to care,” they neglect to mention that the approach of replacing neurologists with lesser trained substitutes is likely to contribute to worsening health inequity. Who will determine which patients receive care from fully trained neurologists and who will be forced to see non-physician practitioners?
Ultimately, both physicians and non-physician practitioners share the goal of providing excellent patient care. Our letter is not intended to call into question this shared motivation, merely to clarify that neurology patients deserve to be cared for by neurologists, who can be assisted by other healthcare professionals with tasks suited to their training and skill level.
Sincerely,
Rebekah Bernard MD Alyson Maloy MD Roy Stoller DO
Phillip Shaffer MD Purvi Parikh MD Carmen Kavali, MD
_____________________________________________________
The response to this letter by the JAMA neurology editorial board was:
_________________________________________
RE: Letter to the Editor
Dear Dr Bernard:
Thank you for your recent letter to the editor. Unfortunately, because of the many submissions we receive and our space limitations in the Letters section, we are unable to publish your letter in JAMA Neurology.
After considering the opinions of our editorial staff, we determined your letter did not receive a high enough priority rating for publication in JAMA Neurology.
We do appreciate you taking time to write to us and thank you for the opportunity to look at your letter.
Sincerely yours,
The Associate Editors of JAMA Neurology
and
S. Andrew Josephson, MD Editor-in-Chief JAMA Neurology
_____________________________________
COMMENTS:
Claiming space limitations is odd in an era when many journals have online communications sections. If JAMA Neurology wished to have this, they certainly could
JAMA Neurology published this full-throated endorsement of APC care in Neurology, including ideas for increasing their use in Neurology. This is obviously controversial.
They received a considered letter objecting to this, written by six concerned physicians. A portion of this letter pointed out how weak their claim of needing APCs because of manpower limitations in Neurology was, given they had accepted only 50% of applicants into Neurology Residencies.
The process of science inherently requires controversial positions be given full airing, with opposing viewpoints being presented on equal footing. The refusal of this journal to publish a reasoned response to the original article’s controversial positions and assertions is the antithesis of science. It demonstrates they have a position they wish to promote, and they will not publish information that challenges there preferred position. It further calls into question the ability of the journal to be objective in all aspects of their operation.
The journal has thus told us they have no space for our counter-opinion. Thus – they reveal they have an editorial opinion – a position they are pushing – that is unrelated to science, but is a political statement promoting non-physician care of patients.
This journal has an agenda that will replace physician care with, as they admit, less qualified mid-level care
Ironically and hypocritically, they are supporting a process that is counter to their statements about health equity. Some of the patients of this department will get expert care, others will get care from people who, as they say, have no training in the field. There could be nothing more inequitable.
