The future of neurology in Europe

Abstract

This is a viewpoint on future developments opportunities and risks for the healthcare of neurological patients. The discipline started with the method of clinical pathologic correlations which has discovered most of the major neurological diseases in the first half of the last century. In the second half research in our field was merged with the one of basic neurosciences currently labeled as translational neurosciences. This period began with the development of neurophysiology and imaging techniques which allow characterizing the status of the nervous system in health and disease. Later molecular, genetic and many other techniques gained importance for our field. These tools improving the understanding of pathogenesis and diagnosis have been instrumental, but the importance of our field came to the attention of the general population only when new therapies were developed based on these advances. This lead to the establishment of neurological departments both at University level and in general hospitals. This ongoing process has made neurology nowadays the third largest discipline for patient care alongside with internal medicine and surgery in many places. No need to say that further specialization within neurology is needed but the discipline as a whole must operate as an entity to make sure that patient care and subspecialist development run in harmony and neurologists can still also practice as general neurologists. The European Academy of Neurology is supporting these efforts. In the future the best strategy to help neurological patients will be to even increase the research to understand neurological diseases and to develop new therapies.

Data on the current status of neurology in Europe are incomplete, and consideration on the future are therefore somewhat arbitrary. In spite of the author gaining some insight into the principles of development, this article should not be viewed as a position statement but as expressing the personal opinion.

Since its inception, the medical speciality neurology has undergone remarkable scientific development. The discipline emerged in the mid-19th century, with textbooks written by Romberg and Brain, and achieved its first major upturn in the beginning of the 20th century. It was during this time that the methodology of clinical–pathological correlations led to a new understanding, predominantly in European countries, of numerous brain functions and their pathological deviations. Charcot, Babinski, von Monakow, Holmes, Wilson, Bing, Cajal, Golgi, Oppenheim, Förster, Sherrington, and Alzheimer are just some of the names associated with this initial upturn in this discipline. Many illnesses were discovered during this time, albeit the treatment possibilities were still limited. A second phase in the development of neurology was triggered by the rapid advances made in the biological sciences following the Second World War. Now developments are no longer being driven only by neurologists and psychiatrists. Instead they were heavily influenced by rapid progress in the life sciences as a whole. Although in the mid-20th century neurophysiology and neuropharmacology became the core disciplines, it was the “wet neurosciences” – neuroimmunology and basic sciences – that became more important for neurology towards the end of the 20th century. Neurologists in Switzerland played a major role in these developments at all times.

Early scientific developments were followed by the institutional establishment of neurology as a clinical care discipline in most European countries. For example, the first chairs of neurology at European universities were established at the end of the 19th century, and the first independent departments of neurology at European Universities were founded at the beginning of the 20th century. However, the vast majority of neurological departments in Europe were not established until after the Second World War. As in many other medical fields, the establishment of specialized care units, hospitals, and specialized education was preceded by the development of new diagnostic methods and emerging treatment options. In many European countries, however, political conditions also played a role in establishing neurology as a separate scientific discipline. This is most clearly demonstrated by the forced “reunification” of neurology and psychiatry that occurred during the Nazi dictatorship in Germany in 1935. It is conceivable that today, in Germany, long-term effects from these events are still influencing the educational concept of neurologists and psychiatrists, as every neurologist in training has to pass 1 year of psychiatric education and vice versa.

Today in most European countries, neurology is the third core discipline alongside surgery and internal medicine and is thus one of the most important pillars of the health-care system for the population. The main drivers of this development are the advances made in the treatment of common and widespread diseases like stroke, inflammatory diseases, epilepsy and neurodegenerative diseases.

Structural trends in neurology

Scientific and particularly therapeutic developments of neurology were the drivers of establishing neurology as a specialty, until the beginning of the 21st century. Since then, however, economic constraints are increasingly becoming a driving force for the development of subspecialties of medicine, its structure, and redefinition in many countries. Neurology is now recognized as not only a fascinating discipline that helps patients but also a cost factor and a source of income; therefore, business economists are playing a major role in the development of the discipline. The establishment of neurology departments is becoming both a cost factor and a revenue factor for large hospitals. Private clinical institutions (and unfortunately more and more public hospitals as well) are now shaping the health-care landscape to comply with economic requests. It will have to be carefully observed if structural changes within neurology, for example, the establishment of separated stroke services or neurologic intensive care units in hospitals, result in a desire to optimize care or the wish to optimize profits. One example of this is telemedicine, which without doubt is commonly installed to improve medical care in areas where specialized care is lacking. However, telemedicine is also used to reduce costs used to reduce costs by replacing the current local multidisciplinary teams of physicians who work well together by at least in part remotely working anonymous radiologists, medical lab technicians and in some cases even surgeons who together decide the patient’s fate without any personal knowledge of the clinical details. Such a situation can potentially contribute to a decline in quality of care.

In the early 20th century, the aforementioned multiple factors have led to a situation where the development of neurology has reached a crossroad whose importance and consequences are similar to those associated with the separation of neurology from psychiatry and internal medicine.

In Europe, the rapid development of neurology has resulted in the formation of subspecializations which meanwhile have become established parts of the health-care landscape. The best example of this is acute neurology used in the treatment of stroke patients and the closely associated development of neurological emergency medicine. The services that are needed for these treatments are becoming more interdisciplinary and reach beyond purely neurological diagnostic and treatment options. A privileged partner in this development is diagnostic and interventional neuroradiology, but this also applies to neurosurgery, neurointensive medicine, and vascular surgery or cardiology. The current high standards of neurological care cannot be maintained without all these disciplines. Established standards for such services like in other disciplines such as cardiology or surgery are that neurology must maintain the role of the primary care provider but associated disciplines have to be included as important providers of specialized care.

This opens the possibility for a spin-off of very important components of neurology. As things stand today, the establishment of stroke units as economically separate units from neurology is a conceivable future scenario. Modifications that would have to be made to the current system are already being discussed. All physicians in such structures would complete a common trunk training program that would cover all key cross-disciplinary procedures, including interventional procedures (thrombectomy). It is conceived by business planners that such a structure can be operated in a highly productive way economically and hence there is a tendency among hospital administrators to yield to such temptations. Other subfields of neurology, such as movement disorders, dementia, or multiple sclerosis, are also possible candidates for a spin-off from the core discipline. There are arguments for and against such a subdivision of neurology. First of all, specialization has been and is a key organizational requirement for achieving progress in research and care. For example, the huge advances made in the treatment of neurological diseases would never have been possible if neurology itself had not broken off from internal medicine and psychiatry. Only after this separation, it became possible to establish facilities precisely aligned along the needs of those physicians seeking to treat patients with neurological diseases. Whether or not such progress can be continued through further subdivision is not clear at the moment. Some university hospitals already divided neurology into subfields of specialization. For example, the University Hospital of Tübingen in Germany has divided neurology into four departments (epileptology, neurodegenerative disorders, neurovascular diseases, and cognitive neurology), and the German Council of Science and Humanities has judged the result to be positive. ¹ However, it should also be pointed out that the hospital in Tübingen receives substantial funding from the Hertie Foundation, which means this model is not representative of university hospitals. In other words, a further subdivision of neurology is unlikely to occur, given the current structures for financing research and teaching at most university hospitals in Europe. At the same time, university hospitals account for only a small portion of neurological care and treatment, at least in German-speaking countries, although the quality of treatment and care is highest at such institutions.

In view of the conditions for basic and advanced neurological treatment, it is understood that a subdivision into organizationally independent subfields of neurology does not seem optimal or even counterproductive, because broad-based general knowledge of neurology is an absolute necessity to maintain the current quality of care in this area. The complex differential diagnosis and therapy requires such broad skills and to achieve all these skills, neurology must remain within one organizational structure. A broad knowledge of all neurological diseases are necessary to make smart and efficient decisions.

Internal medicine has already undergone such a separation into different independent subspecialty, the results of which are obvious. Such developments evidently produce winners and losers, and this becomes very clear when one examines the medical advances made. For example, cardiology has made the most progress and has been able to achieve successes year after year with new interventional procedures, new anticoagulation treatments, and new approaches to treating cardiac insufficiency with medications. Conversely, other subspecializations of internal medicine have become somewhat neglected in academic research and in health-care policy, and rare diseases have frequently been left out by such developments. There is also a lack of “general internists” at many hospitals and this is exactly what is needed for clinical care. One of the most charming aspects of neurology is that all diseases can still be competently managed by the neurologist.

Another argument against the division into subspecializations was from the fact that the subfields of neurology extensively benefit from one another, and the advantages of exchange between subspecialized neurologists within one unit are seen in daily practice at numerous hospitals. There is a common trunk in neurological education. Without broad-based fundamental neurological knowledge, clinical research in subdisciplines will always be very limited. Discussions regarding a possible restructuring of stroke treatment and care systems are currently under way in various European countries. A model that has been discussed in various medical societies would involve a training program for strokologists that would include both some neurological treatment aspects and some expertise in neuroradiology (e.g. thrombectomy and other neuroradiology procedures). Such a training program would make strokologists to replace neuroradiology and the further development of the broad field of neuroradiology would become at risk. Conversely, the general neurological expertise of such trained stroke specialists would presumably be significantly reduced and the specialization itself would be more limited in terms of clinical depth.

Ultimately, all of these would a have a detrimental effect on the professional expertise that drives scientific progress and it would also reduce the level of broad-based specialized knowledge in the areas of neurology and neuroradiology. Interdisciplinary cooperation requires specialist knowledge in both fields at the highest level and for a wide range of problems, and this knowledge must be maintained. Strong disciplines and cooperating partners are also key drivers of scientific progress and successful clinical care and treatment. It is quite possible that while active interventional neurology might benefit, less lucrative research activities and the treatment of certain disorders might be neglected. This would jeopardise a key advantage of having the two separated disciplines neurology and neuroradiology as drivers of their specialized fields as a whole.

Another aspect to be considered is the current discussion about what is being characterized as “contested fields” in neurology. ² This term refers to areas in which neurological involvement is insufficient (pain therapy or sleep medicine) or where other disciplines exert major influence, and in some cases incorporating their interests into the actual care and treatment process (neurointensive care and emergency unit treatment, geriatric medicine, and palliative medical care). Basically, an important element is being alluded to here. Despite the number of neurology specialists and neurologists in training is skyrocketing, capacities are often not sufficient to allow other areas to be more extensively addressed along with the core areas of the discipline. The discipline will thus have to be expanded further.

Cooperation between neurology and neurosurgery is the subject of much less controversy. Numerous fields such as neurooncology or deep brain stimulation would be impossible without such close cooperation. A clear division of tasks between the partners is also crucial here. The common challenges are new ultrasound-based lesional neurosurgery and its application in functional neurosurgery and oncology.

The role of European Academy of Neurology

The European Academy of Neurology (EAN) as a scientific society can provide the current standards of care. We are working hard on defining these standards through our guideline program, thereby defining what is necessary for modern patient care and for research. Within this structure it is also possible to learn from the different approaches in different countries and benefit from “best practice” experiences. In Europe, EAN is playing a major role in harmonizing the content of neurological education. EAN can and will not play any role beyond emphasizing what is necessary for the patients with neurological disease. Health-care structures influence to a great deal the development of our discipline in the different countries, but here the decision makers are the governing bodies and the neurologists within each country. EAN will only take the position of an advisory body through its different committees and panels.

Conclusion

Neurology as a clinical discipline has gained strength over the last 50 years through its focus on clinical research. This has facilitated the increasing therapeutic role of neurology for health care of a population. This is a lesson for us, since in the future we can expect a decline in the available resources for health care, rather than increase. Resources will go into those fields of medicine that provide the most significant and sustainable improvement for the population. This call for ongoing and strengthened research is our opportunity for the future.