Acute Diagnostic Neurology: Challenges and Opportunities

Neurologic emergency care is a well-established subspecialty practice area within emergency medicine (EM) and an acknowledged focus for subspecialist neurologists in neurocritical care and stroke. Much of the emphasis in these subspecialties has been on emergent therapeutics in patients with obvious neurologic illness. Less emphasis has generally been placed on the urgent diagnosis of imminently dangerous underlying illnesses in patients presenting with common neurologic complaints. In this commentary, we distinguish “EM neurocritical care” from “acute diagnostic neurology,” highlighting the major importance of the latter in current EM practice. We discuss challenges and opportunities for diagnostic clinical practice and research at the interface between EM and neurology. We define acute diagnostic neurology as the medical discipline concerned with the initial assessment, diagnosis, management, and referral of patients presenting with new neurologic symptoms that are not obviously due to serious, life-threatening neurologic diseases … but might be. These patients typically arrive with nonspecific complaints such as headache, dizziness, back pain, numbness, or vague neurologic symptoms that have already resolved and are most often due to nonlethal conditions (e.g., migraine, vestibular neuritis, musculoskeletal strain, diabetic neuropathy). On occasion, however, these benign disorders are mimicked by early presentations of acute, dangerous medical or neurologic illnesses that, left untreated, may progress rapidly toward permanent disability or death within hours, days, or weeks. This differs conceptually (and practically) from patients with obvious, dangerous neurologic illnesses that declare themselves as such from the outset, where the focus is primarily on emergent management rather than urgent diagnosis (Table 1). The dominant focus in “neurologic emergencies” training, clinical practice, and research has been on EM neurocritical care. This includes protocols and pathways for treatment of subarachnoid or intracerebral hemorrhage, major ischemic stroke, spinal cord trauma, acute neuromuscular respiratory paralysis, and status epilepticus. There is never a question of whether such patients might simply be “the worried well.” These patients are obviously sick with decreased arousal, major motor deficits, or frank convulsions. The medical expertise required is principally therapeutic, and action must be sure and swift to achieve the best possible patient outcomes. Although hands-on training for EM residents is typically limited,1 this is a domain space and skill set comfortable and familiar to most neurology-focused emergency physicians (EPs), as well as neurologists who practice neurocritical care medicine. By contrast, acute diagnostic neurology emphasizes early recognition of “subtle yet dangerous” (i.e., not so obvious) presentations in which patients do not yet look sick, but may soon decompensate. This requires differentiation of occasional dangerous cases from the more common benign disorders. The medical expertise required is principally diagnostic, and immediate action and rapid decision-making must typically be deferred in favor of careful scrutiny for subtle clues that reveal the true nature of disease. On occasion, minute details from patient history or bedside neurologic examination are the only indicators of a dangerous underlying disorder,2 even when sophisticated neuroimaging or other tests are falsely normal.3 Probabilistic, Bayesian reasoning is paramount.4 This is a skill set less commonly encountered among EPs or neurocritical care neurologists. In fact, these are skills that are rarely even taught didactically,5 let alone through clinical practice. It is reasonable to ask whether there is really a problem here. This, of course, is why there are neurology consultants. They often take extra time to arrive and fully assess the patient, ordering numerous tests and increasing patient length of stay, but surely they identify the correct diagnosis most of the time? It is unknown how often consultant diagnoses are in error or how often delays in care adversely affect patients, but, for better or worse, most ED patients are never seen by neurologists―even among those with validated strokes, fewer than 10% involve ED neurology consultations in community practice.6 Recent studies suggest that misdiagnosis rates with neurologic disorders such as stroke may be higher than previously imagined, particularly among patients with what otherwise might appear to be benign presentations of common symptoms such as dizziness or headache.7 Furthermore, it is increasingly recognized that, in addition to the harms associated with missed diagnosis, the health care costs of diagnostic evaluation in search of dangerous causes are tremendous: for dizziness alone, of the roughly $9 billion health care dollars spent per year in the United States, an estimated $1 billion per year is wasted on unnecessary neuroimaging and admissions.8 EPs acknowledge that diagnosis of common neurologic presentations with potentially occult dangerous causes are ones where gaps need to be filled, and help in the form of decision rules or decision support would be welcomed.9-11 As alluded to above, there is some evidence that EM training for neurologic problems is suboptimal1 and that current diagnostic performance has room for improvement,12 particularly as it relates to bedside assessments by history and physical examination.12-14 Training gaps certainly cannot help, but we surmise that there may be additional sociocultural factors that contribute to the problem. There are important differences in temperament between EPs, who tend to be high on novelty-seeking and low on harm avoidance behaviors15 and neurologists who tend toward the opposite end of this spectrum.16 There are also differences in goals of care and discipline-based role functioning. EPs are, on average, more interested in reaching specific management milestones (illness severity triage, emergent treatment, rapid disposition) in acute care, while neurologists, on average, are more interested in accurate localization, etiologic diagnosis, and carefully considered, mechanism-based interventions. Time management and patient flow are important to all physicians in the modern era, but the scale on which these issues resonate is different in EM (where brief assessments are the requirement) and neurology (where detailed, lengthy exams are the norm). While some EM/neurology relationships are collegial and collaborative, others seem to demonstrate a frank antipathy. EPs often rail against neurologists for lengthy evaluations that disrupt flow and substantially increase length of stay. Neurologists, in turn, often express disdain for lack of neurologic knowledge or skill among EPs or being consulted frequently for benign disorders or “nonneurologic” problems. In the end, both positions reflect a lack of effective communication, understanding, and empathy for demands placed on the other group. The result is often limited cross-training between EM and neurology, relatively poor teamwork in care delivery, and few cross-disciplinary collaborative projects or research studies. These cultures may secondarily become entrenched and self-fulfilling. In EM, lack of training may beget lack of interest in “confusing” or “insoluble” diagnostic neurologic problems. Subtle exam findings favored by neurologists2 may be dismissed in EM as “inconsequential minutia,” rather than “minutia that matters.” In neurology, disinterest in “nonneuro” cases and a sense that EPs do not know or care enough about neurologic problems may cause individuals to shy away from tackling acute diagnostic neurology. These culturally sanctioned positions are further entrenched by extrinsic factors, including pressure on ED physicians to decrease length of stay, absence of a financially viable clinical role for a dedicated ED-based neurology consult attending, and lack of role models. Among older generations of ED physicians, the politics of striving to establishing a new medical discipline (1970s–1990s) may still foster a degree of “hyperindependence” from other specialties,17, 18 including neurology. The changing landscape of U.S. health care presents both challenges and opportunities for acute diagnostic neurology: Together these factors will likely drive important innovations in care delivery for patients presenting common, acute neurologic symptoms where diagnostic approaches are paramount. Critical to this process will be development and dissemination of clinical decision tools (e.g., decision rules, decision support systems, devices) to identify patients at high risk of serious underlying neurologic illness. Ideally these decision tools will guide clinical decisions related to advanced diagnostic test use (e.g., magnetic resonance imaging), reducing both underuse and overuse. Cost-consciousness and an emphasis on evidence-based diagnosis will be critical, as it is neither practical nor societally acceptable to solve the problem of missed or delayed diagnosis with indiscriminate testing.8 We suggest considering steps that might help advance this important, growing subspecialty: Acute diagnostic neurology is an important subspecialty within the field of neurologic emergencies. It deserves special attention because it is underserved in clinical care, education, and research. Millions of patients each year present to U.S. EDs with common neurologic symptoms such as dizziness, vertigo, headaches, and back pain. Billions of dollars are spent annually on care for these patients, much of it focused on intensive diagnostic pursuit of uncommon, yet dangerous neurologic causes. Despite this, misdiagnoses may be more frequent than previously imagined, resulting in harm to patients. Imminent changes in health care financing and delivery in the United States will increase the relevance of efficient, accurate diagnosis for these patients. Historical and sociocultural barriers between EM and neurology may be perpetuating a relative dearth of cross-disciplinary education, clinical communication, teamwork, and research collaboration. More effective partnerships between EM and neurology departments could help facilitate future advances in clinical care, education, and research for acute diagnostic neurology.

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