Neurology in the Twenty‐First Century

“Prediction is very difficult, especially about the future.” - Niels Bohr. The fact that basic neuroscience and clinical neurology have advanced rapidly in the past few decades is now a cliché. What is also true is that few people could have predicted the exact nature of the advancements. Neurology has always been a highly intellectual discipline requiring long years of training that have traditionally focused on disease localization and diagnostic acumen. Neurology has experienced significant advancements in technology and therapeutics in the 21st century.1-4 During this time, paradigm changes have also occurred in healthcare delivery and the organization of healthcare systems.5 These changes are exciting but also overwhelming and highly challenging. Since neurological diseases are common across the lifespan and increasingly prevalent in an aging population, an important question arises: “What skills are necessary to be a neurologist in the twenty-first century?” and “How can we develop preventive strategies?”. We will offer a few suggestions based on what has occurred. The foundational requirement for a neurologist is a comprehensive and robust educational background. General training in medicine and thorough training in basic neuroscience and clinical neurology remain the cornerstones of professional development.6 A recent survey of chairs of academic neurology departments by the Association of University Professors of Neurology indicated that mastery of traditional clinical skills should remain an essential requirement for clinical neurologists.7 While the history and clinical examinations are necessary components of patient care, they alone are insufficient. Communication skills are critical in all aspects of care. Learning how to communicate news about complicated diagnoses empathetically and having end-of-life discussions with patients and their families require special skills that are imperative to learn. Neurologists must also understand and be comfortable with ancillary technologies that refine and sometimes supersede clinical diagnosis. Likewise, they must have a broad understanding and usefulness of the many new and evolving therapeutic modalities for neurological diseases. Because of the difficulties in learning all these skills and the advancements in diagnosis and therapy, 90% of neurologists are now pursuing additional fellowship subspecialty training.8, 9 The explosion of knowledge in medicine and neuroscience means that there is more to learn than ever before. Since no one can learn and master all the essential facts during formal training, education must focus on teaching people how to learn and how to think critically.6, 10 Many residency programs now offer unique “tracks” to enhance the learning experience and focus on specific career pathways such as “clinician educator”, “research”, “procedures for the generalist”, and “neurohospitalist”.11-13 As “burnout” has become an increasingly prevalent problem, neurologists need to learn strategies for coping with stress, dealing with administrative burdens, leveraging strengths, and balancing work–rest so that they can thrive throughout their entire professional career. Neurologists must be proficient in understanding and utilizing advanced technologies.10, 14-16 Familiarity with diagnostic tools such as traditional neurophysiological tests (electroencephalography, nerve conduction studies/electromyography), magnetic resonance imaging (MRI) and computed tomography (CT) scans is a given. Even these traditional technologies undergo continual advancements and refinements, which require continual learning. In addition, biomarkers from serum, urine, cerebrospinal fluid, and skin biopsies may soon allow earlier diagnoses and therapeutic interventions. The diagnostic impact of genetic testing and its insights is far from fully realized. Daily, neurologists must be skilled in using electronic health records (EHRs) and telemedicine platforms, which are now a mainstay of health care. And, of course, having knowledge of artificial intelligence (AI) and machine learning applications in diagnosis and treatment is increasingly important.3, 4 Given the rapid trajectory of science, continuous education and familiarity with clinical trial methodology are critical. Clinical trials are the basis for bringing advancements in basic neuroscience into clinical therapies. In 2023, over 1000 clinical trials for nervous system disorders were started just in the United States (ClinicalTrials.gov), and more are expected in the next several years. Not every neurologist wants to be a clinical trialist, but all neurologists must stay updated with the newest research findings and treatment protocols. There is a pressing need for clinical neurologists to receive training in clinical trial methodology.17 As the lines between traditional academic medicine, industry, and community medicine are blurring, neurologists, both inside and outside traditional academic medical centers, can run clinical trials and perform investigator-initiated research. Recruiting and training more neurologists to perform clinical trials is the only way we will continue to make substantial therapeutic advancements. Neurologists must create multidisciplinary consortia from different practice and research settings that will foster participation in research. This has been done in oncology and can be done in neurology. Engaging in research studies not only contributes new knowledge but helps individuals develop critical thinking skills. Brain health and population health are intimately linked with one another. Maintaining optimal brain function across the lifetime requires assessing and modifying many complex and interactive factors. Recognizing the impact of early life brain health (even prenatal) on later aging processes is critical. For example, anticipatory monitoring, treating cardiovascular risk factors, and promoting a healthy lifestyle are essential for preventing stroke and dementia. Screening and treating psychiatric disorders are part of sustaining individual brain health.18 Neurologists are uniquely trained and poised to lead efforts to promote lifelong brain health that leads to healthy aging.19 Current and future neurologists should view themselves as “principal care physicians” for patients with diseases of the brain and learn how to lead teams of health care professionals in this area. Since socioeconomic and environmental factors are determinants of brain health, neurologists need to participate in educational and research projects related to population health management.20 Medical schools and organizations such as the American Neurological Association, Child Neurology Society, American Academy of Neurology, World Federation of Neurology, and World Health Organization support efforts in education, research, and advocacy that focus on healthy aging and population health.19, 21-23 The days of practicing neurology as a solo practitioner are gone. Health care and research are now team efforts. A multidisciplinary approach is essential for comprehensive “state-of-the-art” care, especially for complex diseases affecting multiple systems. Whether caring for patients in clinical settings or performing research, neurologists must work effectively within a team.5 Developing collaborative interpersonal communication skills is an essential part of functioning in a modern clinic or hospital.24 Although these are part of residency training, developing excellent communication and interpersonal abilities should continue as life-long aspirations and requirements. Although delivering personalized care empathetically is one of the hallmarks of a good physician, patients sometimes feel that neurologists do not communicate well or spend sufficient time with them. Unfortunately, the “corporatization” of medicine has created systems that make it difficult to devote enough time to patients. The additional time needed for administrative tasks, such as completing electronic medical records and obtaining prior authorizations, has undoubtedly contributed to the problem. In many ways, neurologists need to return to the basics of good patient care. In addition to comprehensive knowledge and technical skills, good neurologists must possess strong interpersonal skills and emotional intelligence.6, 10, 16 Neurological diseases often have a profound and life-changing impact on patients and their families. Effective communication is essential to build trust and to explain neurological diseases and therapies. Delivering patient-centered care enhances the therapeutic alliance between physicians and patients. It provides better overall quality of care and fosters better patient outcomes. We should all remember that medicine is a “science using discipline” and not a pure science.25 As such, neurology remains an interpretive practice that relies heavily on clinical reasoning and the one-to-one interaction with the patient. Early and often later in the patient's life, that relationship expands to involve the caregivers. We are hopeful that this guiding principle of medicine will never change. This is an exciting time for neurology. Neurologists can diagnose and treat diseases that a few years ago seemed impossible. Comprehensive and continuing education will remain the cornerstones of excellent patient care. Current and future neurologists should remain committed to patient-centered care guided by well-reasoned clinical judgment and the appropriate use of modern technologies and treatments. Multidisciplinary care teams will become more important for patients with complex neurological diseases. Individually and together, we must support education, research, and advocacy efforts focusing on neurological diseases and public health. If neurologists do these things, the outlook for our patients will be bright. We thank members of the AUPN for helpful comments and suggestions. All authors contributed to this manuscript's content, writing, and review. No commercial products or references to specific therapies are made in the manuscript. The authors report no conflicts of interest. https://www.aupn.org.