COVID-19 has changed neurology

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AJMC Authors: Telemedicine 'Ideal' For Dealing With COVID-19 ...

I generally don’t like to rock the boat on anything, this applies to what I wear, eat, the people I co-locate with and work. It should therefore come as no surprise that my response to our changing practice if anything luke warm. I understand fully (more so than you may credit) the impact that COVID-19 has had on hospitals, and continues to do so. But, in my opinion this should be temporary and not the way forward in healthcare delivery henceforth.

Being a doctor is not something to be practiced at a distance, and as doctors we are at our trained best in the thick of it. So don’t be surprised if my eyes gloss over as I try to listen patiently to the next person expouting how amazing telehealth, and virtual consultations are. In my opinion you’re more likely to learn of the postman’s name (this has truly happened to me) than what is wrong with the person before you with remote consultations.

Hence, I read with some interest the results of this consensus survey from group of Spanish neurologists on how they think the neurology practice will change over the next five years. Agreement is not easy to come by and you may not agree with some of the more popular responses.

“Despite consensus about these statements, the degree of inter-rater agreement was low”.

Table: conclusions drawn from statements for which there was
strong or moderate consensus

Abstract

Review article DOI: 10.1016/j.nrleng.2020.04.010

Will neurological care change over the next 5 years due to the COVID-19 pandemic? Key informant consensus survey

J. Matías-Guiu,, J.A. Matias-Guiu, J. Alvarez-Sabin, J. Ramon Ara, J. Arenillas, I. Casado-Naranjo, M. Castellanos, M.D. Jimenez-Hernandez, J.M. Lainez-Andres, E. Moral, A. Morales, A. Rodriguez-Antigüedad, T. Segura, P. Serrano-Castro, E. Diez-Tejedor

Introduction

The COVID-19 pandemic will give rise to long-term changes in neurological care, which are not easily predictable.

Material and methods

A key informant survey was used to enquire about the changes expected in the specialty over the next 5 years. The survey was completed by heads of neurology departments with broad knowledge of the situation, having been active during the pandemic.

Results

Despite a low level of consensus between participants, there was strong (85%) and moderate consensus (70%) about certain subjects, mainly the increase in precautions to be taken, the use of telemedicine and teleconsultations, the reduction of care provided in in-person consultations to avoid the presence of large numbers of people in waiting rooms, the development of remote training solutions, and the changes in monitoring visits during clinical trials. There was consensus that there would be no changes to the indication of complementary testing or neurological examination.

Conclusion

The key informant survey identified the foreseeable changes in neurological care after the pandemic.

About the author

Neuro Doc Gnanapavan

16 comments

  • Whether we like or not. Telemedicine is here to stay. I would disagree that it’s incompatible with diagnostics in all branches of neurology. I think we’re ok in epilepsy actually. It’s not a case of “I’m alright Jack”. Telemedicine has a place in the post COVID legacy, just think it should be alongside face to face care not replacing it….

  • Hi NEURO DOC GNANAPAVAN,

    It’s a shame they have used percentages to measure agreement.. There are better measures of interrater agreement for multiple raters when there is always agreement due to chance that you want to avoid. I see that they used the CRAN package in R studio, but it’s no clear what they actually calculated overall? What is strong and what is moderate? Pre-set cut off points by the research team? That is the question.

    Best wishes,

    F

    • So in their Primary methods they used SPSS, agreement scores were from 1-5. A qualitative assessment was made: 1) strong consensus, for statements for which one of 2 consecutive scores was given by at least 85% of respondents (12 experts), 2) moderate consensus, when one of 2 consecutive scores was given by at least 71% respondents (10 experts).
      They also analysed degree of consensus between informants for the survey as a whole and for each section using the “rel” package in R – although you’re right they don’t provide further detail on this.

  • Some things I welcome. I need to avoid all viruses due to my progressive MS and I have not appreciated having to sit in stuffy waiting rooms with other waiting patients well over my appointment time. And I never thought hand shaking was a good idea. The last neurologist I saw, prior to COVID-19, was totally dismissive of my efforts to avoid viral infections. She might have altered her attitude a bit by now.

    • It’s interesting you mention hand shaking… I have always thought it is good manners to hand shake with your consultant, at the first appointment at least, as it does build a rapport. I always thought a consultant that doesn’t offer a hand shake, seems a bit distant/doesn’t want to make an effort/ is concerned about catching something.

      But I changed my mind on this, about a year before the Covid-19 outbreak. I would rather not shake hands now.

  • The coding tariff for a telephone appointment is lower, than the coding used for a face-to-face appointment. As a consequence, hospital income will be effected and this financial pressure may be a motivator for return to face-to-face appointments? The previous assumption was that telephone appointments equated to less work hence the lower tariff; although it is possible that management have found a loop-hole in this during the pandemic.

    I think Doctors to be relatively assertive about the limitations of telephone appointments. I will be massively disappointed if the pubs reopen and I am still unable to access any sort of normal healthcare.

      • Yes, for the doctor some 10 minute f2f consultations can take 15 minutes on the phone or AccuRx. For the patient 1 day can take 15 minutes. Isn’t good medicine supposed to be patient centred rather than doctor centric?

    • Hospital staffing is taking a hit as a consequence of telemedicine. There is no need for receptionists or nursing staff to take vitals. Also, doctors in training need to rotate through clinics.

        • No, this is going to be a challenge which must be overcome in order for medicine to keep up with the world. Book vendors who thought going on line was unnecessary have now been superseded by Amazon and shut. The next generation of neurologists will need to learn a new skillset. The MRCGP clinical exam has contained a telephone station for over a decade. I wonder if the FRCP(neuro) exam has done the same?

  • The sad thing is that for the very worst neurological diseases (MND, Huntington’s, advanced Parkinson’s, Progressive MS, dementias) seeing a neurologist in person or via video makes no difference to the patient’s outcome. Using technology to see patients remotely, for example, gives a false sense of security that neurology is keeping pace with technological advances. In reality, the knowledge of the brain and it’s diseases is still in the dark ages despite what the research papers and conferences might suggest.

  • Having made the (great) effort to physically attend neurology appointments I have frequently left having received limited or no examination. The most thorough neurological examination I’ve ever experienced was several years ago while attending a diving medical examiner course by a non-neurologist. Telemedicine would have sufficed for all but 2 of my neurology appointments over the last 5 years. About a year ago, I convinced my MS nurse specialist and Queen Square neurologist to phone me rather than demand an outpatient attendance. This means I can go to work as usual and have my appointment during a break rather than losing a day of paid employment to travel. If CoVID-19 affords this benefit to every pwMS, then it will be a good thing. Before every f2f appointment doctors should ask themselves, “do I need to physically see this person?” and “what will it add to my understanding?”.

    • Think this is the right attitude and approach. Needs to be shared decision making not just on investigation and treatment but also with appointment modality! The future is upon us…

    • But the neurologist does watch how a patient enters the room, the walking gait, watches if they have fasciculations, spasms, tremors and that’s before a neurological examination is done.

      • Yes, a good neurologist will do this, but it’s much harder to assess all of these things when you have been self propelling in a wheelchair for the last few years. Also, I’ve found asking somebody to stand and walk across the room on AccuRx to be very helpful and it’s no more time consuming.

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