What will neurology look like post pandemic?


Jose Angel Soria-Lopez, MD, has an unusually wide perspective on how neurology patients are responding to the coronavirus pandemic. He treats patients at two San Diego–area clinics, one in a poor neighborhood near the Mexican border and another in an upscale city about 65 miles to the north. While the patient populations are quite different, he’s noticed they’ve share one thing in common lately: An unusually intense focus on their personal health.

Dr. Jose A. Soria-Lopez, a neurologist with offices in Chula Vista and Temecula, Calif.

Dr. Jose A. Soria-Lopez

“All of a sudden people are really thinking about their health,” Dr. Soria-Lopez said. “There’s a sense that their health is even more important than it used to be.”

But patients are divided on how exactly they want their health care delivered. Some are embracing the convenience of telemedicine, while others want to be seen in person no matter what. Moving forward beyond the pandemic, Dr. Soria-Lopez expects the upswing of interest in health will persist. And he predicts two kinds of neurological care will emerge: “One based on ongoing relationships that rely on physical encounters as a culture, and a second kind of neurology service where other patients – perhaps the younger ones – will switch to convenient, online follow-ups.”

Telemedicine will endure post pandemic

While some don’t foresee such a big divide between in-person and online visits, several of Dr. Soria-Lopez’s colleagues from around the country agreed in interviews that telemedicine will continue to play a larger role in neurology when the pandemic ends. One neurologist, however, cautioned that telemedicine can worsen disparities in care. And he raised the alarm about another aspect of the pandemic that isn’t going to lift when it’s over: The rise in neurological disorders linked to infection with COVID-19.

Before the pandemic, neurologists said, they rarely if ever treated patients via telemedicine outside of specific settings such as remote stroke care. Over the past year, the use of telemedicine has dramatically increased in neurology as in medicine as a whole. But the levels of adoption differ markedly. Neurologist Andrew N. Wilner, MD, of University of Tennessee Health Science Center, said he has used telemedicine to see a single patient so far. But Johns Hopkins Center for Sleep neurologist Charlene Gamaldo, MD, said her clinic converted to 100% remote visits in March 2020 and remains at that level.

“Where [the rate of telemedicine use] will land will be based on insurance reimbursement and license reciprocation, so it is difficult to predict,” she said. “I imagine that sleep will likely remain a hybrid model if current allowances remain.”

Some patients, especially the older ones, resisted the telemedicine visits at first, Dr. Gamaldo said, and family members had to step in to help. Now, she said, patients prefer them because of their convenience.

Some neurological conditions, of course, can’t be easily evaluated via online video. Dr. Soria-Lopez, who has offices in Chula Vista and Temecula, Calif., prefers that a patient appear in person at first. “It really takes 1-2 physical encounters for there to be some level of trust,” he said, adding that “it’s hard to do the first few visits online unless it’s a very straightforward case with one or two symptoms.”

Neurologists have found that telemedicine is especially useful for med-check visits. Mitzi Joi Williams, MD, an Atlanta-area neurologist and multiple sclerosis specialist, said some patients previously drove 2-3 hours for these visits, which can easily be conducted online. Dr. Williams added that online software can allow her to show MRIs to patients remotely. She simply shares her screen and talks about what the images show.

Mitzi Joi Williams, MD, a board-certified neurologist in Smyrna, Georgia.

Dr. Mitzi Joi Williams

Physical exams are more difficult online, of course, she said: “You can’t see nuances.” And it can be difficult to not have family members in the room to assist with the patient’s history. But some have joined via conference call and that’s been helpful, she said.

Neurologist Rhonda Voskuhl, MD, of the Brain Research Institute at the University of California, Los Angeles, whose clinic has gone to all-telemedicine visits, said telemedicine will make a huge difference for patients who live in remote areas or have mobility problems. In some cases, patients will actually be able to see their doctors more often, she said.

Rhonda Voskuhl, MD, of the Brain Research Institute at the University of California, Los Angeles.

Dr. Rhonda Voskuhl

But she cautioned that it can be challenging to evaluate patients who are having difficulties with walking and sensation, although neurologists could try workarounds such as asking a patient to touch something cold. “We can do some things with coordination like watch patients walk, but walking motor strength is hard to check [via video],” she said. “The best thing to evaluate is cognition. You can talk to them and get a lot of it by asking questions.”

Carlos A. Pérez, MD, a neurologist at the University of Texas Health Science Center at Houston, noted that virtual visits can make it difficult to conduct comprehensive eye evaluations and examine vestibular and neuromuscular components such as weakness. “In multiple sclerosis patients, for example, diagnosing an MS relapse can be particularly difficult, especially when the patients present with mostly visual or sensory problems,” he said.

Carlos A. Pérez, MD, of the University of Texas Health Science Center at Houston.

Dr. Carlos A. Pérez

While he’s a fan of telemedicine overall, Dr. Pérez cautioned that low-income patients may lack computers and access to the Internet. “Access to resources in general seems to vary quite significantly,” he said. “Some patients use their cellphones for virtual visits, and that makes it extremely hard to examine them.”

Neurologist Amit Bar-Or, MD, of the University of Pennsylvania, Philadelphia, noted that in some cases, creativity can make a big difference in helping telemedicine visits to run smoothly. “In examining the cranial nerves, for example, you can get a lot of information. You need to have the person position the camera properly and get close to the camera so you can look at eye movements and facial symmetry.”

Still, he said, “if a patient wants to be seen in person, we should never deny them.”

As for other changes that will linger after the pandemic, San Diego–area neurologist Dr. Soria-Lopez said he expects that waiting rooms will continue to be less populated as patients wait elsewhere to avoid the spread of germs. He predicts there will be more use of “virtual waiting rooms” that allow patients to fill out paperwork remotely and get alerts when medical professionals are ready to see them.

Neurological sequelae from COVID-19

Dr. Pérez, the Houston neurologist, said his colleagues should expect another aspect of the pandemic to persist: an influx of patients with neurological sequelae from COVID-19. As he noted in a 2020 report in Neurology Clinical Practice, coronaviruses have been linked to numerous neurological complications during and after the infectious period. “I have seen a few cases of Guillain-Barré and even postinfectious encephalitis in the clinic [linked to COVID-19],” he said. “Neurologists in general should be aware of the risk for chronic, postinfectious neurologic complications from prior COVID-19 infection.”

And, he said, it’s reasonable for neurologists to add a question to patient histories. It’s a simple yet powerful query: Have you had COVID-19?

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