Neurology! Adieau? (Part 1)
Prof. Dr. Szirmai Imre
Department of Neurology
Balassa u 6
The neurological practice suffered considerable changes during the last twenty
years. The recent therapeutic methods and the acceptance of the ideology of evidence
based medicine, which is based on confidence in statistics, changed the reasoning of the
neurologists. Therapy protocols intrude into the field of individual medicine, and
doctors accept treatment schemes to alleviate responsibility of their decisions. In
contrast with this, recent achievements in pharmacogenetics emphasize the importance
of individual drug therapies. The protocol of intravenous cerebral thrombolysis does not
require defining the origin of cerebral ischemia in the acute stage, therefore, this
procedure can be regarded as human experiment. Following the strict protocol
thrombolysis might be indicated only in 1-8% of patients with cerebral ischemia.
According to the Cohrane database more trials are needed to clarify which patients are
most likely to benefit from treatment. Because of the change in therapeutic principles
transient ischemic attack has been newly defined as „acute neurovascular syndrome”.
Multiplication of neurological subspecialties has been facilitated by the development of
diagnostic tools and the discovery of effective new drugs. The specialization led to
narrowing of interest and competency of clinicians. Several new neurological scientific
societies were founded for the representation of specific disorders. In Hungary, between
1993 and 2000 nine scientific societies were grounded within the field of clinical
neurology. These societies should be thankful to the pharmaceutical industries for their
existence. In some European countries in 2007 only three neurological subspecialties
were accepted, which are neurophysiology, neuro-rehabilitation and child-neurology.
Neuro-radiology is in the hands of general radiologists, the specialization is not granted
for neurologists. Because of the subspecialization the general professionalism of
neurologists has diminished. Among young neurologists the propedeutic skills suffered
most seriously. Subspecialisation of teachers also interferes with the practice oriented
teaching of medical students and residents.
Contents of the part1: Summary – 1. Who needs hospitalist neurologists? 2. The
evidence based ideology. 3. Thrombolysis near sighted. 4. Risk of therapeutic
experiments. 5. If is it doubtful change the name! 6. The specialization.
It's not what you know, it's how you think about what you know.
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Neurology! Adieau? Part 2.
Teaching of neurologists is indisposed worldwide. University tutors are engaged
in teaching, research and patient-care. This triple challenge is very demanding, and
results in permanent insecurity of University employees. To compensate for the
insufficient clinical training, some institutes in the USA employ academic staff
members exclusively for teaching. The formation of new subspecialties hinders the
education and training of general neurologists. At the present four generations of
medical doctors are working together in the hospitals. The two older generations
educate the younger neurologists who have been brought up in the world of limitless
network of sterile information. Therefore their manual skills at the bedside and
knowledge regarding emergency treatment are deficient. Demographics of medical
doctors changed drastically. Twice as many women are working in neurology and
psychiatry than men. Integrity of neurology is threatened by: (1) Separation of the
cerebro-vascular diseases from general neurology. Development of “stroke units” was
facilitated by the better reimbursement for treatment and the interest of the
pharmaceutical companies. The healthcare politics assisted to split the neurology into
two parts. The independent status of „stroke departments” will reduce the rest of clinical
neurology to outpatient service. (2) The main argumentation to segregate the rare
neurological diseases was that their research will provide benefit for the diseases with
high prevalence. This argumentation can rather be considered territorial imperative. The
separation of rare diseases interferes with the teaching of differential diagnostics during
The traditional pragmatic neurology can not be retrieved. The faculty of
neurology could retain its integrity because of the improvement of diagnostic methods
and the more and more effective drugs. Nevertheless, even the progression of
neurological sciences induces dissociation of clinical neurology. Neurology shall suffer
fragmentation if the professional authorities fail to control the separation of
subspecialties, if teaching of future neurologists, including practical knowledge and
skills of diagnostic decision making, is not supported.
Content of the Part 2.: 1. Change of mentality of neurologists. 2.
Qualification of neurologists a) Challenges of medical faculties b) Specialization
is an obstacle in the training of general neurology. 3. Medical generations and
choosing specialization in neurology. 4. Gathering rare diseases. 5. Splitting the
neurology in two. 6. “Scientific” clinical researches.
Truth exists, only falsehood has to be invented
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