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INTRODUCTION

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All subspecialties are a product of their history, and Neurology and Internal Medicine are no exceptions. Classical Neurology evolved in Europe on the bedrock of clinical semiology and postmortem neuropathological correlation in places such as Pitié-Salpêtrière and Queen Square hospitals. The pioneers of Clinical Neurology in the United States and indeed other countries looked to these beginnings when they set up departments and training programs during the last century. From their point of view, a study of the brain and its meager relevant therapeutics had little in common with the wider Internal Medicine. Knowledge of Internal Medicine was not as crucial to the training of a neurologist at that time as neuropathology and repeated exposure to the intricacies of neurological examination. It is in this environment that the neurological method evolved in the image of neuropathological correlation studies: a lesion is localized by detailed neurological examination, differential diagnoses are generated, and individual hypotheses are tested. Apart from the intellectual elegance of this approach, any delay caused by the meticulousness and deliberate pace of progress hardly mattered. There were few time-sensitive therapies to be offered to the neurological patient, and for a long time, Neurology was seen as the very definition of therapeutic nihilism by other subspecialties.1,2,3

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These beginnings had predictable effects on the development of Neurology as a profession, particularly in North America. Most Neurology departments separated from Internal Medicine and, in some cases, Psychiatry to form independent entities with a separate curriculum. Internal Medicine training was relegated to a single year in the immediate postgraduate year of training for neurologists and much of the neurology content was removed or simplified in Internal Medicine training. Most of the practice of neurology was conducted either in the ambulatory setting or in the setting of hospital consultation to the primary care teams. This created a unique gap in American health care provision where the general physicians might not have the required expertise to manage neurological disease, and the neurologists, untrained in the treatment of multisystem disease, might in advertently neglect the general care of their inpatients.

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While Neurology was predominantly a diagnostic and consultative specialty, these deficiencies were less palpable. But since effective therapies are now become available for acute neurological conditions, it is no longer adequate for the neurologists to treat their patients in consultation only or to only accept less critically ill patients into their service. The neurology inpatients now often suffer from multiple serious systemic conditions that complicate their care in the hand of the general neurologist. Recent changes to reimbursements and hospital recruitment policies have taken note of these changes, so that neurohospitalist medicine is one of the fastest growing areas within neurology. Additionally, there is an increased demand for neurological knowledge, for management of strokes and seizures in community settings where access to neurological consultation is either difficult or untimely. Hospitalists, trained as internists, critical care physicians, or ...

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