When a 64-year-old man who had tingling pain in his feet for over 2 years finally decided to see a doctor about his symptoms, he scheduled an appointment with a primary care clinician at the University of Washington Medical Center in Seattle.

The man said his pain had increased substantially over the course of a year and rated his current level an 8 out of 10. The clinician had an idea of what to do next. But rather than just making a referral to a specialist, he sent a brief message with a synopsis of the patient’s symptoms to Ami Cuneo, MD, a neurologist at the same health system.

“Do you recommend an EMG/NCS study, imaging, or other lab workup for peripheral neuropathy or for another cause of his symptoms?” the primary care clinician wrote Cuneo, using an e-consult feature built into their electronic health record system.

Many neurologists might applaud the move. As the number of people living with sleep disorders and conditions like headache increases, some neurologists are calling for more collaborative care with primary care to cut down on referrals amid a national shortage of their workforce.

Without seeing the patient, Cuneo guided her colleague about what questions he should ask next: Did the patient also have lower back pain, any numbness in his groin, was he incontinent? Cuneo recommended a battery of tests to order. From there, the primary care physician was able to handle what could have been a preliminary neurology appointment months later.

“Not only do we get to work as a team with primary care providers, patients can get answers faster,” Cuneo said. Consulting with neurologists “allows the primary care provider to continue to manage the neurological condition and at the same time learn what the next steps would be for this case, which they can reference in future cases.”

Primary care clinicians perform about 40% of neurologic-related visits and provide more office visits for Medicare beneficiaries than neurologists for back pain, sleep disorders, dizziness, and stroke.

In a recent viewpoint in JAMA Neurology, Cuneo and colleagues detailed how e-consultations, collaborative care, continuing education, and more training during residency could help primary care clinicians become more comfortable treating common neurologic conditions. The approach could also help primary care doctors take on initial diagnostic work for more complex issues before referring patients to a neurologist.

“We can start this process so if patients do see our neurology colleagues, they aren’t starting from the beginning,” said Julia Adamian, MD, an internal medicine doctor at NYU Langone in New York City, who uses e-consultations with neurologists in her practice. “The first step is understanding if it’s urgent or if it is something we could manage with workup.”

Sharing Patient Care

e-consults — quick, billable, and virtual — are “one backbone” of the type of collaborative care between neurology and primary care, Cuneo said.

“e-consults are supposed to be a pretty quick question with a pretty quick answer, something with a clear next step,” she said.

A neurologist usually outlines steps the primary care clinician should take, whether it be ordering imaging, blood testing, or prescribing a medication.

A blood test may reveal a vitamin deficiency, such as vitamin B₁₂, which can cause headaches. In these cases, primary care clinicians can prescribe a supplement or injection. In other cases, more extensive tests and a referral to a specialist may be needed.

“More advanced neurological conditions such as Parkinson’s disease, amyotrophic lateral sclerosis, and multiple sclerosis would ideally be comanaged by primary care and a neurologist,” Cuneo said.

Adamian recounted recently caring for a patient at an annual checkup and had recently undergone spinal surgery. He said he was still experiencing a lot of back pain and also had changes in his bowels. Adamian recognized these symptoms as a potential sign of multiple sclerosis. She eventually referred the patient to a neurology clinic but only after consulting with a specialist and ordering an MRI so the test results could be viewed at their first visit.

“It’s easy to give the referral, but it’s much better for the clinicians and for the patients to actually get to that level of curiosity of, ‘let me see what is going on,’ before I initiate that referral,” Adamian said.

In addition to diagnosing headaches, migraines, and peripheral neuropathy, differentiating between normal memory loss and early signs of Alzheimer’s disease is critical for primary care clinicians, said Thomas Vidic, MD, a neurologist at the Elkhart Clinic in Elkhart, Indiana.

Vidic said Alzheimer’s interventions often only work during the early-onset phase of the disease, and “I will often see people too late.”

If primary care physicians are well versed in the differences between the two conditions and can consult a neurologist, patients might receive treatment earlier.

Vidic said primary care clinicians are well equipped to prescribe the first lines of treatments, such triptans or dihydroergotamine for migraine medications. But some insurers pay only for newer, more expensive drugs if a neurologist is the prescriber.

“I am helpful when the usual doesn’t work or when insurance will only pay for some of the newer migraine drugs if a neurologist prescribes them,” he said.

The Art of the e-Consult

e-consultation programs are becoming more common, especially in large healthcare centers.

The University of Colorado’s medical center launched its internal e-consultation program in 2019 to expand access to specialists. Patients typically wait long periods to see specialists — a 2025 study published in Neurology found the median wait time for a neurologist visit was over a month, but 18% of people waited more than 3 months.

“Primary care doctors needed help, but there weren’t enough specialists to meet that demand,” said Samantha Holden, MD, an associate professor of neurology and vice chair of clinical practice in the Department of Neurology at the University of Colorado Anschutz Medical Campus in Aurora, Colorado. “It’s good for those quick questions where you really just need to tag in a friend, when you just need a bit of guidance from a specialist.”

At the health system, primary care clinicians send brief clinical questions with relevant medical history to a neurologist who is open for e-consult requests. Holden said she has received questions about tests to order or diagnoses that should be ruled out.

Neurologists reply with recommendations, including additional questions for the patient, issues to look out for during a neurologic exam, and how to best treat symptoms. Holden said the neurologist should also briefly provide links or summaries of references.

These should be “bite-sized medical education that is less burdensome but that allows the primary provider to continue to manage the neurological condition and at the same time learn about what the next steps would be for a case like this,” Holden said.

The health system also created a portal for rural-based clinicians in Colorado to use the e-consult system.

“We can eliminate this hot potato system of passing patients around and just staying within our siloed system without working together,” Holden said.

Kaitlin Sullivan is a journalist in Colorado covering medicine and the environment.