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Aneurology resident's reflections on an elective in hyderabad.

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TRAINEE’S CORNER
A Neurology Resident’s Reflections on an
Elective in Hyderabad
Josiah B. Ambrose, MD,1 and Demudu Babu, MD, DM2
The Experience
A
s my neurology residency in California was coming
to an end, I had a sinking feeling that there was a
lot more I needed to learn. Over the course of 3 busy
years I had managed hundreds of cases ranging from lifethreatening neurological deterioration to diagnostic quandaries lasting several months. Yet after all this I had been
exposed to a significant, but incomplete, fraction of the
neurological diseases that I had read about in medical
school. Once common illnesses such as neurosyphilis, B12
deficiency, and subacute sclerosing panencephalitis (SSPE)
were frequently discussed on teaching rounds, but were
almost never diagnosed. I knew that this was primarily
due to the success of public health and dietary measures
implemented over the past 50 years in the United States.
Still, these diagnoses are prevalent worldwide and it wasn’t
clear that I could easily diagnose them on my own.
To remedy this I arranged to spend a month at a
University hospital in South India. I planned to join a
group of neurology residents at the Nizam’s Institute of
Medical Sciences (NIMS) in the bustling city of Hyderabad (Fig 1). In doing so I hoped to increase the breadth of
my clinical experience. I looked forward to comparing my
own residency experience with those of my colleagues in
India and gain an appreciation for neurology as it is practiced in a country with a different spectrum of disease.
When I arrived in Hyderabad I was jet-lagged but
too excited to sleep. I immediately joined the residents
and discovered a familiar style of bedside rounding. Senior residents lead the team through the wards and a neurointensive care unit (NICU) while the attendings aggressively peppered the junior residents with questions. I was
comforted to see a well-worn copy of Harrison’s Principles
of Internal Medicine sitting at the resident’s work desk in
the NICU, aggressively highlighted and underlined like
the copy I used in San Francisco.
However, that was where many of the similarities
ended. The Nizam’s Institute Millennium Block Hospital
was partially constructed and designed to see a much
larger volume of patients than I was accustomed to. Each
ward had approximately 15 beds with no partitions in
between. For most of the inpatients at least 1 family
member would keep vigil at the bedside, rolling out a
small sleeping mat between beds and standing with rapt
attention when the neurology team stopped by to discuss
the daily plan. Unlike in American hospitals, patients
almost never presented to the clinic or wards without a
family member in constant attendance. Partly this was to
keep the patients fed (meals were not provided by the
hospital), but additionally there was a palpable sense of
responsibility to family that was always on display.
The neurointensive care unit housed the sickest
patients. A sign designating a strict ‘‘No Shoes’’ policy was
posted at the entrance, with hospital sandals provided to
prevent the spread of dirt and disease. Basic cardiopulmonary monitoring equipment was in place and costly medications such as intravenous immunoglobulin were made available for the prevalent cases of Guillain-Barré syndrome.
Patients with large intracerebral hemorrhages or aneurysmal
bleeds were stabilized, but often required prolonged ICU
stays. This lead to difficult personal and financial decisions
for families who had to determine the extent of the financial
burden they could bear before care would be withdrawn.
Most patient care was paid for by family funds, and team
decisions about diagnostic testing and expensive therapies
frequently took the family’s financial situation into account.
View this article online at wileyonlinelibrary.com. DOI: 10.1002/ana.22412
Received Dec 17, 2010, and in revised form Feb 14, 2011. Accepted for publication Feb 23, 2011.
Address correspondence to Dr Ambrose, 400 Parnassus Ave ACC-8, San Francisco, CA 94143-0138. E-mail: josiah.ambrose@ucsf.edu
From the 1Epilepsy Center, Department of Neurology, University of California, San Francisco, San Francisco, CA; and 2Department of Neurology, Nizam’s
Institute of Medical Sciences, Hyderabad, Andhra Pradesh, India.
C 2011 American Neurological Association
V
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ANNALS
of Neurology
FIGURE 1: Corridor of hospital ward at the Nizam’s Institute
of Medical Sciences (NIMS); Hyderabad, India. [Color figure
can be viewed in the online issue, which is available at
www.annalsofneurology.org.]
Across the street I joined the residents at their outpatient (OP) clinic. Large groups of anxious patients were
crowded outside the clinic door waiting to be called by
the security guard who maintained a tenuous order. The
exam room was shared by two neurologists who worked
across from each other at a large desk. After a patient was
seen, the neurologist would ring a hotel-style bell and the
next patient was then shuttled into the room. Over the
course of a clinic the bell rang almost constantly. I would
see anywhere from 25 to 30 patients with 1 physician and
an additional 25 with the neighboring physician. Admittedly, each clinical encounter was brief. However, this
afforded me an invaluable opportunity to rapidly assess a
large population of patients, most all of whom had profound, objective findings on their neurological exam.
The two patients in the room were generally examined
side-by-side. Often the neighboring patient’s family could listen in on the intimate details of a patient’s history or diagnosis. Initially I felt a sense of discomfort with the free exchange
of ‘‘protected health information.’’ However this privileged
Western sentiment was quickly tempered by an overwhelming
sense of appreciation from the patients. Most all of the
patients had serious medical needs and were grateful for the
care they received. Occasionally when someone received a bad
diagnosis, the neighboring patient would lend a word of
encouragement or sweetly place a hand on their shoulder.
Privacy and confidentiality were forsaken so that a
maximum number of patients could be seen. The result was
a level of efficiency that I had never seen in a medical clinic
before. The physician immediately reviewed the chart and
imaging films that had been brought by the patient. This was
followed by a focused neurological exam. If questions
remained about the diagnosis or treatment, the neurologist
instantaneously received a second opinion from their colleague on the opposite side of the room. If there was a question as to whether the patient’s symptoms were psychogenic
1056
in nature, they were seen by a psychiatrist in an adjacent
room. Then, after seeing an exhausting number of patients,
the neurologist politely listened to brief presentations from
several pharmaceutical company representatives; drug samples were given out and later distributed to patients who
couldn’t afford prescription medications.
I was amazed at the variety of cases that I saw each
morning. Much of my outpatient training in the United
States had been spent in subspecialty clinics where a preselected group of referral patients were evaluated. Overall, the
emphasis on my training had been inpatient care, with
American residency programs looking to broaden outpatient
exposure. In Hyderabad the general neurology clinic saw an
immense array of cases, with adults and children seen simultaneously. As a result my complete knowledge base of neurology, and often internal medicine, was being drawn upon
for each patient. Over the course of the month I developed
my ability to think about cases broadly, and I felt a new confidence as a diagnostician.
Although the residents in Hyderabad had a wealth
of clinical experience, research opportunities were relatively limited. Endless clinical demands left little time for
dedicated research work, and an absence of centralized
medical records made it nearly impossible to perform retrospective chart reviews. Furthermore, there were limitations to online journal access. As a result, the residents I
met in Hyderabad were extremely eager to become
involved in academic research projects, both locally and
through collaboration with institutions internationally.
Comparisons
By spending a month in Hyderabad I was able to see a
staggering variety of neurological disease that would have
FIGURE 2: Brain MRI of patient with neurocysticercosis;
Hyderabad, India. MRI 5 magnetic resonance image. [Color
figure can be viewed in the online issue, which is available
at www.annalsofneurology.org.]
Volume 69, No. 6
Ambrose and Babu: Reflections on an Elective in Hyderabad
taken me several years to encounter in the United States
(if at all). Admittedly, many of the conditions were infectious and endemic to India, such as intracerebral tuberculomas, fulminant neurocysticercosis (Fig 2), Japanese
encephalitis, and subacute sclerosing panencephalitis
(SSPE). Other diagnoses were more specific to the region
of South India, such as Madras motor neuron disease.
Still, most of the interesting neurological diseases I saw
were also present in the United States. However, these diseases are rare and therefore more prevalent in countries with
large populations. During one month in Hyderabad I saw
cases of Takayasu’s arteritis, hereditary sensory and autonomic
neuropathy (HSAN), acute motor axonal neuropathy
(AMAN), Wilson’s disease, hypothalamic hamartoma with
gelastic seizures, Hashimoto’s encephalitis, neurodegeneration
with brain iron accumulation, Creutzfeldt-Jakob disease,
reflex epilepsy with eating, Tolosa-Hunt syndrome, ParryRomberg syndrome, and Friedreich’s ataxia. All of these entities are listed as ‘‘rare diseases’’ by the National Institute of
Health’s Office of Rare Diseases Research (http://rarediseases.info.nih.gov/RareDiseaseList.aspx?PageID¼1), with fewer
than 200,000 cases in the United States.
For the Indian neurology residents this was just another
week on the ward service. They seemed amused at my blatant
enthusiasm for cases they considered relatively mundane. But
for me this was one of the most stimulating months of my
residency. My contribution in return was to offer the Western
perspective on diagnosis and management, or discuss new
therapeutic techniques being researched in California.
In many ways the training experience of residents in
Hyderabad was different than my own (Table 1). None of
the Indian residents were trained to work solely with adults
or children. All were expected to independently perform and
interpret their own electroencephalograms (EEGs), nerve
conduction studies/electromyogram (EMG), and transcranial Dopplers by the time they graduated. During radiology
conference the reading of neuroimaging studies was done
almost exclusively by the neurology resident, with the radiologist only commenting if a mistake or exclusion had been
made. Although the training at NIMS didn’t necessarily represent the experience of all Indian residents, it did reflect a
national emphasis on developing independent, general neurologists with a strong foundation in internal medicine.
I often found myself envious of the extent of their
knowledge and experience. Given the increasing emphasis
of specialization and subspecialization in Western training
programs, it is difficult to gain expertise in all aspects of
neurology. For this reason it has been argued that Western residents may benefit from a return to training
focused on broad-based general neurology care.
By comparing my own residency experience with
those of my Indian colleagues, I realized that my diagnostic
June 2011
and clinical instincts were honed differently than theirs
(Table 2). When I saw a presentation of ‘‘first seizure of life’’
with focal findings on exam I considered the possibility of
the patient having an underlying brain tumor or congenital
lesion. In contrast, residents in Hyderabad immediately saw
this as a likely case of neurocysticercosis or tuberculosis until
proven otherwise. Whereas a stroke in a young woman in
California suggested substance abuse or a neck vessel dissection, in India this presentation was instantly concerning for
venous sinus thrombosis (commonly seen in the setting of
pregnancy and dehydration). I began to see that neurological care is practiced in a very regional way, and that the diagnostic instincts we cultivate are often the result of the
patients we first encountered during our training.
Reflections
When I returned to the United States I felt a change in the
way I viewed my patients and myself. I now had seen a wide
spectrum of neurological disease, and with direct observation there came a level of understanding and confidence
that I couldn’t get from a book. The relevance of this was
clear immediately upon my return to San Francisco. During
my first week back a patient on our neurology ward service
was diagnosed with Wilson’s disease. Although I had learned
about Wilson’s disease at every stage of my training, I had
never actually seen a case of it until the month prior in
Hyderabad. The diagnosis no longer felt exotic or abstract.
Moreover, this patient had recently emigrated from India.
This underscored the increasing frequency with which
American physicians treat patients of South Asian descent.
In Northern California, where South Asian patients make a
up a large percentage of the total patient population, it has
become particularly important to understand the neurological diseases most commonly seen in this group.
Influenced by residents in Hyderabad, I had also
adopted the habit of ordering diagnostic tests and therapeutics more judiciously than before. Although the majority of
medications and testing available in the United States were
present in Hyderabad, their utilization there was more
focused. The enormous patient population constantly
forced the issue of how to best implement resources, with
the practitioner asking ‘‘Why am I ordering this test?’’ ‘‘How
will it affect my management?’’ and ‘‘How will I interpret
the results?’’ Western physicians are trained to think similarly, but tests can often be ordered thoughtlessly, allowing a
checklist approach to dominate over critical thinking.
Another major benefit of my trip was having the opportunity to see fulminant disease. Frequently my patients
in San Francisco exhibited neurological disease at its earliest stages. Seeing advanced illness in India gave me
renewed appreciation for the severity of neurological illness
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ANNALS
of Neurology
TABLE 1: Experiences of North American and Indian Neurology Residents
Aspects of Training
United States
(San Francisco,
Tertiary Referral
Hospital)
India (Hyderabad,
Tertiary Referral
Hospital)
Average number of adult neurology
residents per class
7–9
6–8
Years spent attending medical school
4
4.5 (undergraduate) þ
1 (rotating internship)
Years of clinical internal medicine training
1 (medical intern
training)
3 (including board
certification in
internal medicine)
Years of clinical neurology training
3
3
Population of respective city
808,000
8,900,000
Neurologists per capita (nationally)
1:26,000 (U.S.)
1:3,200,000 (India)
Primary patient languages spoken
English/Spanish/Cantonese
Telugu/Urdu/Hindi
Time spent in outpatient clinic
Minimum 6 months
over 3 years
12–18 months
over 3 years
Average number of patients seen in morning
clinic by a resident (new and follow-ups)
4–8
50–60
Number of hours spent for in-house call
30 (no more than 24
consecutive hours for
clinical duties)
30 (no duty
hour restrictions)
Average number of new admissions/consults
seen during 24 hours of in-house call
6–14
8–15
Average length of stay for
neurology ward patients
2–6 days
4–15 days
Primary means of patient payment
for medical services
Private health insurance,
Medicare/Medical
Out-of-pocket/
company credit
Majority of graduating residents obtaining
subspecialty fellowship training?
Yes
No
Competency in solo practice of
EEG/NCS/EMG at end of residency?
Not required
Required
Dedicated research time during
neurology residency?
Yes
No (however, a research
thesis is required
for graduation)
Governing body of resident education
ACGME
MCI
Required core competencies for
neurology residents?
Yes
Yes
Opportunities for international clinical
experiences integrated into curriculum?
No
No
ACGME ¼ Accreditation Council for Graduate Medical Education; EEG ¼ electroencephalography; EMG ¼ electromyography;
MCI ¼ Medical Council of India; NCS ¼ nerve conduction studies.
in general, as well as an understanding of the urgency for
diagnosis and treatment of diseases that progress rapidly.
Very ill patients had abnormal findings on every portion of
the neurology exam, from cranial nerves to the ever-challenging sensory exam. I compared this to my experience in
1058
San Francisco, where clinic patients would frequently have
subjective complaints, but a normal or unimpressive neurological exam. This often led me to doubt myself and
wonder what findings I was missing. In India I was constantly being reminded that that my neurological exam
Volume 69, No. 6
Ambrose and Babu: Reflections on an Elective in Hyderabad
TABLE 2: Frequent Diagnoses of Common Presentations Seen in North America and India
Clinical Presentation (Adult)
Common Diagnoses by Region (Urban Tertiary Hospital)
San Francisco, CA, United States
Hyderabad, India
First seizure of life
Head trauma, toxin/drug effect
(alcohol, cocaine, medications),
metabolic abnormality, temporal
lobe epilepsy
Granulomas (neurocysticercosis,
tuberculosis), focal cerebral
calcifications, malformations of
cortical development
Headache with fever
(immunocompetent)
Community acquired meningitis
(S. pneumoniae, N. meningitidis),
viral encephalitis, systemic
febrile illness
Cerebral malaria, meningitis
(bacterial, tuberculosis)
Stroke in a young patient
Substance abuse (cocaine/amphetamines),
carotid/vertebral artery dissection,
aneurysmal bleed
Cardioembolic thrombosis,
cerebral venous thrombosis,
hyperhomocysteinemia,
protein S deficiency
Small fiber neuropathy
Type II diabetes, alcohol
abuse, idiopathic
Type II diabetes, leprosy,
paraneoplastic
Acute-subacute onset bilateral
lower extremity weakness
Spinal cord compression (spinal
metastases, trauma, epidural hematoma),
Guillain-Barré syndrome, demyelinating
disease/transverse myelitis
Guillain-Barré, transverse myelitis,
hypokalemia, myositis
had actually evolved into an exquisitely sensitive test that
could detect abnormalities at all stages of illness. The experience of seeing very sick patients gave me clinical perspective and allowed me to interpret the severity and staging of
a patient’s illnesses within a much broader context.
Upon my return to California it was clear that there
was much for residents in Western countries to learn from
hospitals in India and other developing countries. Over the
past 2 years Accreditation Council for Graduate Medical
Education (ACGME) requirements for elective time during
residency training have made it more difficult for American
residents to incorporate international experiences into their
training. This is unfortunate given the value of such experiences and the ease with which they can often be arranged.
In my case, an attending in my local neurology department
who had trained in India helped arrange my trip with a colleague in Hyderabad. The coordination and planning was
done within 2 months over e-mail. Although my experience
lasted 1 month, it is likely that residents would maximally
benefit from experiences lasting 2 months given the time
required to acclimate to a new culture.
Given the ever-increasing ethnic diversity of patients in
Western countries, it seems inherently beneficial for resident
training to incorporate cross-cultural experiences when possible. These experiences may be of the greatest value when residents travel to the home countries of immigrant patients in
their local hospital populations. While it is ultimately of primary importance that residents be trained to care for patients
June 2011
locally, there is tremendous potential in developing skills sets
and clinical experience and that can be applied globally.
On one of the final nights of my stay in Hyderabad,
Dr. Subhash Kaul, the head of the neurology department at
NIMS, invited me to his apartment to have dinner with his
wife and son. His wife, an ophthalmologist, had returned
from a full day of surgery. After dinner Dr. Kaul brought
out his harmonium, a traditional hand-pumped instrument,
and sang some of his favorite Indian songs while we talked
late into the night. It was a wonderful moment of sharing
between physicians of different ages and from different parts
of the world. As Dr. Kaul’s music played on through the
evening I felt reassured that I was going back to my home a
better physician. I saw that my experience as a resident was
not an isolated journey, but rather an experience shared by
many people across the globe who can instantly relate to
each other both as colleagues and friends.
Acknowledgments
We thank the Departments of Neurology at the Nizam’s
Institute of Medical Sciences (NIMS) and the University
of California San Francisco (UCSF). The experience
described is that of the first author, although the points
of view reflect discussions and input from the co-author.
Potential Conflicts of Interest
Nothing to report.
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