Original Paper Neuroepidemiology 1992:11:158-162
B. S. Singhaia R.D. Gursahanih Matthew Menkenc
Practice Patterns in Neurology in India
3 Department of Neurology. Bombay Hospital Institute of Medical Sciences. Bombay. b Department of Neurology, Sir J.J. Hospital. Bombay, India; c Department of Medicine and Neurology. Robert Wood Johnson Medical School. University of Medicine and Dentistry of New Jersey. New Brunswick. N.J.. USA
Introduction In India, a population of 840 million is served by approximately 280 neurologists [1]. This ratio of 1:3 million, is in marked contrast to the current US and UK figures [2, 3] (see table 1). As neurologic training programs and ser vices in India undergo rapid and largely un planned expansion, it was realized that very little information exists on the actual situa tion. In 1989 at the World Congress of Neu
rology, the Research Group on Neurological Education with the support of the Research Group on the Organization and Delivery of Neurologic Services decided to conduct a practice study in developing countries. By identifying the scope and content of neuro logic practice and care in India this should provide some data with implications for edu cation and possibly also manpower planning. To the best of our knowledge this is the first reported study of neurologic practice in a developing country.
Dr. B.S. Singhal Bombay Hospital Medical Research Center 12 Marine Lines Bombay 400 020 (India)
Downloaded by: Kings's College London 137.73.144.138 - 10/17/2017 1:24:51 PM
KeyW ords Health manpower Health services research Professional practice Health occupations, neurology Education, medical
Abstract Sixteen Indian neurologists saw 1,850 patients over a sample 6-day working week. The average daily workload comprised 19 patients including 11 new cases. Epilepsy (27.0%), head ache (19.0%) and cerebrovascular disorders (7.8%) were the commonest problems. Only 2.5% fell in the ICD-9-CM cate gories 780-799 consisting of symptoms, signs and ill-defined conditions. In 43% it was felt that the neurologic consult was not necessary. In the Indian setting this would suggest that emphasis should be on neurologic education of primary care physicians and internists for the appropriate utilization of lim ited resources.
© 1992 S. Karger AG. Basel 0251-5350/92/ 0 1 13-0158Î2.75/0
1 Neurologist-population ratio 2 Ambulatory new:o!d patients 3 New outpatients/week
Materials and Methods Twenty-eight neurologists were arbitrarily selected from the 1990 directory of members of the Neurologi cal Society of India. An attempt was made to compen sate for the geographical concentration of neurologists in and around the metropolitan areas of India by selecting neurologists practicing in smaller cities as well. The selection also reflects the greater proportions of neurologists in office-based than in institutional/ teaching hospital practice. Records were submitted by 19 neurologists to give a response rate of 68% (similar to the 66% response seen in the 1985 Ambulatory Medical Care study in the USA [4]). Of these, the records of 2 neurologists were inadequate. One more neurologist included cases seen by an assisting resident. These 3 were excluded and records of 16 neurologists analyzed. These neurologists included 11 who are primarily office-based and 3 who have both office practice as well as teaching hospital attachments. The remaining 2 arc employed in teaching hospitals (equivalent to a university hospital) which do not permit private prac tice. Admission facilities are available to all of them. Participants were asked to log all patient encoun ters in 1 working week (6 days). The survey instrument/proforma (see Appendix) included details like demographic data, source of referral, diagnosis, etc. The last item was a subjective assessment by the neu rologist concerned of the need for a specialist consulta tion. The diagnoses were coded using the 9th revision of the International Classification of Disease.
Observations A total of 1,850 patients were seen by 16 neurologists over 1 6-day working week, for a weekly mean of 116 and a daily average of 19.
India
UK
USA
1:3.000.000 55:45% (1:0.82) 50
1:308,000(3] 41:59% [5] (1:1.44) 22(5]
1:29.100 [2] 32:68% [4] (1:2.13) 8.3 [4]
The count ranged from 48 to 211 and as such the median of 104 patients per working week is probably more representative. On average each consultant saw 50 new outpatients and 12 new inpatients every week. The 1,850 patients seen overall included more new cases than old (54.5 vs. 45.5%). Outpatient consultations were preponderant (87.4%). Inpatients constituted most of the remainder (12.1%). A small number (0.5%) were seen on domiciliary visits. General practitioners (31.3%), hospital physicians (31.1%) and others (9.7%) were the source of a bulk of the referrals. However a significant proportion came on their own (27.9%). The percentage of self-referred pa tients varies markedly between consultants and is probably a function of practice location and practice styles. Table 2 shows a detailed analysis of patient diagnoses. Epilepsies (27.0%), headache in cluding migraine (19.0%) and cerebrovascu lar disease (7.8%) constituted over half the total diagnoses listed. Psychiatric problems including hysteria came next (4.8%). Parkin sonism and other extrapyramidal disorders constituted 4.3% while spine and disk disor ders made up 3.3%. Peripheral nerve disor ders (4.2%), myelopathies (2.8%), muscle problems and myasthenia (2.2%), facial nerve conditions (1.5%), vertigo and giddiness (1.1%) composed smaller fractions. Neuro surgical problems like intracranial neoplasms (1.2%) and head trauma and its sequelae
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Table 1. Comparison o f practice patterns in India, England and the United States
Table 2. Distribution of diagnoses
Condition
I Headache
2 Epilepsy, fits NOS 3 Cerebrovascular disorders 4
Psychiatric disorders
5 Parkinson’s and other EP disorders 6 Spine and disk disorders 7 Peripheral nerve disorders 8 CNS tuberculosis 9 Myelopathies 10 Muscle disorders
11 Facial nerve disorders 12 Intracranial neoplasia
13 Vertigo, giddiness 14 Head trauma and sequelae NOS 15 Trigeminal nerve disorders 16 Dementias 17 Miscellaneous
Codes
346, 784.0, 307.8 345, 780.3 430-1, 433-8 300, 311 332, 333 721»724 354357 013, 320.4 336, 721.1 358, 359, 710.4 351 191, 198, 225 386, 780.4 854 350 290 331.7
New patients (1,009)
Old patients (841)
Total
205 (20.3)
146 (17.4)
351 (19.0)
178 (17.6) 97 (9.6) 61 (6.1) 44 (4.4) 38 (3.8) 49 (4.9) 18 (1.8) 36 (3.6) 22 (2.2)
322 (38.3) 48 (5.7) 28 (3.3) 35 (4.2) 23 (2.7) 29 (3.4) 27 (3.2) 16 (1.9) 18 (2.1)
500 (27.0) 145 (7.8) 89 (4.8) 79 (4.3) 61 (3.3) 78 (4.2) 45 (2.4) 52 (2.8) 40 (2.2)
17 (1.7) 16 (1-6)
10 (1.2) 7 (0.8)
27 (1.5) 23 (1.2)
12 (1.2) 7 (0.7) 13 (1.3) 7 (0.7) 189 (18.7)
9 (1.1) 7 (0.8) 7 (0.8) 3 (0.4) 106 (12.6)
21 (U ) 14 (0.8) 20 (1.1) 10 (0.5) 295 (15.9)
(1,850)
160
Singhal/GursahanL/Menkcn
Practice Patterns in Neurology
Downloaded by: Kings's College London 137.73.144.138 - 10/17/2017 1:24:51 PM
Figures in parentheses indicate percentage. NOS = Not otherwise spec ified; EP = extrapyramidal. » Cervical spondylotic myelopathy (721.1) included with other myelop athies.
Discussion The shortage of neurologists in India is evi dent from the average workload - 19 patients per day with 11 being new (both in- and out patients). In this sample, the mean number of new outpatients in a working week was 50. This can be compared with the 22 new outpa tients seen by the average British neurologist [5] and 8.3 seen by the average USA (officebased) neurologist in 1 week [4], It is also of interest that the ratio of new to old patients declines with an increase in the neurologistpopulation ratio (table 1) between the three countries. Despite the clear shortage, approxi mately 70% of Indian neurologists are officebased compared with roughly 80% of all US neurologists and notably none in the UK.
Probably as a reflection of this scarcity, the patient mix has a preponderance of diagnoses affecting the nervous system. Sixty-six per cent of the cases could be categorized in ICD9-CM codes 320-389 which does not include stroke. Patients with symptoms, signs and illdefined conditions (ICD-9-CM codes 780799) constitute only 2.5%. In comparison, the 1985 Ambulatory Medical Care Survey of office-based neurologists [4] in the USA found that only 33.5% of all visits were due to a problem that could be characterized in codes 320-389 while 18.4% fell in codes 780799. The possible implication is that when the number of neurologists is high, they tend to encroach on problems that could be handled by primary care physicians. Epilepsy is by far the commonest diagnosis and constitutes over a quarter of the patients seen with headache coming second. Together with cerebrovascular disorders and psychiat ric problems these constitute about half of all patients seen. Broadly this seems to match the experience from other studies over the past 2 decades in the UK [6] and the USA [4], When new outpatients alone are analyzed, the rank order of diagnoses is comparable to the UK practice study [5] (headaches, epilep sy, cerebrovascular disease, peripheral nerve problems, multiple sclerosis and psychiatric disorders). Multiple sclerosis (> 5% of new UK patients) is an anticipated exception. The other one, peripheral nerve problems reaches a higher figure in the UK report because the peripheral and the cranial nerves have been listed together in the UK study. Participants in the UK practice study [5] felt that over 80% of all consultations were justified. In our survey however the propor tion of cases where a neurologic consultation was not considered justified was fairly high 43%. It was thought that the high level of selfreferrals (27.8%) could be an explanation. However, this is contradicted by the fact that
161
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(0.8%) were also less frequent. Dementias (Alzheimer’s, multi-infarct, etc.) formed only 0.5%. Approximately one sixth (15.9%) of the patients fell into less frequently encountered categories (under 1% each). Approximately two thirds of the cases (66.1 %) could be assigned a diagnosis in the ICD-9-CM list of neurologic conditions (codes 320-359) while only a small number of 47 (2.5%) were placed in codes 780-799 (symptoms, signs and illdefined conditions). When new cases (1,009 patients) alone were analyzed, the order changed to a small extent. Headache (20.3%) replaced epilepsy (17.6%) as the most common problem seen. Cerebrovascular disorders (9.6%) and psy chiatric problems (6.1 %) were the next most common conditions. The consultation was thought by neurolo gists to be justified in only 57%. In the rest, about 43 %, it was felt that the problem could have been handled by an internist or general practitioner.
49.7% of the self-referred patients were also thought to merit a neurologic consult. The high proportion of nonessential referrals sug gests that the neurologic education of medical students, general practitioners and other groups of physicians is deficient and requires greater emphasis. This would certainly be a cost-effective way of improving the scope and utilization of neurologic services. t
Acknowledgements Thanks are due to the following participants in the study: Dr. P.T. Acharya, Dr. Ranjit Acharya. Dr. Mukund Baheti, Dr. A. Chatterjee, Dr. Upinder K. Dhand. Dr. Sunil Gajre, Dr. Rajendra Kale, Dr. Sudhir Kothari, Dr. M.C. Mahcshwari, Dr. C.S. Meshram, Dr. J.M.K. Murthy, Dr. Dcvika Nag, Dr. Praful Panse, Dr. P.K. Sethi. Dr. K.C. Shah, Dr. Ajit Sowani. Dr. K. Sriniwas, Dr. S. Valsangkar, Dr. C.U. Velmurugendran.
Appendix The survey instrument (proforma) included the fol lowing items in a column format: 1 Day/date 2 Site of encounter (outpatient department, hospital rounds) 3 Private vs. public 4 New or old patient 5 Principal diagnosis 6 Patient’s age and sex 7 Source of referral (GP, hospital physician, self, other) 8 Whether further consultations (follow-up visits) are required 9 Whether the patient could have been managed by a general practitioner (family physician) or internist
References 3
4
162
Menken M, Hopkins A, Murray TJ, Vates TS: The scope of neurologic practice and care in England, the United States and Canada. Is there a better way? Arch Neurol 1989:46: 210-213. Menken M: The 1985 National Am bulatory Medical Care Survey of Neurologists: A clinician’s perspec tive. Arch Neurol 1989:46:13461348.
Singhal/Gursahani/Menkcn
5
6
Hopkins A, Menken M. DeFrieseG: A record of patient encounters in neurological practice in the United Kingdom. J Neurol Neurosurg Psy chiatry I 989:52:436-438. Perkin GD: An analysis of 7836 suc cessive new outpatient referrals. J Neurol Neurosurg Psychiatry 1989; 52:447-448.
Practice Patterns in Neurology
Downloaded by: Kings's College London 137.73.144.138 - 10/17/2017 1:24:51 PM
1 Directory. Neurological Society of India, 1990. 2 Kurtzke JF, Murray FM. Smith MA: On the production of neurolo gists in the United States: An up date. Neurology 1991 ;41:1-9.
B. S. Singhaia R.D. Gursahanih Matthew Menkenc
Practice Patterns in Neurology in India
3 Department of Neurology. Bombay Hospital Institute of Medical Sciences. Bombay. b Department of Neurology, Sir J.J. Hospital. Bombay, India; c Department of Medicine and Neurology. Robert Wood Johnson Medical School. University of Medicine and Dentistry of New Jersey. New Brunswick. N.J.. USA
Introduction In India, a population of 840 million is served by approximately 280 neurologists [1]. This ratio of 1:3 million, is in marked contrast to the current US and UK figures [2, 3] (see table 1). As neurologic training programs and ser vices in India undergo rapid and largely un planned expansion, it was realized that very little information exists on the actual situa tion. In 1989 at the World Congress of Neu
rology, the Research Group on Neurological Education with the support of the Research Group on the Organization and Delivery of Neurologic Services decided to conduct a practice study in developing countries. By identifying the scope and content of neuro logic practice and care in India this should provide some data with implications for edu cation and possibly also manpower planning. To the best of our knowledge this is the first reported study of neurologic practice in a developing country.
Dr. B.S. Singhal Bombay Hospital Medical Research Center 12 Marine Lines Bombay 400 020 (India)
Downloaded by: Kings's College London 137.73.144.138 - 10/17/2017 1:24:51 PM
KeyW ords Health manpower Health services research Professional practice Health occupations, neurology Education, medical
Abstract Sixteen Indian neurologists saw 1,850 patients over a sample 6-day working week. The average daily workload comprised 19 patients including 11 new cases. Epilepsy (27.0%), head ache (19.0%) and cerebrovascular disorders (7.8%) were the commonest problems. Only 2.5% fell in the ICD-9-CM cate gories 780-799 consisting of symptoms, signs and ill-defined conditions. In 43% it was felt that the neurologic consult was not necessary. In the Indian setting this would suggest that emphasis should be on neurologic education of primary care physicians and internists for the appropriate utilization of lim ited resources.
© 1992 S. Karger AG. Basel 0251-5350/92/ 0 1 13-0158Î2.75/0
1 Neurologist-population ratio 2 Ambulatory new:o!d patients 3 New outpatients/week
Materials and Methods Twenty-eight neurologists were arbitrarily selected from the 1990 directory of members of the Neurologi cal Society of India. An attempt was made to compen sate for the geographical concentration of neurologists in and around the metropolitan areas of India by selecting neurologists practicing in smaller cities as well. The selection also reflects the greater proportions of neurologists in office-based than in institutional/ teaching hospital practice. Records were submitted by 19 neurologists to give a response rate of 68% (similar to the 66% response seen in the 1985 Ambulatory Medical Care study in the USA [4]). Of these, the records of 2 neurologists were inadequate. One more neurologist included cases seen by an assisting resident. These 3 were excluded and records of 16 neurologists analyzed. These neurologists included 11 who are primarily office-based and 3 who have both office practice as well as teaching hospital attachments. The remaining 2 arc employed in teaching hospitals (equivalent to a university hospital) which do not permit private prac tice. Admission facilities are available to all of them. Participants were asked to log all patient encoun ters in 1 working week (6 days). The survey instrument/proforma (see Appendix) included details like demographic data, source of referral, diagnosis, etc. The last item was a subjective assessment by the neu rologist concerned of the need for a specialist consulta tion. The diagnoses were coded using the 9th revision of the International Classification of Disease.
Observations A total of 1,850 patients were seen by 16 neurologists over 1 6-day working week, for a weekly mean of 116 and a daily average of 19.
India
UK
USA
1:3.000.000 55:45% (1:0.82) 50
1:308,000(3] 41:59% [5] (1:1.44) 22(5]
1:29.100 [2] 32:68% [4] (1:2.13) 8.3 [4]
The count ranged from 48 to 211 and as such the median of 104 patients per working week is probably more representative. On average each consultant saw 50 new outpatients and 12 new inpatients every week. The 1,850 patients seen overall included more new cases than old (54.5 vs. 45.5%). Outpatient consultations were preponderant (87.4%). Inpatients constituted most of the remainder (12.1%). A small number (0.5%) were seen on domiciliary visits. General practitioners (31.3%), hospital physicians (31.1%) and others (9.7%) were the source of a bulk of the referrals. However a significant proportion came on their own (27.9%). The percentage of self-referred pa tients varies markedly between consultants and is probably a function of practice location and practice styles. Table 2 shows a detailed analysis of patient diagnoses. Epilepsies (27.0%), headache in cluding migraine (19.0%) and cerebrovascu lar disease (7.8%) constituted over half the total diagnoses listed. Psychiatric problems including hysteria came next (4.8%). Parkin sonism and other extrapyramidal disorders constituted 4.3% while spine and disk disor ders made up 3.3%. Peripheral nerve disor ders (4.2%), myelopathies (2.8%), muscle problems and myasthenia (2.2%), facial nerve conditions (1.5%), vertigo and giddiness (1.1%) composed smaller fractions. Neuro surgical problems like intracranial neoplasms (1.2%) and head trauma and its sequelae
159
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Table 1. Comparison o f practice patterns in India, England and the United States
Table 2. Distribution of diagnoses
Condition
I Headache
2 Epilepsy, fits NOS 3 Cerebrovascular disorders 4
Psychiatric disorders
5 Parkinson’s and other EP disorders 6 Spine and disk disorders 7 Peripheral nerve disorders 8 CNS tuberculosis 9 Myelopathies 10 Muscle disorders
11 Facial nerve disorders 12 Intracranial neoplasia
13 Vertigo, giddiness 14 Head trauma and sequelae NOS 15 Trigeminal nerve disorders 16 Dementias 17 Miscellaneous
Codes
346, 784.0, 307.8 345, 780.3 430-1, 433-8 300, 311 332, 333 721»724 354357 013, 320.4 336, 721.1 358, 359, 710.4 351 191, 198, 225 386, 780.4 854 350 290 331.7
New patients (1,009)
Old patients (841)
Total
205 (20.3)
146 (17.4)
351 (19.0)
178 (17.6) 97 (9.6) 61 (6.1) 44 (4.4) 38 (3.8) 49 (4.9) 18 (1.8) 36 (3.6) 22 (2.2)
322 (38.3) 48 (5.7) 28 (3.3) 35 (4.2) 23 (2.7) 29 (3.4) 27 (3.2) 16 (1.9) 18 (2.1)
500 (27.0) 145 (7.8) 89 (4.8) 79 (4.3) 61 (3.3) 78 (4.2) 45 (2.4) 52 (2.8) 40 (2.2)
17 (1.7) 16 (1-6)
10 (1.2) 7 (0.8)
27 (1.5) 23 (1.2)
12 (1.2) 7 (0.7) 13 (1.3) 7 (0.7) 189 (18.7)
9 (1.1) 7 (0.8) 7 (0.8) 3 (0.4) 106 (12.6)
21 (U ) 14 (0.8) 20 (1.1) 10 (0.5) 295 (15.9)
(1,850)
160
Singhal/GursahanL/Menkcn
Practice Patterns in Neurology
Downloaded by: Kings's College London 137.73.144.138 - 10/17/2017 1:24:51 PM
Figures in parentheses indicate percentage. NOS = Not otherwise spec ified; EP = extrapyramidal. » Cervical spondylotic myelopathy (721.1) included with other myelop athies.
Discussion The shortage of neurologists in India is evi dent from the average workload - 19 patients per day with 11 being new (both in- and out patients). In this sample, the mean number of new outpatients in a working week was 50. This can be compared with the 22 new outpa tients seen by the average British neurologist [5] and 8.3 seen by the average USA (officebased) neurologist in 1 week [4], It is also of interest that the ratio of new to old patients declines with an increase in the neurologistpopulation ratio (table 1) between the three countries. Despite the clear shortage, approxi mately 70% of Indian neurologists are officebased compared with roughly 80% of all US neurologists and notably none in the UK.
Probably as a reflection of this scarcity, the patient mix has a preponderance of diagnoses affecting the nervous system. Sixty-six per cent of the cases could be categorized in ICD9-CM codes 320-389 which does not include stroke. Patients with symptoms, signs and illdefined conditions (ICD-9-CM codes 780799) constitute only 2.5%. In comparison, the 1985 Ambulatory Medical Care Survey of office-based neurologists [4] in the USA found that only 33.5% of all visits were due to a problem that could be characterized in codes 320-389 while 18.4% fell in codes 780799. The possible implication is that when the number of neurologists is high, they tend to encroach on problems that could be handled by primary care physicians. Epilepsy is by far the commonest diagnosis and constitutes over a quarter of the patients seen with headache coming second. Together with cerebrovascular disorders and psychiat ric problems these constitute about half of all patients seen. Broadly this seems to match the experience from other studies over the past 2 decades in the UK [6] and the USA [4], When new outpatients alone are analyzed, the rank order of diagnoses is comparable to the UK practice study [5] (headaches, epilep sy, cerebrovascular disease, peripheral nerve problems, multiple sclerosis and psychiatric disorders). Multiple sclerosis (> 5% of new UK patients) is an anticipated exception. The other one, peripheral nerve problems reaches a higher figure in the UK report because the peripheral and the cranial nerves have been listed together in the UK study. Participants in the UK practice study [5] felt that over 80% of all consultations were justified. In our survey however the propor tion of cases where a neurologic consultation was not considered justified was fairly high 43%. It was thought that the high level of selfreferrals (27.8%) could be an explanation. However, this is contradicted by the fact that
161
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(0.8%) were also less frequent. Dementias (Alzheimer’s, multi-infarct, etc.) formed only 0.5%. Approximately one sixth (15.9%) of the patients fell into less frequently encountered categories (under 1% each). Approximately two thirds of the cases (66.1 %) could be assigned a diagnosis in the ICD-9-CM list of neurologic conditions (codes 320-359) while only a small number of 47 (2.5%) were placed in codes 780-799 (symptoms, signs and illdefined conditions). When new cases (1,009 patients) alone were analyzed, the order changed to a small extent. Headache (20.3%) replaced epilepsy (17.6%) as the most common problem seen. Cerebrovascular disorders (9.6%) and psy chiatric problems (6.1 %) were the next most common conditions. The consultation was thought by neurolo gists to be justified in only 57%. In the rest, about 43 %, it was felt that the problem could have been handled by an internist or general practitioner.
49.7% of the self-referred patients were also thought to merit a neurologic consult. The high proportion of nonessential referrals sug gests that the neurologic education of medical students, general practitioners and other groups of physicians is deficient and requires greater emphasis. This would certainly be a cost-effective way of improving the scope and utilization of neurologic services. t
Acknowledgements Thanks are due to the following participants in the study: Dr. P.T. Acharya, Dr. Ranjit Acharya. Dr. Mukund Baheti, Dr. A. Chatterjee, Dr. Upinder K. Dhand. Dr. Sunil Gajre, Dr. Rajendra Kale, Dr. Sudhir Kothari, Dr. M.C. Mahcshwari, Dr. C.S. Meshram, Dr. J.M.K. Murthy, Dr. Dcvika Nag, Dr. Praful Panse, Dr. P.K. Sethi. Dr. K.C. Shah, Dr. Ajit Sowani. Dr. K. Sriniwas, Dr. S. Valsangkar, Dr. C.U. Velmurugendran.
Appendix The survey instrument (proforma) included the fol lowing items in a column format: 1 Day/date 2 Site of encounter (outpatient department, hospital rounds) 3 Private vs. public 4 New or old patient 5 Principal diagnosis 6 Patient’s age and sex 7 Source of referral (GP, hospital physician, self, other) 8 Whether further consultations (follow-up visits) are required 9 Whether the patient could have been managed by a general practitioner (family physician) or internist
References 3
4
162
Menken M, Hopkins A, Murray TJ, Vates TS: The scope of neurologic practice and care in England, the United States and Canada. Is there a better way? Arch Neurol 1989:46: 210-213. Menken M: The 1985 National Am bulatory Medical Care Survey of Neurologists: A clinician’s perspec tive. Arch Neurol 1989:46:13461348.
Singhal/Gursahani/Menkcn
5
6
Hopkins A, Menken M. DeFrieseG: A record of patient encounters in neurological practice in the United Kingdom. J Neurol Neurosurg Psy chiatry I 989:52:436-438. Perkin GD: An analysis of 7836 suc cessive new outpatient referrals. J Neurol Neurosurg Psychiatry 1989; 52:447-448.
Practice Patterns in Neurology
Downloaded by: Kings's College London 137.73.144.138 - 10/17/2017 1:24:51 PM
1 Directory. Neurological Society of India, 1990. 2 Kurtzke JF, Murray FM. Smith MA: On the production of neurolo gists in the United States: An up date. Neurology 1991 ;41:1-9.
