Tuesday, April 16, 2013

Aaron Berkowitz
PGY-3, Neurology
Travel Grant: Neurology Education in Malawi

Queen Elizabeth Central Hospital in Blantyre, Malawi is the country’s largest hospital, with over 1000 inpatients. As there is no district hospital in the vicinity, the hospital provides all levels of care from primary through tertiary care. It also serves one of the primary sites of medical education for medical students, residents, and clinical officers in training.


On the left, the recently built emergency department at Queen Elizabeth Central Hospital. On the right, mountains seen in the distance behind the hospital.

The main hallway (above) is reminiscent of Brigham and Women’s “Pike,” a seemingly infinite corridor with various ‘exits’ to the wards of the different specialties: medicine, surgery, pediatrics, obstetrics, hemodialysis, oncology, radiology.

One specialty, however, is not represented: neurology. In fact, there are no adult neurologists in the entire country of Malawi (there is one pediatric neurologist). The number of patients admitted for neurologic problems, however, is substantial, as would be expected at any tertiary referral hospital. In just under 2 weeks since arriving and working with only the internal medicine service (generally serving 150-200 inpatients), I have been asked to see 22 inpatients and 9 outpatients with primary neurologic symptoms/signs. In contrast to the usual elderly average age on a neurology service in the United States, the average age of patients I have seen so far has been 36. A few consults have been straightforward (e.g., stroke, neuropathy), but many have been mysterious constellations of symptoms and signs in young patients without clear explanation, and limited diagnostic testing to pursue a diagnosis and craft a treatment plan.

On the left, the entry to the Department of Medicine; on the right, one bay of the women's ward at QECH

When hearing the students and house staff present patients, one is struck by the fact that the first identifying statement for the patient (i.e., age, sex) always includes the patient’s HIV status, and this is presented even before the chief complaint. No presentation of a physical examination is complete without mentioning whether there are Kaposi sarcoma lesions. The prevalence of HIV/AIDS in Malawi is around 12%, and I have been told that 80-85% of the hospital’s patients at any given time are HIV positive. Of the 31 patients I have seen so far, 11 have been HIV positive. HIV and resultant opportunistic infections can affect any part of the nervous system at any stage of the illness from seroconversion to advanced AIDS, leading to complex diagnostic quandaries, especially in the setting of one or more additional systemic illnesses that may or may not be HIV-related.

The medicine department asked for visiting neurologists to come to teach students and residents as there are no neurologists in the country. I have truly enjoyed working with the extraordinarily enthusiastic students and housestaff. Given limitations in diagnostic testing (e.g., no basic chemistries, no CT scans), clinicians here are extraordinary bedside diagnosticians. Teaching how to use the detailed neurologic examination for localization and differential diagnosis in neurology is therefore a natural extension of the exceptionally astute clinical skills already deeply ingrained in the students and residents.

I also had the opportunity to teach the clinical officers staffing the emergency department. Clinical officers are the country’s first line of medical care at district hospitals, clinics, and emergency rooms, with training essentially analogous to a physician assistant in the U.S.

While my primary role here has been to teach, I have surely learned much more than I have taught, not only about HIV-related (as well as malaria and tuberculosis-related) neurologic disease and clinicial decision-making in the setting of limited diagnostic testing, but also about how to attempt to convey the essentials of neurologic clinical reasoning in different ways for non-neurologist practitioners at different levels of training practicing in different contexts.

I am grateful to the Partners Global Health Travel Grant and Partners Neurology Residency for supporting this work.


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