Stories From the Field:

GHANA

How can four neurologists serve an entire country?

Dr. Adam B. Cohen, the Inpatient Medical Director at Mass General Hospital’s Department of Neurology was granted a Center for Global Health Travel Award to work in Ghana. Dr. Cohen spent one month at Accra’s Korle Bu Teaching Hospital in Accra, Ghana to improve specialty care and consultation through innovative technology.

Ghana – nine times the area and four times the population of Massachusetts - has fewer practicing neurologists than the Mass General Epilepsy department. Yet, both Massachusetts and Ghanaian healthcare systems struggle to meet the demands of referring physicians for specialty physicians.

Even with the large number of practicing neurologists in Massachusetts, over 200 at MGH alone, we struggle to meet the needs of patients with neurologic problems – wait times for new appointments can be months and inefficiencies plague patients’ pathways to specialists.

At MGH and across Massachusetts, physicians, hospitals, and businesses are advancing innovative approaches to specialty care efficiency, many of which will have great relevance in western Africa, as well. These approaches often focus on “pre-consultation,” which is the time window between when a referring physician needs and receives specialty input. In this period, patients and their referring physicians strive to receive the right amount of care at the right time by the right specialist.

In Accra, a vibrant, densely populated, equatorial, coastal city, and the capital of Ghana, I worked with the neurology team at Korle Bu Teaching Hospital. Korle Bu is the University of Ghana Medical School teaching hospital and the major referral center in Ghana. Everyday, the grounds buzzed with activity – students, mainly from Ghana, but also from other African countries, physicians, researchers, and many, many family members. The warm weather allowed families and relatives to create temporary posts on outdoor walkways as few designated family waiting areas existed.

At Korle Bu, the neurology medical team consisted of two attending neurologists, two neurology residents, and a host of rotating medical residents and students. Each morning, we rounded in large community-style inpatient wards, in a four-story partially open-air inpatient building, which sat on the edge of campus.

We saw a mix of patients with medical and neurologic problems and two days per week we also staffed busy outpatient neurology clinics, where patients lined up outside, seated in long, weathered, painted benches. Clinic rooms often held more than one patient simultaneously, so when a patient and I had English-Ghanaian language difficulties, the other patient translated.

Before we discussed the clinical problem, patients told us where they lived. As in Massachusetts, Ghanaians often traveled great distances to see specialists because closer ones did not exist or they sought second opinions. Also similar to Massachusetts, journeys were riddled with inefficiencies and ripe for change.

In both Massachusetts and Ghana, pre-consultation is unstructured and inefficient.

Also like Massachusetts, a primary care physician in a remote region has no official means to find or communicate (by phone, email, videoconference, or other application) with the correct specialist in a well-resourced region before office consultation. A primary care physician in Mole, of the far Northern region, typically initiates pre-consultation as we do in Massachusetts: the referring physician first decides he needs help from a specialist equipped with resources and connections unavailable to him. He then books a consultant appointment at the tertiary care specialty center. The patient then waits, travels, and hopes everything works out.

The Mole (or Western Massachusetts) primary care physician has no structured means to find and connect with the correct specialist. If specialty advice were available sooner, he might instead handle the patient problem himself and prevent the patient’s full day journey to the capital, which requires family assistance and lost work.

If he could speak to the neurologist sooner, the patient might avoid waiting months for a clinical plan or might find out an appointment wasn’t needed at all. Conversely, earlier communication might change the plan in a different way – perhaps the patient not only needs face-to-face care in Accra, but also requires it immediately and treatment should be started even before official consultation.

Telemedicine and physician communication applications are quickly making great strides in the United States, but they will also find great utility in Ghana. Global telemedicine models now focus on connecting highly specialized tertiary care centers from the West to health care centers in the developing world. In this construct, expertise is outsourced to the West, which typically delivers sporadic, case-by-case piecemeal advice, often heavily limited by time zone differences and referring site Internet speed.

Although we recognized value in this traditional telemedicine model, my Ghanaian colleagues and I explored a different model: Ghanaian specialists themselves would be available for remote consultation to distant sites without specialist expertise. We laid the groundwork for a small number of referring pilot sites in underserved regions of Ghana.

To foster this, Korle Bu neurologists would be afforded time to field phone calls from referring providers. Fortunately, Vodafone, the country’s largest mobile phone service provider, has a program whereby physician-to-physician phone calls are free.

The goal of our pilot program is to better utilize available neurologic resources, thereby better matching patient needs to resources. Some referrals that normally would have yielded office consultations will be converted into phone (or e-mail) consultations, representing avoided visits. This model may not only result in faster management for patients and less wait times and travel, but the Korle Bu neurologists may have more time to use office visits for patients who need them.

Particularly because specialists are scarce in Ghana, the need for improved pre-consultation is magnified. Although both Ghanaians and Americans need better pre-consultation, a population of 25 million served by only four neurologists is much more susceptible to inefficient pre-consultation than a Massachusetts population of over six million being served by hundreds of neurologists. Although it might seem like a few Ghanaian specialists hardly represent the ideal candidates for innovative “Western” approaches to healthcare inefficiency, they might be the ones who need them most.

Acknowledgement: I was fortunate to have warm, witty, and inviting hosts in Accra: Dr. Albert Akpalu, the chief of neurology, and Dr. Patrick Adjei are the neurology leaders in Ghana. They strive to continually improve their service, while educating non-neurologists and neurologist alike. My time in Accra was made particularly special by additional wonderful hosts, Drs. Kwodwo Nkromah, Isabella Amoyaw, Fafa Gadzanku and Ruth Owusu-Antwi