Neurology Beyond Borders: India

Neurology looks very different when one specialist may serve hundreds of thousands of people and patients travel hours across states just to be seen. We sit down with two renowned Indian neurologists, Dr. Singal and Dr. Lalkaka, to map what neurology care really feels like in India and what the rest of us can learn from it.

We talk through the daily reality of neurology practice in India, from outpatient clinics filled with headache, epilepsy, Parkinson’s disease, stroke follow up, and psychosomatic complaints to inpatient care that still includes emergencies and complex diagnostic puzzles. They explain how the country’s disease patterns have evolved, with fewer classic infection dominated presentations than in prior decades and more non communicable neurological disease as life expectancy rises, alongside growing visibility of dementia and cognitive impairment.

The conversation goes beyond medicine into culture and systems. We unpack how joint family networks can provide powerful support for stroke recovery and memory decline, while also shifting decision making away from patient autonomy. We explore stigma around epilepsy, the impact of Ayurveda and homeopathy alongside Western evidence based care, and why palliative care and quality of life discussions remain difficult in many settings. They also break down the healthcare landscape, including government hospitals, trust hospitals, and corporate centers, plus the hard truth of out of pocket costs when insurance coverage is limited.

We end with a forward look at neurology training, genetics, precision medicine, and AI, anchored by a clear principle: use tests and technology as tools, not masters, and never let the clinical exam or compassion fade. If you care about global neurology, medical education, or building smarter systems of care, you’ll take something practical from this conversation. Subscribe, share the episode with a colleague, and leave a review with the biggest lesson you’re taking into your next patient encounter.

Transcript

SPEAKER_01 0:10

Welcome back to the Neurophilia Podcast, a medical education podcast dedicated to dispelling neurophobia one conversation at a time. We are your hosts, Dr. Newper Boyle and Dr. Blake Goleco. This season, we're taking neurophilia beyond borders. Today we are traveling to a region known for its rich culture, numerous dialects, and beautiful landmarks. We are talking about neurology in India. We are so honored to be joined by two incredible neurologists who will share their journeys and insight. Dr. Bean Singhle as well as Dr. Jimmy Lovell Kopka. Thank you both so much for joining us on the Neurophilia Podcast. We are so grateful to have you here. We always like to start our conversations by asking our guest speakers how they first got interested in neurology and walking us through their journeys to where they ended up today. I was wondering, Dr. Singal, if we could start with you and if you could tell us about your journey.

SPEAKER_04 1:11

Well, you know, I did my undergraduate, as we call it, MBBS in Grant Medical College. After that, we do internal medicine for three years. And at that time, as you know, neurology in the 50s, it only started to be known in the medical colleges, not by the public. So I had a mentor by the name of Professor Noshir Wadiya, who just returned from England under training by Lord Russell Brain. He had worked at the London Hospital and at the Mayow Hospital. I was very, very impressed because earlier I think neurology was hardly taught. But I found him seeing the patient's clinical porte, you know, coming to diagnosis on the clinical ground extremely important. So I asked him what course I should follow. So he said, be a neurologist. I said, why? He said, look, you will not make money because there are no tools at that time in the 50s, you know. And you will have a good living, but it will be a challenging thing, you know, to make the diagnosis and give the advice. At that time, we don't have much treatment or tools, you know. So therefore, you know, I think he gave me an introduction. I went to England, walked over there, and came back as started practicing as a neurologist, as his assistant at the college, you know, teaching and practicing. That's how my journey was.

SPEAKER_01 2:38

Well, it sounds like he gave you some pretty good advice. And look at how much of an impact you've been able to have throughout your career. Um, Dr. Dr. Lalkaka, do you think that you can also walk us through what your journey has been like?

SPEAKER_03 2:52

Yes, you know, my father was a doctor, and I always wanted to be. In those days, you know, people who took up, you know, graduation in science had only two options, really medicine or engineering. And uh so I was lucky to get into medicine, did my MD in general medicine. And then, of course, you know, I was so attracted by the neurology department at JJ Hospital and Grant Medical College. At that time, as Professor Single said, you know, there were three sort of giants. There was Professor Wadya, Professor Single, and Professor Katrak. And I was very fortunate to get in at that time. And then the rest, of course, is as we see.

SPEAKER_01 3:40

And could you provide a little information? Um, you know, you did training in neurology. Did either of you subspecialize at all, or do you practice mainly general neurology?

SPEAKER_04 3:51

Well, actually, I think we have interest. We're not specialized. We don't specialize subspecialty. And uh, you know, my interests have been in autoimmune disorders like myastenia gravis and multiple sclerosis. Otherwise, of course, I'm a general neurologist and do everything.

SPEAKER_03 4:10

I'm also a general neurologist with a special interest in movement disorders. So uh many years ago, it was uh Dr. Single only who requested his dear friend Ivan Lorenz from Sydney to you know take me in. And uh, you know, I spent a few months there in Sydney, you know, with uh, you know, for movement disorders. So there's a special interest of movement disorders in me. But otherwise, I'm basically a general neurologist.

SPEAKER_06 4:43

Along the same lines, do you mind taking us through what it's like uh as a typical day for you in clinic? Do you do any hospital coverage? Um, how does how does your day-to-day or week to week look?

SPEAKER_04 4:59

Good. You know, in the beginning, of course, as you know, in the um you know, 60s after I came back in 62 in India after training in England, I always wanted to come back to serve the people in India. At that time, you know, we had the opportunity to work in an academic institution to teach, and academic institutions were affiliated to hospitals which were caring for the poor. At the same time, they didn't pay us anything much, you know. And then we had to work in the afternoon and the evening in a trust hospital or a private hospital. That is the sort of thing that was in India. So at least, you know, I was teaching and continued till 91 in the Grand Medical College. And thereafter, of course, I have been at the Bombay Hospital, which is a trust hospital, serving all people, rich and poor.

SPEAKER_03 5:54

Right. What about you? No, I um uh uh initially, you know, um, you know, I have been into private practice, and uh, you know, initially I was affiliated to three or four hospitals and have my own consulting rooms in the evenings. After COVID, you know, I have been restricting myself largely to my clinic where I see a lot of uh outpatients, and one hospital where, you know, I see patients and who are referred to me.

SPEAKER_01 6:32

And then, you know, you both mentioned that you have certain interests within neurology, but at large at heart, you are general neurologists. What are the types of patients that you're typically seeing either in clinic or in the hospital setting?

SPEAKER_04 6:47

Good very good question. Actually, in the outpatient department, as you know, generally we have patients with headache migraine. We have patients, you know, with epilepsy. We have even a diverse variety of cases that come over. You know, some of them, of course, who are acutely ill will go to the casualty medical officer or they will get admitted. But majority of the patients will come for consultation, accepted stroke, patients with Parkinson's disease, patients having epilepsy. But they in a day, you know, we would be mainly seeing patients with headache and psychosomatic complaints, epilepsy. And of course, uh, you know, I mean, these are the sort of things, and Parkinson's disease patients, many of the patients who do not require admission will be seeing in the outpatient. As an inpatient, of course, uh we will have a variety of cases. We'll have uh, you know, acute medicine patients like acute stroke, we will have patients with uh state of the epilepticus, we will have patients with infections, which used to be very common earlier, tuberculosis meningitis and things like that. And of course, uh, you know, sometimes uh even the patients who have a neurosurgical problem may come to us, but we will direct them to the neurosurgeon after making a diagnosis.

SPEAKER_03 8:04

Yes, I think in the uh in the outpatient, as uh Professor Single said, you know, we we you know I do see uh a variety of cases, but in my case, I think it is a bit skewed. I uh uh I think the majority of my cases are either Parkinson's disease and related extrapyramidal disorders and a lot of cognitive impairment dementias. You know, I'm a Parsi, and in this Parsi community, you know, we live longer. And so we have a very large number of people with cognitive impairments. So, you know, we, you know, I have been exposed to a lot of uh, you know, these besides the other, you know, uh patients.

SPEAKER_06 8:50

That's a really interesting point. And I was thinking through, and one of the questions that we've been trying to discern or ask of a lot of our guests, especially this season, is uh I'm sure that you both have colleagues from all over the world. Do you feel like you see something where you're practicing that may be disproportionate to what you're hearing from your colleagues in other areas of the world?

SPEAKER_04 9:14

I think the earlier on, as you know, infections used to rule tuberculosis, cystoposis, violent infections. Uh, but today I think uh we are seeing more of non-communicable diseases. In the West, of course, uh, they're doing a lot of research as well. And I think uh, you know, when I was in England, for instance, you know, we would see a variety of cases as inpatient. We were doing mainly inpatient service, you know. And I think uh otherwise, I think uh non-communicable diseases are beginning to be a major concern as we are also living a bit longer. And I think infections are you know relatively less. Autoimmune diseases have been today quite uh, you know, an important thing. Various sorts of encephalitis, viral encephalitis, viral infections. And of course, you know, the I think uh uh that's uh sort of a pattern. We would in a, I mean, both Dr. Lalkaka and myself, perhaps in a month, see a variety of cases, you know, myasthenia gravis, Parkinson's disease, tumors, uh uh stroke patients. So a variety of cases, I think. A large load of these patients.

SPEAKER_03 10:30

You know, echoing uh Professor Single's uh observations, we see a lot of cases, but you know, in terms of cognitive impairment and other, you know, such allied conditions, I think the awareness is now much more. And the moment the family members realize this fellow is you know uh sort of forgetting a lot, they immediately tend to seek advice. So I think awareness is definitely uh much more. And so we are seeing many more such cases.

SPEAKER_04 11:02

I might add here a large section of the population, the rural area, yes. And you know, middle class and the upper rich people, the urban class, you know, maybe one-third and two-thirds ratio. Now, in the another thing which is very relevant here is that we have a joint family system, especially in the rural area. It is tending to decrease in the rich society in the urban area. And therefore, many of the patients who may have a memory decline may not get noticed because of the support. And similarly, patients with stroke and others, I think they get a lot of family support. So that I think is a major distinction, whereas perhaps in America and also other countries in the West, you know, they may not be, and they have to probably go to the store, drive themselves. So that is a major difference between the, you know, our place and your place.

unknown 12:04

Yeah.

SPEAKER_06 12:05

I was also curious in one of our other um episodes that we had talked about, we heard a little bit of the differences between private sector care, um, public sector care, uh, private practice versus hospital systems. Can you take us through a little bit about what the different types of healthcare systems look like in India?

SPEAKER_04 12:30

You know, we have actually uh one, of course, is the government setup. We've got the institutes for teaching and also for the very poor people. There they have to not pay or pay very little, you know. It is but of course the services are not to their standard, other things are improving now. Then we have also many places which are sort of small nursing home type of things, you know, which actually I hope will disappear sooner or later. And then we have the private institutions. There are two types, you know, one are the trust hospitals, another the corporate hospitals. Now, in fact, the corporate hospitals practically the facilities that exist in the West are being beginning to be provided. So this is the sort of structure that we are having. Of course, the rural area, the people may have to reach to get the medical facility, may take about five to six, ten hours to reach. So that is the shortcoming. We still don't have telemedicine to support them. So they're primary healthcare people who try and uh treat them. I think this uh would be, I think, uh the major difference. And I think the government hospitals, you know, the nursing homes, community hospitals, and mind you, here there's uh insurance is very poor. There's no insurance coverage, and patients who pay from their pocket. So you've always got to be at least concerned about the how the expense things are.

SPEAKER_03 14:04

Jimmy, you want to add? May I just add that on any typical day at even today at Dr. Single's office, there are probably more patients who come to him from out of Bombay, from distant lands, to see him and consult him. People from, you know, Gujarat, which is another state, and other places, they all come. So he's quite right, you know, the facilities are still uh, you know, not as good in their hometowns. And they do still make a beeline here to get the best possible advice. One more thing I might like to add here that the great patient load.

SPEAKER_04 14:46

I think one neurologist, perhaps half a million people. And what is important here, that patient can be seen the same day, investigated the same day into the MRI or CD scale, if you wish, so that even the next day or the following day they can go. Some of the Indians, you know, who are staying in London and maybe even in America, since the appointment due to six months later, I think they probably come down to India to meet the family, friends, and people at the same time had the medical consultation. That's it, because we have had patients, you know, who because they come here, it's such a good place. My appointment was six months later, and they get the MRA answered on the same day. Yes. Yes, report the very next day.

SPEAKER_01 15:33

That's incredible.

SPEAKER_04 15:34

Yeah, yeah. But I think uh despite uh they being patient load being so excessive, I think the appointments are pretty easy to get then.

SPEAKER_06 15:45

What do you attribute that to? Whenever I hear that there's such a demand um and and that people are coming from all over and the patients uh are just in such need, how how what do you attribute the ability to be able to one see and evaluate these patients and to be able to complete all their testing in such a short period of time?

SPEAKER_04 16:07

You know, basically, you know, I think uh we of course uh see a limited number of patients, but I think uh there are people who are colleagues who don't see many people and they work from morning till late at night to accommodate them. That's one thing. Number two is the clinical basis, of course, is our main pro day. In the sense that, you know, ask the questions, do the relevant examination to find out which system is involved. What is the, you know, which area anatomical you would assign to? What is the pathology? Is it improving, static, regressing? What were the relevant investigations? In the early days, you know, when I had come back, we did not have CD scan, or we did not have any MRI. CD scans came only in the 70s and MRI only in the 80s. So we used to rely basically on our clinical judgment. And even today, I think the majority of them would go by the clinical judgment and do the relevant investigations. That's a major difference, you know, I think now. So earlier we would be doing the to support our diagnosis, we would be doing the crude thing, you know, we'll be doing air studies, you know, inject the air in the back, which floats up. So now there's a space occupying lesion. And number two, in geography, you'll be surprised to know we used to puncture the carotid artery.

SPEAKER_03 17:31

He was quite expert at that. It's quite amazing. Yeah.

SPEAKER_01 17:38

And that's it's so interesting to hear. And you know, we we just interviewed um two neurologists who were from Ecuador originally, and they had, you know, similar uh uh practices where you know resources such as CT and MRI machines are very it's very dependent based on where you are, especially in Latin America. And so one thing that they also cited was having a very strong clinical presence and really trusting your clinical exam, which is so important within neurology. Um, this has been an incredible conversation. And I wanted to backtrack a little to something, Dr. Single, that you mentioned about, you know, the joint family network and how oftentimes pathology like dementia or stroke can sometimes be compensated because there are such strong cultural values. And I'm wondering, you know, India is a place that is, you know, known for having very rich and diverse cultures depending on what state you're in. Um, for those who are not familiar with um the magnificent Indian culture, can you provide us with some context as to how that influences patient care and what we should know as people practicing in the states and worldwide?

SPEAKER_04 18:46

Well, if I understand correctly, you know, the cultural things do have a great influence in our management. You know. One important thing is the beliefs. For instance, you know, we practice, of course, the Western scientific medicine. But there are people who also still believe in, say, homeopathy and Ayurveda and Urani system. You know, they become sort of competing things, you know. And of course, uh, not much uh, you know, sort of literature the evidence or any trials done there. And I think the uh people have started accepting, but they do feel sometimes that uh one has to be a bit careful. Unfortunately, you know, we don't have time always to explain all the psychic effects. So I think otherwise, I don't think uh majority of the people have a similar sort of view. I don't think the, you know, uh anything would change very much. But the people who are very poor and people who are also education-wise are also deficient, you know. So I think poverty, population, rural area, all these things are impacting them considerably.

SPEAKER_03 19:53

Would you add anything? Yeah, I think we have uh, you know, we still have the joint family system. And, you know, so many of our, you know, the decision making can be very family-centric, which in a way is good and in a way is not good. Family-centric means there's more people to look after, more caregivers. But at the same time, that can be at the expense of the patient's own autonomy. It's usually the senior most people, the grand, you know, the grandparents who will take the decisions. So there are plus and minus points there. Also a bit of gender role, you know, most of the caregiving and all is done by the ladies. So they have a much, much more significant role. And of course, as Professor Signal said, you know, these myths and beliefs, particularly in epilepsy, where you know it's supposed to be still taboo and people don't uh really uh you know, marriage. Often they they hide the fact that they are they they are on these medicines, they either stop them and then when they get the seizures, they may just throw them out. So these are issues which are prevalent in our country.

SPEAKER_04 21:06

But the stigma is getting less, I might say that. You know, I think stigma, but I think uh the important thing really here, I'd like to mention is the question need for plantative care. And understanding, you know, that quality of life is more important than life. This is still not dawned on the people. So that even when, you know, I mean the person is practically there's no chance of recovery, yeah, they still continue to prolong. You know, they still think that miracles might happen. And they still, I think some of them, quite apart from taking the medicine, go away to the temples or mosques, you know, and try and pray. That aspect is still quite a myth in India, uh, all over, I would say. Even the people who are well educated might also believe in that and going along to the temples, you know, to pray for the Recovery of the person.

SPEAKER_06 22:04

I was curious to know um whether or not there are additional resources, considering you are seeing so many family units. Are there resources for caregivers or are there conversations that are held that may be different than what we see without a strong caregiver or family unit?

SPEAKER_03 22:25

I think this is an extremely interesting question. You know, other, you know, how to help the caregivers. And you know, I'd like Dr. Single to just elaborate a little bit on two very important foundations that he has established, but in particularly in this matter.

SPEAKER_04 22:46

I was interested in the multiple sclerosis, so I was a part of the multiple sclerosis society. Then it so happened that uh with Dr. Lalkaka, the co-founder, we decided to form a neurology foundation. That was in 1998. Basic idea was to people can't go overseas to learn, so therefore, they can have sessions. You know, we can arrange, we do an update meeting every alternate year. We have been doing since 1996, and our next meeting is in February this year. We usually invite experts, whether researchers overseas, you know, it can be from America, Australia, Europe, Europe, England. And they're kind enough to spare their time. You know, we provide them with logistics, you know, we give them the travel and we give them uh, you know, the stay in the hotel, and they spare their time to teach. And uh practically over a thousand or fifteen hundred people come over to attend these sessions. That was one. Number two, we also thought that we should go out to the rural area and to try and see you know what we can do for the people living over there. And we also started giving some funds, and we also have many societies in India, some MS Society, Epilepsy Society. So we started raising the funds to pass on the money to them so that they can do for the patients, you know, as social welfare. That was one. And the second thing, you know, I was a member of the working group on Parkinson's disease. We used to meet, you know, to decide as to how the government should interact and what should be done for the patients for this chronic disabling disease. So therefore, what we did at a meeting in Tokyo, Mary Baker was from England and Mark Herrett was from the NIH, you know. So they said, okay, organize a meeting in India to increase the awareness and see what can be done. So I said, okay, give me some time. So with the help of Dr. Lalkaga, we organized the Parkinson's Disease and Movement Disorder Society. Now that society was registered as a nonprofit organization in 2001. And 2003, when we did not have the cell phones and we did not have the computers readily going, you know, we organized a symposium where we invited 40 international experts from America, England, Europe. It's outstanding. You know, we also have a parallel session for the patients. And now we have nearly, with the help of our team, we built up a team. We have 70 support centers for Parkinson's movement disorders. All over India. All over India. Northeast, Central India, South India, West, everywhere. And we have a dedicated team of people, and in fact, our CEO, Dr. Barreto, Mark Barreto, and she's actually internationally known. So there's a Parkinson's uh conference held internationally, and she's a co-organizer. So I think uh that has been a very satisfying thing that has been done. So we want to help the community as well. And Dr. Jimmy Lalkaka has been helping me considerably in this co-co-founder.

SPEAKER_01 26:18

You know, and and in preparing for this talk, I read all about the incredible work that the both of you have done in creating these nonprofit organizations, how many lives that you have touched and made better, and how much you've increased care and access to neurology through the work that you guys have both selflessly done over the last few decades. Um, I guess my question for you is in I'm sure a lot of hard work, a lot of sleepless nights went into creating these organizations. Um, what was your biggest takeaway or the thing that you learned the most by creating these organizations?

SPEAKER_03 26:58

I think the greatest satisfaction is knowing that you know we have touched so many lives and so many people whom we don't personally know, uh, you know, right across India. And, you know, it's quite incredible. The Parkinson disease, we know we have support groups all over. And the the common refrain is that look, when we go to these meets and do our physio and interact and do you know various things, they feel much, much better than the actual medicines that are given to them for these disorders. So I think there is a tremendous amount of uh you know uh health and satisfaction. And I think all credit to him for having uh really founded, and even now, uh, you know, he's absolutely at the helm of these both organizations.

SPEAKER_04 27:55

And I think uh spending some time for the community is always a great satisfaction. But as Dr. Lalkaka says, I think the patients are immensely pleased with this activity. In fact, even the relatives, if the patient passes away, they come back and say that these are the best years of the prescribe the drugs, you know, which usually they do help. They do also the surgery, you know, the DBS and all that. But I think uh they're most satisfied by the the point is the interaction, they feel isolated. Yes, and they feel depressed. But when they come together, they're singing and dancing, you know. Singing and dancing also makes a lot of joyment for them. We usually have a World Parkinson's Day meeting on the on in April, on uh 11th of April generally, uh, where all the patients uh gather from different areas. So it's quite a quite a good feeling at that time. So I think that's uh it's a great satisfaction. I think being a neurology, as you know, where you have to have a lot of compassion. And that is very, very important, I think. Uh compassion has to be there. We have to listen to them patiently. There are many complaints. Then we examine the relevant, and then considering the cost, we do the relevant investigation and give them the treatment. And as you know, we have the generic drugs, you know. There are drugs, you know, which are, after all, a lot of research and expenditure have been evolved and they're very expensive if you get the imported drugs. But at least in India, when the patent is expired, the generic drugs are available and sometimes otherwise also, you know, they make in a different manner. You know, not the patented method. So I think uh generic drugs are boon to them. So I think that uh so that actually is the issue.

unknown 29:49

Dr.

SPEAKER_06 29:49

Single, you just you you've been one step ahead of me almost this whole conversation. Everything that I think about asking, you lead right into it. Um, I was wondering about the medication access, um, especially with some of your interests in autoimmune. Uh, we hear about new therapeutics almost uh on a monthly basis now through clinical trials or or other publications in evidence-based medicine. Do you hear about medications that sound so promising and are unable to be able to have them for your patients? And is this something that you you deal with day in and day out? And how do you try to mitigate this whenever it comes up?

SPEAKER_04 30:29

It's a good question that you have asked, you know, access to the medications, you know. Well, one, of course, the important thing is that in India, a lot of people are taking part in clinical trials, you know. We have a, you know, I mean, the patients are quite quite many, and therefore many of the drugs and multiple sclerosis, I think our people have taken part, similar in epilepsy and other drugs. So one, of course, has been partaking in the clinical trials. And number two, of course, as far as access to the medicine is concerned, you know, we do not as yet have a good insurance system. Patients have to pay from their pocket. So therefore, the generic drugs are great. Say, for instance, a patient drug for the, you know, for uh uh multiple sclerosis, you know, the B cell depleting drugs for that matter. I mean, here in India, we will get much cheaper, at least one-tenth the price than elsewhere, basically when the generic drugs are available. Till then, of course, the I must say the companies overseas also try and help us in reducing the cost considering the things in India and the other poor countries. So resource-based countries you know have a lot of issues regarding the cost of the drug and the drugs are available. I mean, practically, and if the drugs are not available, we can import them by taking a special permission. So this aspect can be covered. I think they can't, and they can they will be they will not be denied. And I must confess that even sometimes, say, for instance, Mompei disease, a genetic disease, you know, muscle disease, you know, the company provides them free of charge, you know, the drug because it's a very expensive drug. So I think uh but basically patients have to pay from their pocket. And I think in coming time, I'm hoping that insurance will cover. Government can do up to a certain extent, but not much.

SPEAKER_03 32:33

Two issues here. I'd just like to add that there is one patient who I recollect, you know, with neuromyelitis optica in Dubai. And there they don't, uh, you know, retuxie map is not, you know, uh sort of the their insurance doesn't cover that. So they actually come to Bombay to get the Rituximap every six months and go back, and it's it's worked for them. And the second thing is that uh, you know, the insurance, I think, as uh as Professor mentioned, uh, you know, is uh very little. And and those who have also they will always try and find loopholes to try and avoid paying the insurer. So there's often a battle, you know, between the doctors, the patients, and the insurance people.

SPEAKER_06 33:28

I wanted to just shift gears a little bit quickly. Uh, I'm partial to education uh and and training. And one of the things that we see a lot of here is the um uh a very large expansion of sub-specialty training and sub-specialist here, especially in North America. Um, I was curious, I know that you both have interest, but you're both general neurologists. You see anything that comes to you. Are you finding that the landscape in India is similar to that, or do you find it changing as time is going on, where a lot of people are going and having sub-specialty training and coming back to the area and that you're interacting with more subspecialists, or do you still find that the majority of people and your colleagues are still general neurologists?

SPEAKER_04 34:12

I think a speciality or completely restricting to a spatiality may take another 15 to 20 years, I think. Because just now, one neurologist for half a million people. So even those people who are interventional neurologists are still saying patients with other diseases. Yes. So I feel that it will be quite a long time, you know. I think they although we have uh now uh setups, you know, for training neurologists, we have a three-year course for DM neurology. We also have another course about for DNB. So we're getting about say six to seven hundred neurologists every year. But for this population, it's quite still very less.

SPEAKER_03 34:54

Yes, I think the uh I think I can't think of anyone who is completely dedicated to their sub-speciality. They all have you know interests and they focus on them, but almost all of them will practice general neurology.

SPEAKER_06 35:15

I'm still a believer in in the stance that you have to be a great general neurologist to be a great subspecialist. So I hope, uh, even though the landscape is changing, that we never completely lose sight of that.

SPEAKER_04 35:31

On the other hand, we have now people, for instance, acute stroke management. I think uh we have dedicated people who do that. They see the other cases also, but we quickly refer the cases. For instance, I'm not able to handle acute stroke. So I request my colleague to take over the case, you know. So I think this sort of a cooperation is also quite a bit in India, you know. I think I at least in the institutions. Other aspects, of course, are the rehabilitation, you know. The rehabilitation I think uh has a lot to be improved upon, you know. We have uh rehabilitation teams, social workers, you know. Uh infrastructure has to be also improved along with the doctors, you know.

SPEAKER_01 36:20

One of the remaining questions that I have um is you know, we talked a lot about how much neurology has changed throughout the course of your career in terms of the different types of imaging that's available, as well as treatment and access to care that you both have been instrumental for. What do you hope changes in the next 20 to 30 years when it comes to neurology care in India?

SPEAKER_04 36:46

That's a good question, you know, foreseeing that. You know, but I feel that uh there will be more and few more neurologists, especially, but clinical forte will remain. They will continue to use the clinical uh specs more strongly, even over the next 20 years, although tendency is now to say look at the MRI picture before you see the patient, but that we are trying to dissuade the people. But I think there will be more these tools, you know, should be used as tools and not as masters, you know. So I have a feeling over the years, clinical uh neurology will still play a dominant role. We're using the other tools, you know, including the artificial intelligence in a sensible manner. I think it'll change the horizon considerably. So I think a lot will happen. And I'm quite sure there's an improvement all around, all the time happening. And uh luckily there's a lot of interaction, you know. The inter people go for international meetings, you know, say multiple sclerosis, we have pectrims, actrines, and similarly, they go for stroke meeting, they go for the all India meeting. There's a lot of exchange happening, they're bringing in good ideas as well.

SPEAKER_03 37:59

Yeah, I think genetics, the uh the newer drugs, the you know, precision medicine, you know, targeting, you know, will certainly, certainly improve as time goes by. But the basic uh, you know, clinical examination must never die. In fact, I feel that with all these sophisticated investigation facilities, more emphasis has to be paid on the basic neurological examination, history taking, the most important thing. It can change everything. We've seen people who have been, you know, treated as sort of you know, in a probably not an appropriate way because the history and examination was not thoroughly done. So I think that can never die. I hope it never dies.

SPEAKER_04 38:50

Over the next 20 years, I think there were a lot of uh changes happening, you know. I think uh because now we are seeing this, all the you know, CART cell, and we are seeing uh, you know, the genetic engineering, genetic diseases, immunological disorders, advances in the treatment of the malignancy, including clavlastoma in the brain. I think there's a lot of change happening, you know. And in fact, uh, we have very good hospitals in all for instance. We have a cancer hospital, Tata Hospital, doing a great job. They're doing some research as well. So research at the moment is also happening, you know. Although very basic research may not be happening as much as you want, but there's a good collaboration with the institutes of science and IITs and other sciences with the medical colleges and the institutions. So I think in the next 20 years, India should be on a reasonable footing, you know.

SPEAKER_06 39:45

When you were talking about neurogenetics, uh, I think it's it's so interesting to think about because I think of everything from medication responsiveness for some people, take something as easy as clopidogrel and being able to really target which patients are responding to a medication that's even a simple anti-thrombotic. And then to your point, all the way to glioblastoma uh and looking at all the cellular markers and the directed therapies that we're able to start thinking through. So um I started thinking a lot about what you were talking about and what the landscape of neurology may look like when we can truly individualize patient care, but then also coming back and saying it still all starts with very good clinical acumen, with all of these other things being supportive to try to do individualized care for our patients. And I think it's exciting to think about it's also a little bit overwhelming to think about keeping up with all of this. And so, especially in an area where even if you do have specialized interests to be able to maintain your knowledge base of everything that's going on in all of these different fields, do you have any tips and tricks as to stay updated on everything that's going on in the whole community of neurology? Because clearly you've been able to do it for your whole career to this point. How do you envision young people being able to stay up to date in the next 20 years through their neurology journeys?

SPEAKER_04 41:09

Should not be very difficult, actually, you know, in the sense that because now we have uh previously we didn't have access to the journals, you know. Today, you know, I mean the say on the on the internet and all that, you can get all information. And even the AI can be used in a very useful manner. Of course, we can't depend on that. And of course, in neurology, I feel the human touch has to be there. Your human touch has to be there because compassion plays a very important role, you know. Yeah, even eye contact and listening to the patient is so important. So I feel like landscape will change considerably, and I hope they continue to use these new advances as their tools and not as their masters.

SPEAKER_06 41:53

Yeah. And sometimes I hear from uh residents and I hear from fellows that uh, as nice as it is to be able to have some more uh educational material and journals at their fingertips, sometimes it can be very overwhelming to try to keep up because there's so much out there. Um, it's hard to discern what is meaningful, what is not. And so uh I wonder if there's gonna have to be a balance at some point about uh being able to decipher through what information is actually useful.

SPEAKER_03 42:24

I think there's a certain degree of experience also, which is so important. One can, you know, think of 20 different causes for a particular ailment. But for that patient, what does our experience tell us over the years? I think uh, and that need not always be evidence-based medicine. I think that's where you know the number of years that one uh practices, you know, uh helps a lot, to certain extent.

SPEAKER_04 42:55

Yes. But I must say that I think uh these uh AI and all tools will be of great help. It will make a lot of change. Well, after all, it's a quick accumulation of all the scientific material. And uh mind you, I find if I go on the rounds with the residents, they are ahead of me because of the they already looked up the Gemini or the you know, whatever they want, you know, so that they already know many of the answers, you know. But of course, uh, as he rightly says, you know, clinical examination and what exactly the patient wants is more important, you know, too.

SPEAKER_06 43:32

Yeah. All right, Newper, take it over.

SPEAKER_01 43:36

All right. Well, this has been an incredible conversation. And just to be mindful of both of your times, why don't we move into our no-brainers? Um, these are going to be five uh rapid fire questions that you can answer one word or one sentence. And then we'll start with you, Dr. Singal, um, with the first question and Dr. Lilkaka, you can answer next, and then we'll move on to the next question and then go through all five. Does that make sense? Okay. So the first question that I have, what was your favorite part of this conversation?

SPEAKER_05 44:16

Yeah, interacting with you people, Rati, you have asked such sensible questions.

SPEAKER_03 44:22

Yes, I think the two of you, I think that's the most important thing. And we don't know where the time has gone.

SPEAKER_01 44:32

It's been a wonderful hour. Um, the second question that I have if you could leave listeners with one message about neurology in India, what would it be?

SPEAKER_04 44:44

Do I answer that, Jiro? Yeah, my answer would be that rely on your clinical ability and use the tools as your servants, not as masters.

SPEAKER_03 44:55

It's interesting, it's exciting, it'll get better, but always keep the patient at the center.

SPEAKER_01 45:03

Beautiful. What is one word your family or friends would use to describe your job?

SPEAKER_04 45:15

Yeah. Care of the patients, you know, satisfying, getting a good feedback from the patient that you do something good for the patient.

SPEAKER_03 45:25

Family would always, you know, would feel that you know one is spending too much of time on this and would like, you know, me to spend more time in other things. Work, like, work balance, you know. Yes, work and family balance. I think that's very important.

SPEAKER_01 45:45

What skill has been most essential to your practice?

SPEAKER_04 45:51

Listening to the patient carefully.

SPEAKER_03 45:57

Yes, I think absolutely. Listen, listen. We keep the MRIs and the CT scans aside, other people's prescriptions, and listen to what they say.

SPEAKER_00 46:09

And the last no-brainer I have, what are you most proud of?

SPEAKER_05 46:18

Why? Well, I think uh to be humble.

SPEAKER_04 46:22

There's a lot to learn. To be giving and not receiving. That would be my objective.

SPEAKER_03 46:32

I think proud of our two organizations, really proud.

SPEAKER_01 46:43

Thank you for listening to this episode of the Neurophilia Podcast, and a huge thank you to our guests. We have many more exciting episodes planned for season four. See you in the next one.