a world health organization ( who ) report indicated that neurological disorders are a challenging problem in public health circles . approximately 6.7 million patients died from stroke in 2012 worldwide and this ranked as the second leading cause of death after ischemic heart disease . even in the us , there are several issues regarding the neurology workforce . the demand for neurologists is proposed to be 21,440 in the year 2025 with an approximate 19% shortfall resulting in long waiting times to see neurologists . in asia and the neurologists per population ratio in thailand was 1:178,830 , while the average ratio for singapore was 1:81,132 . numbers of neurologists are needed to be increased worldwide to catch up with the increasing population . not only is there the limited neurologist issue , a survey from spain conducted in neurologists also showed the need to improve neurology training for both undergraduate and postgraduate physician training particularly for family practitioners . approximately two thirds of neurological practices in thailand were in the out - patient setting . to improve neurology training , knowledge of disease distribution and problems at the ambulatory neurology clinic the neurology training should focus on common neurological diseases as well as diagnoses of difficult diseases . this study aimed to evaluate the functions and problems of the neurological clinic in a university hospital in thailand with the specific aim to improve quality of care and neurology training . the results here may apply to other tertiary care hospitals in thailand as well as in asian or southeast asian countries . a prospective study was performed in the ambulatory neurological clinic , srinagarind hospital , khon kaen university , thailand . this healthcare facility is a university teaching hospital located in the northeast area of thailand . the total number of patients for all disease possibilities is approximately 3000 outpatients per day . there were three neurologists providing services at the clinic , each one ran one afternoon session , once a week . data were recorded on numbers of patients , characteristics of patients , consultation notes , and time spent for each patient . the study protocol was approved by the ethics committee of human research , khon kaen university . the total number of visits to doctors was 6137 in a period of 9 months ( 681 visits / month ) . of those , 1488 patients ( 53% ) were female , while 1346 patients ( 47% ) were male . most patients , 2652 patients or 93% , were thai , while 161 patients ( 6% ) were chinese , 15 patients ( 1% ) were laotian , and 6 patients ( 0.2% ) were caucasians . the ten leading diagnoses among the outpatients were : i ) cerebrovascular diseases ( 33% ) , ii ) epilepsy ( 16% ) , iii ) movement disorders ( mm , non - parkinson s disease , 12% ) , iv ) parkinson s disease ( pd , 10% ) , v ) general medical diseases ( 4% ) , vi ) headaches ( 4% ) , vii ) neuromuscular junction ( nmj ) diseases ( 4% ) , viii ) central nervous system ( cns ) infection ( 3% ) , ix ) cranial nerve neuropathy ( 2% ) , and x ) neurodegenerative diseases ( 2% ) as shown in figure 2 . the patients were divided into 2 classes : 2317 former patients ( 82% ) and 517 new patients ( 18% ) . out of the 517 new patients , 337 cases ( 65% ) had not been diagnosed before seeing a neurologist . of these , 151 cases ( 29% ) , however , had the correct diagnosis by the referring physician , whereas 29 patients ( 6% ) had wrong diagnoses . these patients with wrong diagnoses included myelopathy and radiculopathy , syncope , a spinal cord disorder , hydrocephalus , motor neuron disease , delirium , sleep disorder , polyneuropathy , tumors in the cns , vertigo , neurodegenerative disease , neuropsychiatric disorder , peripheral nerve disorder , cns infection , cranial nerve neuropathy , and muscle disease . cerebrovascular disease was the most common disease in this study , similarly to who data . the rate of cerebrovascular disease was somewhat lower than the previous study in 1993 ( 33% vs 38.4% ) . with the time lapse of 16 years ( 1993 to 2009 ) , the most commonly found disease remained the same . note that numbers of patients with epilepsy and movement disorders except parkinson disease were quite high . the survey in 1989 with 23 neurologists found that there were 1700 patients per week or 73.9 patients / neurologist / week . the present study showed that the average patients per neurologist per week was approximately 105 . this finding indicated that the numbers of patients seen by neurologists at the university hospital were almost 1.5 times the 1989 average of thailand . the average time spent per patient was only 6.34 minutes . during this time period , the neurologists needed to take care of patients and also supervise residents at the same time . a survey performed by world federation of neurology found that only 65% of residents passed the national board examinations . among the new patients , there were wrong diagnoses in only 6% of cases and 65% of new patients had no diagnosis prior to neurological consultation . in total , the diseases accounted for in this group were somewhat uncommon diseases such as radiculopathy , myelopathy , and neuropathy . again , the problem will be part of the overwhelming issue of the workload for neurologists . neurologists are required in general hospitals to assist the primary care doctors to diagnose rare neurological disorders . compared to other countries , the number of neurologists are fewer in both thailand and the us , which causes long waiting times and short visits ; only 6.34 minutes in this study in thailand . university hospitals are the main postgraduate training sites for residents , but regional or general hospitals could play an important role in neurological training as well . moving some training to the general or regional hospital may increase numbers of trained residents . this study emphasized the need to improve ambulatory neurological care due to the high number of patients and limited numbers of neurologists . this survey also addressed workforce and workload issues of neurologists that are directly associated with burnout issues . the government should provide more support in funding training in neurology . with comprehensive training , general practitioners or internists should be able to handle simple neurological diseases including stroke patients and refer only difficult patients to neurologists . the main limitation of this study is that it included a study population that represented only the tertiary care level in thailand . another study should look at the outpatient clinical patient populations at regional and general hospitals . improvement and additional training of general practitioners and internists at a higher level may lighten the load in tertiary care hospitals in thailand . this study included only the ambulatory workload because most neurological workload is located in the outpatient service . . further collaborated studies with other asian countries may provide insights into new strategies to lighten the load in tertiary hospitals and provide better training opportunities for residents , general practitioners and internists . in conclusion , ambulatory neurology clinics are overwhelmed in university hospitals in thailand . neurology training focuses on common neurological diseases such as stroke , epilepsy , and movement disorders . diagnostic training of other difficult diseases such as myelopathy or motor neuron disease should be emphasized as well .
the burden of neurological disorders is high in developing countries . 
 real life data from neurologists as to how they practice in thailand are limited in literature . 
 practices of neurologists in a university hospital clinical setting in thailand were studied . 
 a prospective study was performed at the ambulatory neurology clinic , khon kaen university hospital , between 1 february and 31 october 2009 . 
 the following data were recorded : numbers of patients , characteristics of patients , consultation notes , and time spent for each patient . 
 there were three neurologists , each of whom ran one afternoon clinic , once a week . 
 there were 6137 visits during the 9 months , with an average of 681 visits per month . 
 the total number of patients was 2834 . 
 the three most common diseases were cerebrovascular diseases ( 33% ) , epilepsy ( 16% ) , and movement disorders ( non - parkinson s disease , 12% ) . 
 neurologists spent an average of 6.34 minutes per patient . in conclusion , 
 neurologists in medical schools have limited time to take care of each patient . 
 several strategies are needed in medical education and neurology training to improve the quality of care .