Tuesday, January 12, 2010

Reorganize Orthopedic Education & Training – This is the Right Time

 Dear All,

Orthopedics has grown by leaps and bounds in the last 50 years.  It has evolved from treatment of orthopedic ailments to achieving reasonable function with accepted sequelae to the treatment objective of achieving near normal function and form.  Improved metallurgy, asepsis, intensive care facilities, anesthesia, imaging has allowed us to progress fast.  Orthopedics has evolved into many sub-specialties like spine, pediatric orthopedics, trauma, hand, sports medicine, arthroscopy, arthroplasty, foot and ankle, shoulder and elbow. The training for super specialists in each of these subspecialties is available and accessible only in high income countries (HIC), where orthopedic subspecialties are clearly demarcated without any overlap in all hospitals. 

At the end of PG training of three years in Low Income Countries (LIC) like India a student has only a very basic knowledge of each or a few of these subspecialties.  University/teaching hospitals in LICs still do not have clearly demarcated subspecialties in their respective orthopedic departments.  The teaching hospitals are busy in providing basic care and do not have infrastructure to perform state of art subspecialty work.  There is an insufficient effort to promote the development of orthopedic subspecialties in teaching hospitals.

The clinical problems in HICs and low income countries (LIC) used to be same 50 years ago.  With improved nutrition, sanitation, health infrastructure, certain diseases have been practically eliminated from HIC while LICs continue to face same disease profile.  Industrialization and urbanization has added a high disease burden in LIC.  The high disease load with poor health infrastructure has altered the natural history of trauma.  However, education continues to follow the same pattern as taught in the west and is unchanged since  60 years.

India has a heavy patient load with cases in different stages of natural history.  The students need to learn and be trained about all disease profiles, including the natural history of disease, neglected traumatic and non traumatic pathologies as well as newer trends.  The training imparted also has a wide range.  Some centers are state-of-art where they train for specific procedures while other centers lack infrastructure and the student is taught basic management.  Teachers in such centers have no exposure to state-of-the-art facilities. The service component because of heavy work load take precedence over teaching hence the quality of delivery of education is not assured.

Student evaluation is not structured.  A student trained in basic orthopedics faces a super specialist, or vice-versa, during the examination; hence they perform miserably. 

At present we concentrate on providing basic orthopedic care.  No effort is being directed towards preventive orthopedics.

The shortcomings at present can be grouped as:

1.       Absence of  revised curriculum

2.        Absence of  structured training program

3.       Undefined “must know areas” or undefined core competence area

4.       Absence of mechanism to evaluate the trainee

5.       Absence of training avenues for teachers

6.        Absence of structured evaluation method

7.       No balance in service component and training component

 This is an attempt to invite opinions on the issues involved in training of orthopedic surgeons.

1.       Duration of course

2.       Need for post MS training

3.       Defining core competence for 3 years PG Training

4.       Structured curriculum

5.       Structured evaluation

6.       Objective method to ensure delivery of training.

7.       Need for thesis/dissertation

8.       Duty hours of PG during training

9.       Learning time during 3 years

10.   Log Book

11.   Training of teachers

12.   Balance of service component and training component in medical college.

13.   Make training and evaluation more predictable

14.   Need for training in skill lab.

15.   Mandatory core facilities at teaching institution

16.   Ensuring the availability of core facilities and infrastructure

17.   Ensuring the delivery of orthopedic education

18.   Difference between a basic orthopedic trained person or trained in a subspecialty

These are some issues which have been put up for valuable opinion of each and every orthopedic surgeon in the country and world over.

Objective:

The objective of this blog is to elicit opinion on the standard of orthopedic training and suggest solutions  to arrive at a consensus to provide wholesome orthopedic training to serve our population better.

What is the use of these opinions? 

The problems will be tabulated along with the solution suggested.  A brain storming session will be conducted in the middle of 2010 to achieve a consensus on various issues and publish them as a symposium in IJO and prepare a policy paper for future use.

 

Dr. Anil K Jain
Prof. of Orthopedics in University College of medical science
Senior Orthopedic Surgeon GTB Hospital Delhi
E-mail : dranilkjain@gmail.com

 

Comments

1. santosh venkatachalam said...

Being a post graduate from India, I would entirely agree with the comments above.

I am currently pursuing specialist training in the United Kingdom.

The programme here appears to be more structured. This is definitely due to the better infrastructure, government funding the programme, the national health service (NHS) providing free care without financial implications on the mode of treatment for the patient, developement of preventative orthopaedics, and identification of competencies before becoming a consultant.

these areas can be improved by having an option of rotation through different hospitals/ subspecialities during the 3 years or extended residency programme, attainment of competencies as assessed by a central programme director, and identifying hospitals that could provide the required training with regards to staff and management.

2. Dr Tapan Bhatt said...

Dear Sir,
I Agree entirely with your perspective of the making of orthopedic surgeon.Though problems like infrastructre etc which are money oriented are constrained because of money issue howvever i do have few suggestions
1. Instead of making it easy for a student to become a surgeon which the current govt are doing like payment seats, reservations rules should become more stringent so that only the best with hunger for knowledge should be admitted will probably solve the problem by the strong initiatives of such student themselves. I think this simple step will go far in improving the quality of orthopedic surgeon coming out in short time, till we are financially capable of implimenting the reforms needed

3. Dr J K Dave said...

Strongest area to be seen in revamping of education ie 1-increase duration to 4 years(cut down 1 year from MBBS(2)-follOW American pattern of training ie emphasis on subspeciality training.(3)Rigourous mentorship programme under only seriously interested teachers.Those teachers who have tight schedules need not participate in mentorship.(4)More fellowship/training opportunities for institution attached teachers (Not only medical colleges.one can find very good people in public sector/pvt. sector hospitals ,better than plenty of medical college guys.

4. satishchandra gore said...

WE also need to include teacher assessment. I congratulate u for this great initiative. I would suggest pl allow max junior intraining surgeons to comment.

5. Ashish Anand said...

It is high time that the education system is overhauled.The first step is to have a standard National Board of orthopedics which lays down stringent parameters of training.Right now with dual degrees like DNB and MS-there is no standardisation.Surgical training has to be handon and not bookish ,unfortunately thats the training right now.With the advent of subspecialities traing has to be restructured to produce finer quality of orthopedic surgeons who are well versed in practical knowledge.

6. Dr. Md. Quamar Azam said...

Post-graduate Orthopaedic Training in India Needs a Thought

Orthopaedics, as a surgical speciality has tremendously expanded in the last couple of decades. To meet the growing demand, this branch witnessed as many as six major divisions (specialities) viz. arthroplasty, arthroscopy (sports injury), spine surgery, paediatric surgery, advanced trauma and orthopaedic oncology. In the developed countries, increasing number of post-graduate orthopaedic surgeons is registering themselves for exclusive training in any one of them.
Unfortunately, our orthopaedic training is grossly inadequate for more than one reason.
1. M.S (orth.) is the highest degree granted in India after a training period of three years. Moreover, the training is not structured and ability of the fresh post graduate depends on the institute. It is not a wonder that we pass out without assisting a total hip/ knee arthroplasty, without touching the arthroscope and without seeing surgical management of routine spinal surgeries.
2. The problem is more serious, that even the genuinely interested candidate has nothing to opt (sub-speciality) after passing their M.S Orth.

Are two years diploma training or three years M.S (ortho) training adequate for offering the best to growing demand of patients? If not- what do we have to offer to our post-graduates to improve their skill in any one speciality? Indeed, it is essential that a road map be drawn to explore beneficial changes to meet growing demands of specialized orthopaedic surgeons. After all, it is the stalwart’s vision & guidance and responsibility. May I suggest the following, which may mark a change for the coming generations of budding orthopaedic surgeons:
1. Like many other developed countries; it may be made obligatory that the residents must undergo at least six months exclusive training in one sub-speciality even if that requires going to other institute.
2. Like many other countries; the learning goals for every year residency should be meticulously designed and there should be a uniform theory (even if objective) exams every year before promotion.
3. We must strive harder to initiate M.Ch degrees like other specialities. Like the paediatricians have DM option to choose from or general surgeons have various M.Ch to look for.
3. To organise more structured fellowship programmes.
4. In many countries it is imperative that residents undergo at least six months training in each major sub-speciality before passing and for this they are rotated in various teaching hospitals.
Reference
1. Tuli SM. The art and science of orthopaedics in developing countries. J. Bone and Joint Surg. 1985; 67- B (5): 840-43.
2. Swiontkowski MF. A simple formula for continued improvement in orthopaedic surgery post-graduate training: courageous leadership. J Bone Joint Surg Am. 2008;90:1175.
3. Laura R, Mathias B, Edward C and Thomas PS. Proposals for Change in Orthopaedic Education: Recommendations from an Orthopaedic Residency Directors’ Peer Forum. J Bone Joint Surg Am. 2010;92:245-9

7. Wilfred D'Sa said...

One must understand the existance of an orthopaedic surgeon. In the past, a medical student used to train in a prestigious institution, usually run by the government. They would be taught syllabus related to the bones and joints and would exclusively treat patients with bone and joint disorders. Some would continue to teach orthopaedics and some would do private practice, helping the needy who could not travel and who could afford treatment. In turn the surgeons would benefit financially and would hence prosper. As time went by, newer techniques emerged. The surgeons who worked in institutions experimented and researched for betterment of the technique, idea, etc. and likewise the surgeon in private practice used newer techniques and refinements for financial gain. The final aim or goal seems to be satisfying the mind.
Hence my modest opinion would be to organize the system of education such that the mind is completely satisfied from the start to the finish.

All said and done, one must understand the educational system as well. Nowadays there are Government run colleges and Private run colleges, there is the MCI recognition and the National Boad recognition. Nowadays we have subspeciality or superspeciality units or departments in some colleges. Things are getting complex as far as the educational system are concerned.

In view of all this, I think we should answer only one question: do we intensively need to train for subspeciality right from medical college? or do we need some basic and general trainig first before we learn subspeciality?

I firmly believe that most of our doubts and fears of reorganization of training will be answered by finding an answer to the question quoted above.

A simple way of reorganizing the training would be to tailor make it to individual needs. Sounds simple but it is a tough task for those running the systems.

Hoping for a more systematic reorganization of our training system that benefits "everybody"

8. dr+rajeev+anand said...

HELLO DR JAIN
YOU ARE STARTING V FRUITFULL AND USEFULL DEBATE.WE SHOUL KEEP THIS ALSO IN MIND THERE IS SO MUCH DIVERSITY IN OUR COUNTRY,DEMANDS OF PTS ARE DIFFERENT DUE TO THEIR VARRIED SOCIOCULTURAL NEEDS AND ECONOMICAL STATUS

9. pankaj Kumar said...

1.Required regular traing for teacher
2.Either increase the duration of course or required post MS traing as supersepciality course and registered in MCI as either spine surgeon, hand surgeon etc
3.Thesis is burden
4.MCI is giving recognition where no such facilty of traing and teacher are available

10. drakagrawal said...

this is very well taken important issue which you have raised . methodology is effective. i am sure this shall bring useful suggestion and useful changes in curriculum shall come.

11. SUJAY NATHAN said...

Sir, The issues discussed by you were in the minds of many people which could not be expressed due to lack of a platform. I thank and congratulate you for giving us this opportunity. My first concern is with regard to the training of our post graduates.I feel that Orthopaedics should be considered as a super specialty to surgery, that is we need a basic training in surgery before you train for orthopaedics. the need for specialized training should be over emphasized in this contest. The evaluation of the trainers in our educational institutions is another area where we need to improve a lot. regular assesment of trainers should be made mandatory with need for proper documentation

12. why do u need it said...

teachers are now private practitioners.they donot teach.they are busy in private practice.They donot allow students to do surgery.it is a autocratic way

13. Ram+K+Shah said...

Dear Dr Anil Jain,
It is indeed a very timely exercise to make an effective change for good.
We need to rethink about the duration, contents, skills labs, annual assessments and final exit exams etc.for the orthopaedic programs of MS/DNB in India.
On one hand we need more specialists to serve the growing needs of our people while on the other hand we need competent, qualified and skilled orthopods to keep the pace with the changing time on a global perspective.
Therefore, the specialist training program in Orthopaedics certainly needs re-thinking and I will be happy to participate in the debate.
Sincerely,
Prof Ram Kewal Shah
Kathamndu, Nepal

14. n s dhaniwala said...

I agree with the thought.I think stress on common topics and acquisition of skill is must for basic doctor.Uniformity in the training and exam pattern is also needed.At p g level it is important to revise the contents and make it more practical and country oriented.Revision on the lines of subspeciality should also be thought of.

15. Dr. Sanjay Chaturvedi said...

It is nice attempt to think about reorganizing the orthopedic education; I tried to find the syllabus for our postgraduate course and found that it is comprehensive and covers all the essential points.
I tried to find the objective and goals of PG teaching and you will be surprised to know that they have made it very comprehensive but what we lack is how to achieve that and how to assess that we are on right direction. No evaluation methodology – only one exam and you are through.
Goals
1. PATIENT CARE ABILITY : A candidate in orthopaedics surgery at the end of its 3 yearcourse should develop proper clinical acumen to interpret diagnostic results andcorrelate them with symptoms. He should become capable to diagnose common clinical conditions/diseases in the speciality and to manage them effectively with success. He should be able to decide for making a referral to consultation with a more experienced colleague/professional friend while dealing with any patient with a difficult problem.
2. TEACHING ABILITY : He/she should be able to teach MBBS students about the commonly encountered conditions in orthopaedics, pertaining to their diagnostic features, basic pathophysiological aspects and the general and basic management strategies.
3. RESEARCH ABILITY : He/she should also acquire elementary knowledge about research methodology, including record-keeping methods, and be able to conduct a research inquiry including making a proper analysis and writing a report on its findings. Team work : He/she should be capable to work as a team member. He/she should develop general humane approach to patient care with communicating ability with the patients’ relatives, especially in emergency situations such as in casualty department, while dealing with cancer patients and victims of accidents. He/she should also maintain human values with ethical considerations.
Objectives to be achieved by an individual at the end of 3 years of training
A candidate at the end of a 3-year course should acquire the following:
1. COGNITIVE KNOWLEDGE : Describe embryology, applied anatomy, physiology, pathology, clinical features, diagnostic procedures and the therapeutics including preventive methods (medical/surgical) pertaining to musculoskeletal system.
2. CLINICAL DECISION MAKING ABILITY & MANAGEMENT EXPERTISE : Diagnose conditions from history taking, clinical evaluation and investigations and to develop expertise to manage medically as well as surgically the commonly encountered disorders and diseases in different areas.
3. TEACHING : Acquire ability to teach the MBBS students in simple and straightforward language about the common orthopaedic ailments/disorders, especially about their signs/symptoms for diagnosis with their general principles of therapy.
4. RESEARCH: Develop ability to conduct a research enquiry on clinical materials available in hospital and in community. Patient doctor relation: Develop ability to communicate with the patient and his/her relatives pertaining to the disease condition, its severity and options available for the treatment/therapy.
5. PREVENTIVE ASPECT: Acquire knowledge about prevention of common conditions especially in children such as poliomyelitis, congenital deformities, cerebral palsy and common orthopaedic malignancies.

Then I tried to remember my Postgraduate days and tried to find out the cause why we lack knowledge-
1) We had PG teaching consisted of Seminar, journal club and case presentation - it was actually adequate to cover each aspect but the problem was it was mainly based on common cases mostly which we come across and discussion was mainly to the diagnosis and treatment - we seldom discussed the differential diagnosis, Pathoanatomy or pathophysiology.
All faculty members need to present in the teaching class which is mainly 8 to 9 but mostly come around 8.30 and end at 9 as need of OT etc. so most of the faculty not involved in the discussion and usually this remains as diligent presentation by PG students which need evaluation but lack the same.
We also need to attend UG classes usually once a week and there teacher were teaching to undergraduate students so not much practical discussion and even covers just superficial things about the subject.
The third place where any PG student is exposed to the teaching is in OPD or OT which are mostly overburdened so Teacher seldom get the time to teach.
The other place where PG can get the knowledge by teaching undergraduate students in the evening classes which were used to be twice per week in our time and now I think it has stopped altogether because of orthopedic getting minimal number for evaluation at undergraduate level.
We did not have any log book except attendance on the attendance register to get the PAY CHEQUE.
Now the question arises from where we can get the knowledge I suppose most of the place we are getting knowledge to Practice (Pvt.) rather than improving the knowledge. Teacher is telling that you will learn more by doing work in the ward and OT rather than getting theoretical knowledge. That too we were getting from ward boys and OT technician who use to tell us about hanging weight EK INT ka Ya do INT ka, he was there to help us in giving the Slabs (SO we were getting Practical knowledge). IN OT if teacher is there mostly he struggle to complete the OT list and if it is Thesis case than PG is busy in getting his irrelevant details.
So PG is being trained to as a technician rather than an educationist not getting knowledge of why? How? And when? or when not?
Complication he comes to know in the Dressing room.
One more thing what PG does is dissertation in last one year in the form of thesis and 20 to 25 cases.
So what is wrong in PG training if I need to summarize
1) We have syllabus which covers all aspect for orthopedic learning but we do not have any method to cover the same or evaluate.
2) We are not trained to teach the PG students - In conference we only stress about few boring lectures which mostly restricted to most recent surgical method - TKR THR as we get to know from Industry rather than teaching the basics (making foundation strong) and approach.
3) We do not have any method to evaluate teachers.
4) We have training methods which are old and outdated.
So in my opinion we need to find ways and means to implement our Goals and objectives rather than wasting time in changing the basic objectives which in my opinion will remains the same just few words here and there. The concept of Social medicine is coming which will make this scene worst by getting the rural orthopedic doctors which may be turned out to be greater JHOLA CHAAP than at present as they will have official stamp also. – Government or Thinkers need to reevaluate this idea before implementation. – long live IOA

16. Prof. V.P. Sharma said...

Dear Dr. Jain,
Thanks for asking comments i wish all the orthopaedic
training must have
fix duration training in spine hand trauma oncology kyphoscoliosis spinal cord injury prosthetics & orthotics fields every posting must have training moudule like assistance in surgery clinical assesments etc. and end of the training the reports off the unit incharge must be submitted before permeting for the final eximination.
The training must be practical oriented with good theoretical encludeing latest development in this field.
Thanks
Yours sincerely
(Dr. V.P.Sharma)
Prof. & Head
Deptt. of PMR

17. Dr John Ebnezar said...

There is no denying the fact that the orthopedic education needs to be rehauled. The focus should shift from curative to preventive. The training should aim at producing a orthopedic graduate who can make a difference in the society not merely earn a living. PG's of today lack focus and invariably end up joining the rat race after completion and not service to the mankind. Orthopedics is not only about bones and joints but it is about the complete individual who own these bones and joints. The focus should be towards the human being and not at the bones and joints. OUr training needs to change and change now.

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