Saturday, January 16, 2010

Winds of Change in Orthopedic Training: Isnít it Time?

 Thomas J Kishen, Ashish D. Diwan,

Spine Service, St George Hospital and Clinical School, University of New South Wales, Sydney, Australia.

Correspondence:

Dr. Ashish D. Diwan

Spine Service,

53, Montgomery Street,

Kogarah, NSW– 2217, Australia.

E-mail: a.diwan@spine-service.org

 

Orthopedic surgery as a specialty has evolved over the years. The quantum leap in diagnostic technology enables us in early and accurate diagnosis. Research in genetics and molecular biology has enhanced our understanding of disease etiology and pathophysiology. Advanced instrumentation systems and implants allow the conduct of complex surgical procedures with lower complications rates and superior outcomes. On the other hand, high patient expectations, low tolerance to unfavorable surgical outcomes and increasing medical litigation are modern day realities.

In this evolving scenario, we need to critically analyze whether the current orthopedic training program (post-graduate course) caters to the future needs of Indian orthopedics. Most medical colleges have an adequate and varied caseload, but there is a lack of uniformity in the orthopedic training programs across the country. The purpose of this article is to initiate a debate on improving the standards of orthopedic training in India to attain international conformity while serving the needs of the country.

Although there are numerous issues to be addressed, this article focuses on the structure and duration of the training program. In addition, we have made some recommendations that need to be debated by the orthopedic community and considered for implementation to improve the quality of orthopedic training in India and the career stream of future trainees.

 

A competency or outcome-based orthopedic training program:

The current orthopedic training program, based on an opportunistic learning pattern or “apprenticeship” model, needs to be replaced by a “structured” training system.1 A competency based or outcome based education (OBE) is a structured program in which decisions about the curriculum are driven by the outcomes the students should display by the end of the course.2 OBE focuses on outcomes to be achieved at the end of the course and the learning activities and course content are tailored to achieve these outcomes.

Learning outcomes provide a broad overview of guaranteed achievements3 for students who complete a course. Learning outcomes in orthopedic surgery can be broadly divided into three categories – knowledge, skills and attitudes. Learning activities [Table 1] including lectures, case presentations, skill labs, assisting and performing surgery independently are aimed at attaining these learning outcomes. Assessments conducted during and at the end of the course test the attainment of each of the outcomes. Although patient care related activities form a significant and crucial part of a trainee’s schedule, it is equally important to allocate time for learning activities.

Duration of training:

The orthopedic training curriculum needs to cater to the unique disease spectrum of the country. This is influenced by the socio-economical and cultural needs of its population. The duration of the course should be dictated by the time required to achieve the learning outcomes. Training programs across the globe have been modified from time to time to accommodate these changing needs. Currently, most American Hospitals have a four to six year Orthopedic Residency program, preceded by a year of basic surgical training. The increase in the duration of training came into effect prior to limitations on resident working hours and was a direct response to the evolution of the orthopedic specialty. Similarly, Specialist Registrar training in orthopedics in the UK4 lasts six years and is preceded by one year of mandatory basic surgical training. Progression through higher surgical training depends on regular in-training assessments. Since 1986, orthopedic trainees in Singapore5 have been undergoing three years of basic surgical training followed by three years of orthopedic training.  

Table 2 lists the duration of basic surgical training and advanced orthopedic training in six countries. The current three year MS/DNB orthopedic course is inadequate to train orthopedic surgeons competent in the knowledge, skill and attitude categories and comparable to international standards. The three-year senior residency program provides an excellent path for continuation of training; unfortunately, it is limited to a few states and central institutions. Further, if a trainee has to undergo three more years of mandatory training after being certified as an orthopedic surgeon, it clearly exhibits the inadequacy of the primary course. With the explosion of knowledge in the field of orthopedic surgery and the development of numerous sub-specialities, a six-year training program is appropriate at the end of which the certificate of training is received. This will be the combined duration of MS/DNB course and senior residency.

If this argument is extrapolated to the two-year Diploma in Orthopedics course (D’Ortho), then a stand-alone D’Ortho course (without subsequent MS or DNB training) serves the aim of developing competence in the field. However, to achieve the ideal surgeon to population ratio of 1:25000, India will need 40,000 surgeons. Hence, in the Indian scenario with limited resources, the D’Ortho surgeon can play an important role if limitations are placed on their clinical/surgical work.

Issues for consideration:

  1.  Increase in duration of the training program to six years.
  2. Structured uniform training program to ensure competence in the knowledge, skills and attitude domains.
  3.  Issues surrounding thesis work. Does it serve any purpose in its present form?
  4. Maintenance of factually correct log book to assess the surgical exposure of the trainee
  5. Limitations of clinical/surgical work after a stand-alone D’Ortho qualification
  6. Institutional re-accreditation based on training program
  7. Regional private–public hospital partnerships to allow multi-hospital rotations for trainees
  8. Streamlining sub-specialty training in orthopedics with a data-base (handbook) maintained for the purpose
  9.  Evidence of knowledge and skill up-gradation (professional development) as a criteria for renewal of registration.
  10.  Indian Orthopedic Association can play a proactive and regulatory role in Orthopedic training.

SUMMARY

There is an urgent need to address numerous issues relating to the post-graduate orthopedic training program. We hope that the Indian Orthopedic Association initiates a debate on this subject and takes steps to ensure a uniform, structured, high quality training program.

 

ACKNOWLEDGMENT

The authors would like to thank Helen Houridis RN for proof reading this manuscript.

 

REFERENCES

1.  Toms AD, McClelland, Maffullin N. Trauma and orthopaedic training in the United Kingdom. J Bone Joint Surg Am 2002;84:501-3.

2.  Harden RM, Crosby JR, Davis MH. An introduction to outcome based education: AMEE Guide no 14: Part 1. Med Teach 1999;21:7-14.

3.  Harden RM. Learning outcomes and instructional objectives: Is there a difference? Med Teacher 2002;24:151-5.

4.  Pitts D, Rowley DI, Marx C, Sher L, Banks T, Murray A. A competency based curriculum. Specialist training in trauma and orthopaedics. Available from: http://www.ocap.org.uk/orthocurriculum/Content/00_Contents_160707.pdf. [accessed on 2009 Sep 15].

5.  Wang W, Lee EH, Wong HK. One hundred years of orthopaedic education in Singapore. Ann Acad Med Singapore 2005;34:130C-6C.

Comments

1. satishchandra gore said...

I am happy that we are now maturing enough to question what was put as a set of rules in past for training. The openness is good. I congratulate ashish for this initiative. I would like to add my observations. With our socio economic factors i think extending our training will not serve any prupose if the incoming drs are same. We have to realise that we will have to start screening candidates at an early age "catch them young" and then look at putting them into specific posts. This may smack of authority but present way of candidate getting marks and then choice of branch has utterly failed. Our screening is irrelevant.
We also need to make a comprehensive list of skills needed for a trauma or spine or joint replacement surgeon which i am sure are NOt same. In the ear of superfine technology to critically analyse patients we need to ANALYSE candidates opting to enter orthopedics and see if they are fit to enter and then mature in this stream. Other issue which we have not tackled head on is way present day entry is decided its entirely MONEY and sycophancy. In a clinic or set up which only encourages chatugiri we can not hope to get mature independent thinking surgeons. SO may be we need to also include a screening test for teachers. I would mention that famous statement by a innovator" in schools i learnt physics, chemistry but NO one ever taught me how to think and solve problems". We need to reinvent that spirit of enquiry. One last shot why we see our own INDIAN surgeons excelling out of motherland and bogged down here. We need to apply our mind to this issue and treat the cause not by kids gloves

2. Dr.A.KALILUR+RAHMAN said...

Six years of post M,B,B,S training is a nightmare.Full time 3 years residential training is a better alternative.Allocation of seats must be only by merit and by an all india entrance irresective of Govt or private college.When the degree is the same (M.S.ORTHO), the ultimate goals of skills to be uniformly defined.
Minimum hours of training in each aspects like theory ,clinicals,surgery to be pre determined and to be adhered.Evaluation to be corse oriented not by mere 3 hours of theory and threatening clinicals where an examiner can utter non sens questions irrelevent to practice. What ever method of assesment will be to bring out the skills aquired by PGs, and to point out lacanas to get him corrected throughout the course.The research aspect and encouragement to newer ideas to be shown from the providers side.

3. Ram+K+Shah said...

I agree with your view point that the current Course of MS/DNB needs to to re structured to allow adequate time/duration for obtaining necessary knowledge, skill and develop attitudes for providing standard orthopaedic care.
Moreover, I also agree that there should be interlinked & structured program for service requirements and academic requirements of the country. The D.Orth should be for 2 years and they will go to serve the needy people/places within limits of knowledge & skills, then the suitable and interested candidates from D.Orth after 2-3 years of sevices may be offered to progress to MS/DNB which will be of 3 years duration; after that the candidates will have to do at least 2 years of Senior Residency under supervision which will finally enable the candidate to obtain the licence of practice as a trained Orthopaedic Surgeon.
One more point is that there must be effective annual assessment for promotion The Thesis or dertation serves only a formality and so it also needs to be given a new thought. In my openion training in research methodology and writing scientific papers would be enough.

4. praveen+sarda said...

I think you have started a very topical and important debate. I think our training programme hasn't changed at all in the last 50 years, while Orthopaedics as a specialty has changed beyond recognition in that time. It is vitally important to revamp the system to make sure the surgeons we produce are properly trained and fit for purpose. Unfortunately there is little comprehension of this issue in India itself, and the difference in training is only recognised by people who go outside country for fellowships etc and are exposed to western training system. I agree with most points you have raised, but have some difference of opinion about how this can be delivered:
1. Duration of training: 6 years is doubling the duration of training, and has huge implications in terms of the financial burden on government. We have to remember we cannot look at Orthopaedic training in isolation. So if we suggest 6 years for Orthopaedics, it has to go up across the board in all specialties, which means effectively at least doubling of budget for residency program itself. There will also be issues of ensuring proper training and experience for increased number of trainees, and increasing the number of PG guides. The govt hospitals are struggling to retain the staff they have due to poor pay and working conditions. Under the circumstances, we are talking of a widespread reforms which need not only the MCI support, but also strong political will. In my opinion, it would be more practical to increase the duration to 4 years, with a provision for 1 or 2 years after that for superspecialty fellowship training at recognized centres, something on lines of Mch in India.
2. completely agree with point 2. there needs to be uniformity of curriculum as well as assessment, and I favour national exit exams for MS on the lines of DNB. There should be an independent body carrying this out which can be free from MCI or IOA. We are all too aware of how things are conducted at present .
3 and 4: Thesis is a very important part of the curriculum and it needs to be more realistic to be effective. At the moment it is regarded as a necessary exercise that neither trainee nor the trainer is particularly interested in. We need to train the PG teachers first about methods of research and how to conduct a thesis. Becoming a professor after 10 years of govt service does not necessarily equip one with knowledge about research. currently we have thousands of students completing their thesis every year, yet, only a handful are ever published. There needs to be more awareness of benefits of honest thesis, but in my opinion it is totally down to the trainer community to get this right. There needs to be an electronic logbook, which should be verified independently so that authenticity is maintained. This will also help ensure that the institute is meeting minimum required critria to maintain accredition as a training institute.
This is currently only a paper exercise and it is a public secret that most private institutes get accredition by greasing palms.
7. Private public partnership is perhaps the best method of reforms in our systems, but already there are powerful vested interests in private sector that could seriously flaw the process. Currently PG Ortho seats go for more than 1 crore rupees, and the quality of training that residents get there is abysmal. Government has already made the right move by derecognising 44 "deemed" universities, and it will be imperative to have watertight credentials before granting accredition to any private institute. PG eduction presently is a massive money making business that involves politicians at all levels. This needs to be more performance based in future.
Finally, I believe IOA should be the body lobbying for these changes. MCI is a "den of corruption" as pronounced by the Supreme court of India, and it is upto the IOA to lobby and get our training in order. We need to have committed people to take this forward, not vested interests that we seem to inevitable get.

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