The origin of this post comes from my participation in a recent Panel discussion about improving Surgical Training in India. The session was titled “HOW WE CAN IMPROVE SURGICAL TRAINING IN THE INDIAN SUBCONTINENT” organized by Learning General Surgery Group. In the group we have recently been seeing an uprise of frustration among surgical residents about not getting enough operative opportunities, and surprisingly the problem is countrywide. On one side there are clear prescribed guidelines on the kind of surgeries a resident is supposed to do during his training and the role of resident in each surgery is clearly prescribed in the course brochures of MS and DNB General surgery by the governing agencies like NBE, NMC and respective Medical Universities. But the same is not being put into practice which is causing the rising frustration in the community of surgical trainees in India. Most residents will agree with my views and most faculty will not and may think that they also did the same, why create all the fuss. But if the system has to be improved, an open-minded approach towards discussion and deliberation is necessary.
The Problems with the Surgical Training in India
In this section, before talking about the solutions, let’s start by clearly defining the problem statement while keeping in mind the perspectives of both the surgical residents and faculty. Below I have enumerated the problems which I could identify as most pressing:
1. Surgical Residents are increasingly being used for Clerical works
Everyone is aware of the systemic deficiencies our hospitals have (especially government institutes). Many jobs which are clearly a nursing job are not done by nurses due to their indifferent attitude, strong unions, lack of clear guidelines from hospital administration, nursing administration and medical administration. Many nursing jobs are imposed on residents as nobody else does them.
Similarly, due to the absence of efficient IT systems, collection of lab and radiological investigation reports are also considered to be the responsibility of surgical residents or interns.
2. No Facility for Intermediate surgical training
Most Indian surgical institutes do not have any facilities (functioning) for intermediate surgical training like Wet Labs, Skill Labs and facilities for Cadaveric anatomic dissection and cadaveric surgery sessions. So, the current surgical teaching process in practice is “read-observe-operate”, rather than “read-observe-practice-operate”. We are currently missing upon this big opportunity where the residents can practice and master a specific surgery with procedure simulations over animal models before operating on real patients, for example- Bowel anastomosis simulation, vascular anastomosis simulations, lap simulations etc.)
3. More number of Senior Residents and Assistant Professors above the trainee residents
The number of posts of senior residents and Assistant professors have increased and since they are also in their learning stage, a major share of surgeries (especially laparoscopic surgeries) is taken up by them and the trainee residents are left with a very limited number and variety of procedures.
4.. Number of Residents is increasing
In the last 4-5 years there has been a big increase in PG seats by atleast 70-80 percent since 2014. This has led to distribution of operative cases between the increasing number of residents, hence reduced the overall operative exposure.
5. Increasing number of litigations making senior faculty uncomfortable in giving operative free hand
Since there has been an increase in litigations over patient outcomes over the past few decades, the faculty are getting uncomfortable in giving operative free hand especially in private medical colleges and private hospitals running DNB courses.
6. Culture of Teaching during surgeries is gradually dwindling
The culture of teaching is gradually dwindling in medical institutes and the usual excuse given is that the residents are not up to the mark and have not come prepared (while they are day and night busy with clerical work, emergency duties and ward duties).
7. Paying patients expect only their consulting surgeons to be operating on them
Paying patients in private medical colleges and Private hospitals running DNB courses come with expectation that only their consulting or star surgeon to be operating on them (they usually come with an expectation that all surgical steps including opening and closure will be done by him).
8. No mechanism for quality audits for surgical teaching programs
The procedures which a resident is supposed to assist and do independently during his residency program are clearly outlined in the course prospectus of MS/MCh and DNB/DrNB surgical courses. But the guidelines are seldom put into practice and there is no mechanism to ensure if these training guidelines are being followed or not. In short, there is no quality feedback mechanism both for the institute and also for the surgical residents to decide which institute to choose during counselling.
Proposed Solutions for improving Surgical Training in India
- Mandatory provision for cadaveric training and simulation training facilities in each institute running a surgical residency course.
- Anatomical dissection hall to be allowed for PGs and Super specialty residents also who want to revise their anatomy before particular surgery.
- Attending forensic autopsy can also be one avenue to be explored where residents can get the feel of anatomy and real tissue.
- The quality feedback mechanism can be introduced by any of the following means:
- Transparent Quality audits by governing agencies (NBE, NMC or Concerning Medical University)
- A system for anonymous rating by surgical residents based on which ranking of institutes can be populated, so that institutes offering better training and exposure get higher ranking doctors. In the current scenario, the doctors choose their institutes based on hearsay and face value of the institute rather than the real value. There is no method for objective ranking of the institutes.
- Residents should take learning seriously and show more involvement in overall patient care so that faculty becomes more interested in teaching. Similarly, faculty should also take teaching as a responsibility.
- Private medical colleges and DNB institutes should be mandated to arrange for postings in Government colleges for hands on exposure.
- Clear distribution of cases by complexity between 1st, 2nd, 3rd year residents, senior residents and assistant professors while keeping in mind course guidelines for surgical training (course brochures).
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