Sunday, January 17, 2010

Reorganize Orthopedic Education & Training – This is the Right Time - Dr Anil K. Jain , UCMS

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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.
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
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