Orthopedic training in India: Time to change.

The moral code of Hippocrates states: “As you were trained, so you should train.”

Orthopaedic services and training in India are at cross road.1–3 Medical education that stands today is the experience that has had been garnered over the years when clinical examination was the only way of finding out a discrete condition and speculation alone was the way to arrive at a diagnosis. Throughout the past half century nothing significant has been changed in the medical education system - the structure, syllabus, training and evaluation - but everything else has gone a volume of change i.e. population, diseases, economy, epidemiology and treatment methodology. With the advancement in knowledge, technology and resources, what took 50 years to achieve in the past can be achieved in 5 years. Infact it has been quipped that the next big revolution in India after IT is in the medical field-education, treatment and research.

The specialty of orthopedics in particular has grown by leaps and bounds in the last 50 years thanks to the modern day pandemics – road traffic accidents and osteoporosis. From a neglected specialty that dealt with deformity, osteomyelitis and low energy trauma, it has become a specialty of demand and glamour, ever growing with quantum leaps. Improved metallurgy, asepsis, intensive care facilities, anesthesia, imaging and diagnostic methodology has allowed us to progress faster. Orthopedics has evolved into many subspecialties like spine, pediatric orthopedics, trauma, hand, sports medicine, arthroscopy, arthroplasty, foot and ankle, shoulder and elbow.

But sadly this has been never realized or willfully neglected while training orthopedic postgraduates. Our orthopedic postgraduate training that is currently followed is atleast 50 years old and belongs to those days. The Gen Y ortho resident is faced with a plethora of ways of dealing the same old condition that used to be. Unlike western countries, we do not have clearly demarcated subspecialties for training. Much worse is there is an insufficient effort to promote the development of orthopedic subspecialties in teaching hospitals even though we have high patient loads. With high patient expectations, low tolerance to unfavorable surgical outcomes and increasing medical litigations, it is time that our current orthopedic training program is critically analyzed and appropriately modified/ amended to cater to the future needs of Indian orthopedics.

Numerous issues needs to be addressed, but priority would be for change in curriculum, structure of training program, duration of training and evaluation methods.

Existing postgraduate degree curriculum should be improved to achieve global standards. More weightage should be given to practical skill-oriented learning and evaluation. New postgraduate programs according to our health care needs should be given consideration. Tropical diseases and their management should be given more weightage. The method of didactic lectures should give way to more interesting ways of teaching such as workshops and hands-on. Investing in the development of the medical colleges to provide high quality library facilities and research labs to unlock the campus to the community should be the norm of the day. Skills development centers and cadaveric labs should be made essential to the entrant postgraduate before he can lay his hands on patients. Multicenter demographic studies should be encouraged with the participation and amalgamation of large number of institutions so that knowledge can be shared. More PhD and research programs must be encouraged.

In all developed nations like UK, US, Singapore, the duration of orthopedic training has been increased to 6 years which includes basic surgical training.45 M.S (orth.) is the highest degree granted in India after a training period of 3 years. Moreover, the training is not structured and ability of the fresh postgraduate depends on the institute. By the end of 3 years one can only qualify in basic orthopedics which seems grossly inadequate and for diploma in orthopedics it is two years with no regularization or limitation of surgical work which differentiates them from MS candidates. This insufficiency can badly reflect on the poor patients. We have to define the minimum achievable competence for each course as well as minimum eligibilities to be generalist and subspeciality experts. Diploma in orthopedics course should be abolished. By the end of 4 years of basic orthopedic training candidate must be evaluated and merit-based subspeciality training in interested field for 2 years as extended training program imparted which includes public private partnership to balance case loads of government sector and advancements of private sectors.

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 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.

International standards in health care delivery and lively atmosphere with dynamic campuses will open our doors to student exchange programs where our students will have the chance to visit other facilities around the world. “Catch them young” – Educational independence should be given to the youth of today and he should be encouraged to do research from the early years of his life.

The quality of work done by the teachers should be monitored as well. They should be given enough training and some minimum standards are required for them as well. Research papers, presentations and academic work should fetch more credentials. Promotions and perks should be given to those who have better credentials than by simple virtue of age. Train the trainers program should be implemented as a routine by the universities so that the incompetencies and autocracy among the educators are removed.67

A collective effort by the Medical Council of India, the health universities and the Indian Orthopedic Association in framing the future needs of the orthopedic education is the need of the hour. The universities should play a greater role in evaluating the needs, dictating the priorities and recommending realistic methods by which these might be implemented.8

Progress is a nice word. But change is its motivator. And change has its enemies. The path of innovation is never easy. Change is always painful. But it is the only path with the potential of bringing forth the resources needed for the task ahead. The future does not belong to those who are content with today, timid and fearful in the face of new ideas and bold projects. Rather it will belong to those who can blend passion, reason and courage in a personal commitment to the ideals.

The future is dynamic. A sloth will not have place in future. Constant innovation and improvement will be the only way to stay in the race and to be ahead of the rest, time-tested hard work and dedication is the best.