Whither venereology training in India?

Sir,

Training in venereology has changed a lot in independent India. As with most other branches of medicine, venereology too witnessed a period of rapid growth of facilities and manpower during the initial decades after independence. But, unlike its sister specialty of dermatology, training in venereology seems to have got stagnated during the last 2 decades. This letter takes a look at the reasons for that and tries to suggest ways forward.

There has been a marked drop in the number of patients seeking care in sexually transmitted disease (STD) clinics of medical colleges.[123] Many view it as a reflection of decreasing prevalence of sexually transmitted infections (STI) in the general population. Population-based studies from Karnataka and Delhi indicate that prevalence of acute symptomatic STI is quite low in the community.[456] Though vaginal discharge diseases are highly prevalent, only a few of the sufferers seek medical care; and they too prefer consulting general practitioners or gynecologists rather than attending STD clinics.

Decreasing attendance to STD clinics in medical colleges could also be an offshoot of successful integration of STD care to the primary and secondary levels of care as per the National STD Control Programme. Treatment of target groups with involvement of nongovernmental organizations (NGO) also has been reasonably effective. While these developments are welcome, did these inadvertently retard development of tertiary care and training facilities? A poorly developed referral system, which allows only little interaction between medical colleges and general health services further aggravate the situation.

Last 3 decades have witnessed few significant advances in investigation facilities of the STD clinics attached to medical colleges. Newer tests such as viral culture, chlamydial culture, immunological tests, and molecular diagnostic tests such as polymerase chain reaction (PCR) and nucleic acid amplification test (NAAT) are still not available in most centers. This renders the medical colleges poorly equipped to lead quality research too. As a result, expertise of the specialists and tertiary care centers in research remain underutilized in important areas such as microbiological profile, drug sensitivity, and resistance pattern.

The manner in which most of the venereologists responded to syndromic management oscillated between two extremes. When introduced in the nineties, many were reluctant to accept it as a potentially effective public health strategy to control STI. But later, syndromic management effectively became the treatment norm even in STD clinics. This factor has arguably diminished the zeal for diagnostic work-up even in medical colleges.

So what could be done? First, there is an urgent need to revise curriculum—undergraduate and postgraduate—pertaining to venereology. The curriculum needs to reflect changes in epidemiology of STI. Need assessment surveys among various sections of population could be a good starting point.

Second, we should aim to enhance the capacity of the teaching faculty of venereology through workshops and training. There should also be a greater emphasis on interprofessional education- involving microbiologists, gynecologists, internists, nurses, sociologists, and psychologists.

Third, there should be greater interaction among institutions of primary, secondary, and tertiary care levels of healthcare. Medical students should be exposed to primary and secondary care levels of healthcare during their training. Capacity building in health services (through training and continuing medical education) should be a priority. Development of a robust referral network and defining standards of care at different levels are also important.

Fourth, there is an urgent need to upgrade the investigational and treatment facilities of STD clinics in medical colleges. This is important to upgrade the quality of service, training as well as research. Culture for chlamydia, herpes simplex virus (HSV), and human papilloma virus (HPV), molecular diagnostic tests such as PCR and NAAT and serological tests for syphilis and chlamydia should be made more widely available.

It is time for introspection about the current status of training in venereology. Different stakeholders including policy makers and academicians should ponder over ways to meet current challenges. Failure to do so could have adverse implications on the larger national goal of effective STI and HIV control.