|Year : 2009 | Volume
| Issue : 2 | Page : 251-253
Urological education in India: A status report
Department of Urology, Christian Medical College, Vellore-632 004, Tamilnadu, India
|Date of Web Publication||24-Jun-2009|
Department of Urology, Christian Medical College, Vellore-632 004, Tamilnadu
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Gopalakrishnan G. Urological education in India: A status report. Indian J Urol 2009;25:251-3
| The Beginning|| |
Urology is as old as surgery. In the late fifties and the sixties, general surgeons in the country were in-charge of urology. Urology as a specialty was still in its infancy. Urethral dilatation was the treatment of choice for stricture. Complex stone disease was either untreated or if required a nephrectomy was done. Freyer's prostatectomy was the treatment for benign prostatic hyperplasia. Meanwhile, urology as a specialty had taken off on either side of the Atlantic.
It is difficult in India to pinpoint the genesis of urology, but as far as I am concerned, it was an American general surgeon called John Spencer Carman in Christian Medical College, Vellore, who sowed the seeds.  Why do I give him credit? The reason is, he realized that urological problems were growing and needed special skills and training. He went to the United States in 1958 and worked for a year as a urology fellow, returned and nominated Dr. HS Bhat, a general surgeon, working under him in CMC Vellore, to take on the task of developing this specialty. Nephrectomy and Prostatectomy alone do not constitute Urology as a specialty. A surgeon, who can do all these in such impressive manner, is to be admired as a gifted surgical technician. But he certainly has not the time and training for the urological way of thinking, which can only be acquired by a wide-based specialty training practice over a period of time, under the guidance of an academic specialist. , The rest as we know is history. In 1965, the specialty gained recognition when the University of Madras accepted its need and started a two-year MCh degree program that one could do after completion of the basic Masters in General Surgery. This was the wisest move since it considers urological training as a University accredited specialty.
Urology in those days had to reach across the length and breadth of this country. Dr. Bhat was able to train people from all over the land, who would then return and start their own departments. At the same time, the Madras General Hospital too started a specialty that trained the State government services personnel under the tutelage of Dr. A. Venugopal. The All India Institute of Medical Sciences (AIIMS) in Delhi under Dr. SM Singh, Sawai Man Singh Medical College in Jaipur under Dr. KC Gangwal, and Post Graduate Institute under Dr. Bapna in Chandigarh, were instrumental in strengthening these early beginnings. There were a large group of surgeons who after completion of their FRCS in the United Kingdom and Canada, specialized in urology, and returned to establish private centers dealing with urological problem in India.
Since then urology has not looked back. Urologists of the country joined hands and formed the 'Urological Section' of the Association of Surgeons of India (ASI). We finally severed the umbilical cord from General Surgery in 1978. The Urological Society of India was founded in 1979 as a totally independent organization.
| The Current Scenario|| |
Presently, there are approximately 2000 trained urologists in India. A vast majority have been trained within the country except for a few who received their formal training overseas and returned to their homeland. Formal urological training in India is possible via two streams, the MCh and the DNB degrees. MCh is an accredited university degree.
Earlier candidates were selected not only on merit-based but also needbased scholarships. Senior teachers of General Surgery from Government Institutions would come for training in Urology. Many of them, sponsored by local State Governments, Central government including the Defence Ministry, would attain the MCh degree and go back to start departments in their respective institutes.
Today the scene has changed. Urology is the most sought after higher specialty. Selection to MCh courses in the country is through entrance tests conducted independently by the State Governments, private institutions and is both merit and need-based. Training imparted to the candidate and the training centre itself undergo periodic appraisal by the Medical Council of India.
The National Board was established in 1975. This was with the prime objective of improving the quality of medical education, by elevating the levels and establishing standards of post graduate examination on an all India basis. The DNB program has seen several changes over the year. Currently, private institutions that have the requisite faculty and facilities can apply for accreditation and recognition to the National Board to start a higher specialty training course. Once the center is given the go ahead, it is then assessed periodically by a team of inspectors who will assess the trainee, trainer, and the center. By virtue of the fact that the National Board is a single apex body controlling and governing selections and examinations standards, it appears to carry more weight internationally.
In the early years, urological training was for two years subsequent to basic general surgical training. As the specialty grew, it was felt that the two-year period was too short for an adequate urology training. Thereby, the training was made three years for both MCh and DNB.
The selection processes have undergone considerable changes over the years. Institutions offering MCh programs conduct an entrance test and select candidates on merit. In some centers, there is a quota for sponsored candidates. Currently, the selection for DNB is via a common entrance test conducted by the Board and selected candidates choose their specialty.
The DNB program has seen several changes over the years. Private institutions need to apply to the National Board for permission to start the course. The National Board then appoints a team of inspectors to see if the center fulfills the requirements for training in urology by possessing the necessary faculty, clinical materials, and infrastructure. The National Board also conducts 6 monthly appraisals for trainee and faculty of the centers, to observe if the course is running adequately.
The current status of urologic education and training is best answered if we evaluate the Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis. 
| Strengths|| |
The organization strengths are its resources and capabilities. The biggest resource to urologic education and training is India's very large patient population, irrespective of the state or city or town. This is in a way a double-edged sword; while it allows ample opportunity for gaining experience, it is also a factor in slowing the trainers and the trainee due to overcrowding, delayed diagnosis, and therapy.
Next in order is the quality of the urology resident. Urology is the most sought after specialty and hence we are able to attract among the best of the residents into our program. We have a very committed workforce of 'foot soldiers' who are knowledgable and are keen to learn, improve, and excel. We also have a committed and capable group of teachers - some being very proactive - who conduct teaching programs and live operative workshops with enthusiasm. This has helped us to see and learn new procedures. Some of the procedures are performed by the very group or persons who were the first to describe it - either nationally or internationally. Many of these educational programs are carried out under the aegis of the Urological Society of India. The Society also conducts mock examinations twice a year which enables the resident to prepare and perform well in the exit examination.
The current urologic training program is of three years, and while this gives ample opportunity and experience to learn, it still does not seem enough considering the rapid strides that urology has made in the last decade.
| Weakness|| |
The absence of certain strengths may be viewed as weakness. The weakest link in this chain of urologic training is its lack of uniformity. Training in some centers is better than other centers. Some centers excel in a particular procedure. At this time it is fair to say that no single center gives the candidates exposure to all areas of urology. The reason for this is lack of subspecialization. While all of us realize the need for this, in many centers it is not possible because of markedly reduced or low faculty strength. Most academic teaching centers of urology in India face the problem of lack of teachers. Faculties move away into the private sector as the salaries are attractive. The situation is changing in some states and centers, but not throughout the entire country. In the present context, many feel that in each department one person should develop in at least two areas of specialization. Many centers lack the necessary infrastructure especially in terms of equipment. Urology currently is a technology-driven specialty. Private institutions are able to procure some of the latest in technology for their institution. Those in the government sector have to work with and against the bureaucracy who slow things down. If faculties are not given the equipment it does become difficult for them to develop the newer modalities of treatment. The candidate does not have the exposure to such procedures and feels let down at the end of the training. Many senior trainers have realized this problem and therefore do not hesitate to send their trainees to other centers. In some universities it is a stipulated rule that candidates be allowed to spend two months of their training in centers of their choice to gain an overall exposure to urology. While most of the centers do allow external rotation, there are still a fair number who do not permit it.
One of the biggest lacunae in the training is lack of exposure to research, research methodology, and paucity of publications. Many excuses are offered starting from lack of time, large patient load to take care off, and lack of consistent follow-up. Only a handful of training centers are involved in research and publications. For the remaining, it appears to be a 'mind set' and this attitude unfortunately starts from the top. With the large patient base the clinical experience is enormous but there is nothing in writing to boast off.
Training in surgery and urology in particular has been likened to the airline industry. To try and achieve the Six Sigma Level requires an in-depth training and use of simulators. Access to dry and wet laboratories is still a far cry. The use of animals for training has a lot of bureaucratic hurdles. Few centers have acquired this facility and the numbers of the surgeons needing to be trained is so large that the equation is never balanced. The cost of training is not cheap and this is yet another deterrent. Many centers offer post residency fellowship overseas. There are recognized accredited programs which allow their trainees to apply for suitable positions with their subspecialty skill. Few centers offer fellowships in the country itself. While this might help the candidate in the long run, the credibility given to such training/program leaves a lot to be desired.
| Opportunity|| |
The world has now been called a global village. Travel and communication has become extraordinarily easy. This has offered some residents the opportunity to see and learn. The use of the World Wide Web has made it possible to access material and literature from across the globe. There are some sites which allow open access to both urologic literature and operative videos.
I personally feel that access to urologic journals and material should be made free and open for all. Numerous agencies in India offer funding for studies and projects in the research area. This is not being put to maximum use. Many lack the skill to write up research grants, but on the other hand such expertise is freely available in most teaching centers. Telemedicine has taken off in India in a big way. The National Board provides regular updates for e-learning on a regular basis for all the postgraduate students. The use of satellite linkages has allowed viewing newer surgical techniques from across many centers in the world. This however comes at a cost. Many institutions have entered into MOUs with a number of overseas institutions that allows access to their institution for learning and training. Once again the spirit is willing but …….
| Threats|| |
There is hardly any serious threat to urologic residency program in India. There is an yearning among the residents to go overseas and get trained. And why not? Did we all not do that? Sadly the doors to such opportunities are closed or being closed. It leaves only a few who have the finances and the resolve to go and restart a residency elsewhere. I believe that currently our programs are as good as any. We as trainers need to sit down evolve a comprehensive module which provides equal and fair opportunity for our residents. We need to be more committed together to fight bureaucracy and enable more centers to start, and also upgrade the existing ones.
India's population is 1 billion and rising. We have approximately 2000 trained and registered urologists who are members of the Urological Society of India. Our urologists are in larger cities. We need to reduce the numbers of roaming urologists and encourage private public partnerships to enhance urological service to the community.
| References|| |
|1.||Archives Department of Christian Medical College, Vellore. |
|2.||Personal Communication with Dr. HS Bhat. |
|3.||Urology - Why a speciality? HS Bhat VI Indian Urology Conference Brochure Jaipur September 1970. |
|4.||SWOT - Albert Hamphrey, Stanford University, 1960-78. |