|Year : 2009 | Volume
| Issue : 2 | Page : 230-233
Diary of a urologist as a trainee at AIIMS
Department of Urology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
|Date of Web Publication||24-Jun-2009|
Department of Urology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-110 029
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kumar R. Diary of a urologist as a trainee at AIIMS. Indian J Urol 2009;25:230-3
When I joined medical school, the aim was to become a surgeon. Once I had qualified for medical school, joining a surgical residency did not seem too difficult. I fared well in my graduating examination and the medical institution that I graduated from reserved a number of training positions for its medical graduates. I know things have changed since then; these preferred selections have considerably declined and getting a surgical residency is no longer easy.
For me, the problems began only after I had begun surgical training. Super-specialization seemed a natural next step and I was eyeing Urology. During the first year of surgery, all residents were rotated through three super-specialty programs. Unfortunately, one would get to go to either urology or pediatric surgery and my roster showed me slated for pediatric surgery. Selection into the super-specialty course after surgery was significantly dependent upon the faculty interview, and a rotation through the department was considered an important pre-requisite. After spending the next week making numerous trips to the Roster In-Charge and the Head of Surgery's office, I finally managed to trade what was considered a 'light' posting in orthopedics and cardiac surgery into one for urology.
The three months that I spent in urology during this rotation firmed up my decision that this was the final career for me. There were few emergencies that required more than a tube insertion; the patients usually walked back home within a week after surgery and residents rarely broke into a sweat.
Qualifying for a urology residency position, however, proved to be much tougher than I had imagined. On an average, there were 40 trained surgeons competing for every position available. The competition got even tougher for the premier programs such as the one in my institution, and my institution no longer provided special advantages to its own graduates.
This was one of the lacunae of our urology training programs where entry competitions never seemed to end. A direct entry into a five- or six-year program would certainly have prevented this double examination. Further, it wasted crucial time because when I finished my surgery training, there were no urology residency seats available in my institution. I often envy my friends who took a direct five-year neurosurgery or pediatric surgery course straight after graduation. Not only did they not have to sit for an additional entrance examination, they also completed their overall training up to two years before I did and joined the faculty before I could, thus obtaining a crucial seniority in future appointments. This three-year General Surgery training seems to me to be a relic of the British education system, which still follows it. Parkar et al.,  recently reported that only 11% of the European urology programs continued this practice - UK being one of them. The average time spent in General Surgery in the US and European urology programs is under two years compared to our mandatory three, but practically, often over, four, years.  Having said this, I must admit that I totally enjoyed every day of my surgical residency. The adrenaline rush of attending to polytrauma patients, the pressures, and the camaraderie reinforced my belief that this was the only profession to be in.
Urology, in that sense, seemed an anticlimax and initially depressing. Despite having lived on the campus and worked in the hospital for nearly 10 years, the first two months in Urology seemed inordinately long. Retrospectively, I think this stemmed from the sudden demotion from a Senior Registrar in Surgery, who is practically the king of the unit, down to the Senior Resident in Urology who has to draw all the blood samples, collect the reports, fix appointments, and do the dressings. The All India Institute of Medical Sciences (AIIMS) residents' manual was published only in 2003, but I am sure it has been based on the experience of many first year residents since it clearly describes such tasks as a resident's responsibility.
The first three months of the residency were spent acclimatizing myself to the department, its work culture, and basic procedures. The model of learning was clearly apprenticeship-based and watching others and asking questions seemed to be the right way forward. This was no different from what I had experienced in surgery, only the personalities were more refined, probably because most of my colleagues were now older, significantly more experienced, and married. During these three months, it was important to establish one's position in the hierarchy of the department and its working staff. Having been in this institution since graduate school was clearly an advantage, since I did not have to go through the initiation process others had to. AIIMS can be a daunting place for a newcomer who comes from one of the smaller medical colleges. It carries an aura among students and patients alike, and people working here often do nothing to lower it in front of newcomers.
An important part of the first three-to-six months of residency is the decision on research projects and a thesis. A thesis submission is a pre-requisite to appearing for the final examinations and, in urology; the thesis was expected to consist of four papers - two original articles and two case reports. A thesis is generally considered a necessary evil that has to be endured during residency. It is better to choose a project that requires no follow-up of patients and has a minimal number of departments involved. Indian patients are notorious in failing to follow-up, not that one can blame them considering the distances they come from, their meager resources, and the queues outside the consulting rooms. Minimizing the number of departments clearly meant a lower number of consultants who needed to be satisfied before publication.
There were two ways of going about deciding your research project. One was to explore the options yourself and take the suggestions from one of the faculty guides, and the other was to wait for one of the faculty guides to allot a topic to you. Research, in most cases, was paid lip-service. It was endured to meet the end of publications, but held little greater charm for residents. There was precious little time available after clinical work and resources were always strained. None of the three-year period was devoted exclusively for research and no one in his right mind would opt for a laboratory-based project that required the resident to actually perform the investigations. The exposure to clinical statistics and research methodology was also extremely limited and most of us simply believed what our statisticians told us.
This is probably another reason why the three-year program seems insufficient: There is just not enough time to do quality research. While it may be said that everyone does not need to do research, it surely must be a part of the curriculum at the doctorate level of urology training, considering that one of the purported aims of this education is to train future teachers. You cannot appreciate literature unless you have the basic knowledge of how to conduct research, and evidence-based medicine mandates this basic knowledge among the practitioners.
By the time we had gone through the first six-month period and the projects were in place, we got a hang of the subject and were able to perform a number of minor surgical procedures. We were posted independently at various workstations and were given independent charge. One of the important differences between a surgical and urological residency was the relative equality of residents in all stages of training. While in surgery the hierarchy was always in place, in urology each resident was responsible for his own workstation and not necessarily answerable to any other resident other than the Chief Resident, who looked after the administration. The Chief Resident was perhaps the most important person to keep happy since he/she decided what patients would be admitted on your beds and consequently what surgeries you would get to assist or perform. Here, it is important to understand the system of scheduling surgeries at large teaching hospitals in India. Patients are seen in the clinics and a plan of intervention is decided upon in consultation with one of the faculty members in the clinic. There are waiting lists for surgeries and patients are admitted to the wards a few days prior to the surgery. While in hospital, they are assigned to individual residents for their care.
Out of the three-year residency, about two years are spent looking after admitted patients in various wards. Ward postings are interspersed with relatively lighter postings in areas such as extracorporeal shock wave lithotripsy room, urodynamics, and minor operation room. The ward postings are among the most hectic of the residency period. Each day begins by making an individual round of all patients and entering progress notes. You also need to decide investigations that need to be done that day and ensure the samples for blood investigations are drawn before morning deadlines. Operating theaters start at around 8:30 am and if you happen to be the first assistant in the first case, you are expected to be in the theater by the time the patient is wheeled in. Often enough, you would spend the entire day in the operating room or finish just in time to attend the afternoon clinics. The evening is again spent making rounds on your patients and completing the day's work. Evening rounds also happen to be teaching rounds and the department had a policy that every resident must be fully aware of the condition of all patients including those not directly under his care. The rounds would usually last till about eight in the evening and if you were not on emergency call that day, you would be able to return home.
This whole routine sounds reasonably well organized, but is actually far from being so. The biggest problems in a residents' life are resource management. Most of the patients admitted are too poor to afford anything. However, once they are admitted, it is the responsibility of the resident-in-charge to ensure that all investigations are in place and the patient is fit for the intervention planned. Often the delay between the last outpatient evaluation and admission is greater than six months and a number of investigations need to be repeated. We then ran around fixing up appointments, usually on the basis of personal rapport and friendships with the residents in the other departments. The patient may not even have the money to purchase the disposables required for the investigations and this initiates another round of what we called 'beg, borrow, or steal'. Even after the investigations were done, there was no guarantee that we would get the report on time and we had to walk down to the concerned department to collect the reports. These clearly took a major toll on the time available to us. It was also extremely frustrating to have to seek personal favors to achieve results. Individual resourcefulness made a major difference to how we fared in these chores, and since the consultants would usually turn a blind eye to how things were achieved as long as the outcome was good, it provided an opportunity for us to score brownie points. I must confess that this is another situation of the institute probably helped me.
Getting to operate is probably one of the most important aims of any surgical residency. Our department ran two major operating theaters (OTs), five days a week. The theaters were assigned to individual faculty members who would post patients admitted under their care for surgeries. The resident-in-charge would be the first assistant. Both our operating theaters were equipped with a full range of upper-and lower-tract endoscopy equipment and all endoscopy was performed using endoscopy cameras. As a result we were able to see everything and follow each step. We also had C-arm fluoroscopes in each OT and acquired a Holmium laser machine towards the end of my third year. Open surgery, laparoscopy, and endourology would all feature on the surgical lists, although there were clearly personal choices of different consultants for similar cases. For complex surgeries including laparoscopy, the consultant would invariably be scrubbed from incision to closure.
What a resident got to operate on was dependent on two factors: the time available to each faculty member and the perceived skill of the resident. Operating time was invariably at a premium due to the long waiting lists. If a resident demonstrated the ability to be safe and reasonably quick, he/ she was more likely to be allowed to be the operating surgeon than one who was slower. Each faculty member also had his/her own predetermined notion of what a resident should be allowed to do at what level of training. While there was a residents' log book available, this was almost never filled and was certainly never used to decide what a resident needed to operate. The consequence was an invariable difference in the amount of surgeries conducted by different residents. This would be more evident in the more complex surgeries such as percutaneous nephrolithotomy (PCNL) and radical cystectomy than the ureteroscopies. The consultant would often be around, not actually scrubbed in, and watch what was going on while the whole case was completed by the resident. It was uncommon for the consultant to actually be the first assistant for the entire surgery; he/she would often allow us to do a bit before taking over and completing the procedure. This, I suppose, is common to all surgical training.
As we grew more experienced, we learnt techniques of admitting and posting patients when the consultant was likely to be busy so that we would be delegated the task of completing the surgery. It served both their purpose and ours. Another common option was to admit patients as an emergency in the evening and operate the same night, particularly for bladder tumors. The consultants actually appreciated not being called and developed greater confidence in our abilities. On the whole, I do not think we cribbed too much about the amount we got to operate. I would surely have loved to do far greater numbers, but that is a perpetual wish. I believe I was also fortunate to have had consultants who were confident of themselves and their abilities, allowing us freedom to even create situations that they needed to salvage. Most had operated enough not to actively seek doing more cases of one type, a problem often faced when the consultants are themselves rarely doing certain procedures.
By the time we finished our three years, all of us were confident enough to handle most cases on our own. We had performed enough lower-tract endourology to not be daunted by these procedures. We had also performed quite a few ureteroscopies each, but were probably short of confidence on PCNLs and certainly laparoscopy. By my second year, I had become specifically interested in microsurgery and male infertility. This partly stemmed from my earlier experience in microsurgery during my General Surgery training. Andrology was never a strong choice among most trainees and gradually I became solely involved. This worked almost like a fellowship for me as I performed a large number of procedures independently. For most others, the training seemed enough to begin a practice in general urology, but not enough to specialize. We felt the need to develop certain areas to a greater depth and sought out opportunities both in India and abroad to address these lacunae. Surprisingly, in our batch of seven who graduated in one year, four continued in academics at various institutes. Only one went abroad on a permanent basis and one into private practice. One continued in a non-academic hospital practice.
Another important aspect of the training was the development of a professional relationship with a number of our colleagues and teachers, some of which have now developed into a strong friendship. The opportunities available to the trainee are often dependent on the drive and personality of the teacher. Our department had consultants who were usually of the aggressive go-getting variety. We organized two large, international conferences during my tenure as a resident and the experience of organizing these conferences has helped me tremendously down the years. It also resulted in exposure to other members of the urology community, something which would otherwise have taken years. I was also able to assist in the publishing of two books, which again not only improved my curriculum vitae, but brought me into contact with a number of stalwarts. These interactions, which occurred because of the drive of my consultants, decreased my gestation period for breaking into the league of 'known' people. This 'consultant drive' was also responsible for my first international fellowship and I believe a lot of what I have been able to achieve is due to the stride set by my mentors.
Finally, when I look back at my training and the training that I now impart to my students, I believe there are areas where we can improve. The single most important aspect would probably be to decrease residents' workload for things that are not actually their job. Widespread use of information technology and computerized patient data management would go a long way in decreasing these unnecessary pressures. It would also simplify research and data gathering. Regular audit of all procedures with fixed responsibilities would also help end the system of blame assignment and make the working environment more cordial. Greater availability of online journals, travel grants, and active exchange programs with institutions more developed in specific areas would round out my current wish list.
My training served a few essentials. At the end of it, I was confident of handling most cases on my own. For those that I could not, I knew where and whom to turn to, hopefully before making a mess. I knew my limitations and was also acutely aware of the need for greater exposure to international institutions, not necessarily to learn more urology, but to learn better ways of doing things that I was already doing.
| References|| |
|1.||Parkar SP, Fuglsig S, Nunes P, Keskin S, Kniestedt WJ, Sedelaar JP, et al. Urological training in Europe: Similarities and differences. BJU Int 2005;96:207-11. |
|2.||Gautam G. The current three-year PG program in urology is insufficient to train a urologist. Indian J Urol, 2008;24:336-8. |
|3.||All India Institute of Medical Sciences (AIIMS) Residents' Manual. Sarma RK, Vij A, editors. New Delhi: AIIMS, 2003. p. 232. |