Year : 2009 | Volume
: 25 | Issue : 2 | Page : 254--256
Urology training in India: Balancing national needs with global perspectives
Laparoscopic and Robotic Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
Glickman Urological and Kidney Institute, Cleveland Clinic Main Campus, Mail Code A100, 9500 Euclid Avenue, Cleveland, OH-44195
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Aron M. Urology training in India: Balancing national needs with global perspectives.Indian J Urol 2009;25:254-256
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Aron M. Urology training in India: Balancing national needs with global perspectives. Indian J Urol [serial online] 2009 [cited 2021 Dec 3 ];25:254-256
Available from: https://www.indianjurol.com/text.asp?2009/25/2/254/52938
The specialty of urology in India, an entity now distinct from general surgery, is less than 50 years old. The Urological Society of India (USI) was created initially as a 'Urology Section' within the ambit of the Association of Surgeons of India (ASI) at their Annual Conference in Baroda in December 1961, with the late Dr. G.M. Phadke as Chairman. At inception, the strength of the 'Urology Section', later renamed as 'The Urological Society of India', was 32 members, most of whom were general surgeons, with just a handful of formally trained urologists. 
The first independent department of urology in India was created at George's Hospital, Bombay, in 1961-62 with Dr. B.N. Colabawalla as Chair. In the next few years, additional independent centres were established in Madras, Vellore, Delhi, and Chandigarh under the Chairmanship of Dr. A. Venugopal, Dr. H.S. Bhat, Dr. S.M. Singh, and Dr. B.C. Bapna. Currently there are approximately 20-25 centres recognized that provide M.Ch. (Urology) training and about 10-12 centres recognized by the National Board of Urology for the award of DNB. 
Here we discuss the various aspects of urological training in India with special emphasis on national and global perspectives.
Existing Urology Training in India
Across the world, the specialty of urology is in constant evolution.  We have seen multiple eras starting with open surgery, followed by endourology, laparoscopic urology, and now robotics. Constant refinements in andrology, female urology, pediatric urology, and neurourology have made them distinct, advanced subspecialties. It is almost impossible for an individual to have an in-depth understanding of each of these subspecialties. On the other hand, a safe and effective treatment of the vast majority of common urological ailments does not require subspecialty training. What should then be the goal of urology training in India?
Currently, the urological training in India is a three-year supervised program which a trainee enters after completing the three-year general surgery training. The nature of the entrance examination is such that the trainee possesses a good theoretical, and in some cases practical, knowledge of urology prior to entering the training program.
During the three-year supervised urology training, the trainee gradually improves his/her understanding of urologic disease processes and their management. The trainee also undertakes a variety of urological procedures under supervision. The goal of the three-year program is to produce a reasonably well-trained general urologist who has a broad understanding of most common urological conditions and an ability to comfortably perform the majority of common urological procedures.
Lacunae in Urology Training in India
No training system is perfect and each has its own pros and cons. Some potential areas of improvement in the Indian system of urological training are listed below:
Duration of Urologic Training
As the system stands today, the trainee should learn all of the urology within a span of three years. While this may be enough for some who may have pre-existing informal urologic training, the vast majority of trainees do not get adequate operating experience in the three years. As a result, most of them have to 'learn on the job' after they have already been 'trained'. This is true even for 'bread and butter' procedures such as transurethral prostatectomy (TURP) and percutaneous nephro lithotripsy (PCNL).
Lack of Structured and Standardized Training Curriculum
Most training centres lack a structured training curriculum. Most trainees (and trainers) do not have a clear idea of what skills they are expected to acquire on a semester-to-semester basis. Additionally, each centre may have a different focus in urology. Some may focus on endourology, while others on laparoscopy. Training in other disciplines may suffer under such circumstances. As a result, trainees from different centres complete the training with varying levels of skills and knowledge.
Culture of Training Among the Trainers
Many trainers are still learning 'on the job' themselves. As a result they may not be in the best position to teach others. The experienced senior trainers may not have enough time to guide a junior trainee through a procedure such as PCNL, TURP, or radical cystectomy.
Research appears to be a low priority in the majority of training programs. Programs that produce the vast majority of clinical research papers in India are only those where the faculty takes the initiative. Most programs lack PhD scientists who could lead basic science projects. Moreover, there is no protected research time for residents and faculty.
Currently, there is no provision for formal subspecialty fellowship training in the Indian urological training system. It is largely left to the initiative of the trainee to seek out additional specialized training in India and overseas.
Comparison with Other Systems : Global Perspectives
In the United States, students usually complete four years of college after high school. Subsequently, they enrol in medical school for four years, after which graduates apply directly for urologic residency. In 2008, 110 non-military accredited urology residency programs in the United States listed 247 positions with 246 vacancies being matched.  Urology residency is 5-6 years long, beginning with 1-2 years of general surgery experience, followed by 4-5 years of urology. A few six-year programs have a dedicated research year built into the training curriculum. The curriculum is structured with specific training objectives for each year. In-service examinations are held every year to assess their knowledge, and remedial measures undertaken when appropriate. Residents operate under supervision and maintain logbooks with minimum numbers prescribed for various procedures. At the completion of the residency program, residents have an option of a variety of subspecialty training fellowships, ranging from 1 to 3 years in length. Most academic programs, and increasingly many private practices, prefer to recruit physicians who are fellowship trained in a particular subspecialty.
Given the number of different countries in Europe, urology residency training is quite diverse. In a recent survey, data obtained from 27 of 34 European countries shows that residency training in urology starts after graduation from medical school in 44% of countries, after internship in 26%, after a 'pre-residency' urology elective in 19%, and after common trunk training (same initial training shared by several specialties) in 11%. The shortest possible time for board certification is 2 years in the Ukraine and 9 years in the UK. The actual length of training calculated from medical school to board certification is 4-12 years. 
A third of countries have integrated research into their residency training. Estonia, Italy, and the Ukraine are the only countries where no time is spent in general surgery. In the remaining 24 countries, residents spend a mean (range) of 16.2 (0-48) months in general surgery/common trunk training. Of these, 13 countries require surgical training to be completed before starting urology, while in the remaining countries this can done at any time during residency. The mean (range) for urological training is 3.9 (2-7) years. Almost 19 countries (59%) have definable educational goals for every part of urological training. A logbook is maintained for registering resident activities in 78% of the countries. 
The Surgical Education and Training (SET) course of the Urological Society of Australia and New Zealand (USANZ) is a six-year training program. The first two years are devoted to general surgery and related specialties, while the last 4 years to core urology. Rotations recommended, but not mandated, for the first two years include general surgery, urology, other surgical specialties, anesthesia, intensive care, nephrology, internal medicine, emergency medicine, and geriatric medicine. The sixth year is treated as a fellowship year during which the trainee is encouraged and supported to seek subspecialty training elsewhere. 
Recommendations for Change
While the global urology is moving towards subspecialization and specialist-centred care, the role of the general urologist in treating day-to-day urologic ailments or channeling patients to the appropriate specialist remains paramount.
Urology trainees in India are faced with unique challenges. First, they need to be trained primarily to become good general urologists, the reason that the vast majority of urological problems in this country of over a billion people can and should be managed by generalists. Second, a certain percentage of trainees exiting the residency program need to acquire subspecialist training so that the highest quality specialist care could be provided, close to home, to those patients who need such care. Third, trainees need to realize that economic considerations of urology practice in India are different from that of western medical systems, which are driven by free market principles. Cost benefit analyses are very pertinent when the available resources are limited. Last but not the least, careful consideration is required about the geographical location of practice, the available resources in a given area, and balancing opportunities for professional development with personal and family aspirations.
The following suggestions for change are intended to stimulate discussion so that, going forward, the most appropriate program could be put in place for urologic training in India. Some of these views have been previously espoused. 
Six-year urology training to commence after the compulsory rotating internship. The first two years should be devoted to general surgery and other relevant specialties (intensive care, emergency medicine, nephrology, colorectal surgery, vascular surgery, etc), while the next 4 years should be devoted to core urology. At the end of six years, i.e. after successful completion of the exit examination, residents should have the option of pursuing a 1-2-year fellowship program in various subspecialties at designated centres of excellence.Integrate all urology training and fellowship programs nationwide under the aegis of the USI.Define a standard broad-based nationwide training curriculum for all urology programs. Each program must satisfy the minimum criteria and should provide training in all relevant disciplines. If certain programs do not fulfil the requisite criteria, they should not be accredited by the USI for urology training. My suggestion would also be to eliminate the distinction between MCh and DNB programs. All programs should include MCh training and be affiliated to appropriate universities. While the degree could be granted by the university, all other aspects of the training program should be administered by the USI.Common nationwide competitive entrance examinations in all urology courses for both residency and fellowship.Common nationwide exit examination at the end of six-year residency. No exit examination should be included at the end of the fellowship. However, the USI should provide a fellowship completion certificate based on surgical log during fellowship along with a recommendation letter of the fellowship director.Instead of a dedicated research year, I propose a one-day protected research time for each resident every week. Also define a minimum research/publication output per resident per year beginning in the second core urology year (year 4).Define strict goals for every 6 months of training and assess whether these were achieved. If not, remedial measures must be taken.Maintenance of a surgical log should be mandatory and minimum numbers for various procedures need to be specified and met.If various goals are not being met repeatedly over a two-year period, the reason for the failure should be identified by an unbiased committee of the USI (comprising residents and faculty) and appropriate individuals held accountable.Six-monthly trainee evaluation of trainers should be an integral part of the residency program. Repeated negative reports over a two-year period should be addressed by a nonpartisan committee of the USI.Overall, urology training in India has been reasonable over the years. Most trainees in the Indian system have a vast fund of theoretical knowledge, although the practical surgical training has not been of the same standard. Trainees from the Indian system have done well, both in India and overseas. Having said that, I suspect, a lot of that credit goes to individual initiative, drive, and hard work. The formal training system in India needs to be revamped to provide better technical training so that the 'trained' urologist is able to perform most 'common' surgical procedures with aplomb. Some of the steps listed above could contribute to improving urological training in India, so that Indian urologists are more in sync with their global counterparts and are able to play leading roles in rapidly changing urological practice scenarios across the world.
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