musculoskeletal training of orthopaedists and non-orthopaedists – experiences in nepal

Ashok K. Banskota MD, FACS

Training of OrthopaedistsUnder Ministry of Education & Sports

Tribhuvan University (TU) Kathmandu University (KU)

• Under Ministry of Health & Population– BP Koirala Institute of Health Sciences

(BPKIHS)– National Academy of Medical Sciences (NAMS)

Trends in Post Graduate Program Development

IOM, (TU) MBBS Higher Studies1979 1982 (PG) 1998

(Ortho)KU 1994 1999 (Ortho)BPKIHS 1994 1998 (Ortho)NAMS (PG Institute) 2003 (Ortho)

ALL Pre Requirement1yr House officer, Post MBBS NMC Registration

IOM (TU 4 yrsBPKIHS 3 yrsKU 3

yrs*NAMS 3

yrs**

Global ObjectivesMeet increasing specialist manpower needProduce a skilled orthopaedic specialist of at

least minimum international standardsProvide a training experience with an

adequate knowledge base of the applied basic sciences, trauma care principles and management of common orthopaedic disorders.

Candidate Selection CriteriaSlated CriteriaAll

Entrance Examination for pre qualifiers

Interview

Special CircumstancesAccommodating diploma

Holders (NAMS)Scholarships (Foreigner)Manpower needs of

training institutions (KU)BPKIHS (meeting

National manpower needs)

Costs of TrainingUniversity ExpensesStudent – monthly

stipendTraining institution

logistic expensesExpenses for Special

courses / meetings

• IOM• KU• BPKIHS• NAMS

Challenges in Orthopaedic Care – Nepal

Specialist needs enormous 90 orthopaedists / 26 million No uniformity in standards of practice –

trainees from different backgroundsPractice opportunities limited – enormous

input required throughout the country

Kathmandu University – Ortho Residency (1999)

MS – B & B Hospital + Hospital and Rehabilitation Center for Disabled Children (HRDC)

Initiated to meet growing needscompliment of case load / institutional base / preceptors

Controversies – (now resolved)1999-2006 : 11 graduates10 Lakhs

Pre-Residency University Program

E

X

A

M

Registrar

1 year 3 years 1 year

IOM – TU PG Ortho (1998)TUTH – VenueForeign nationals /

Paying4 years courseIntake initially 2/year

now 4/yearCriteria: Entrance ExamPassed out : 15Cost 10 Lakhs

BPKIHS – Ortho 1998Medical University – 3 year ProgramCentral Government of India

collaborationApex institute for manpower training

Intake initially 2/year now 4/year (foreign nationals)Total passed out : 16Cost : 10 – 14 Lakhs

NAMS – Ortho (2003)Bir Hospital (PG Institute) Valley Group of

HospitalsAccommodation of Diploma Holders in Government

PositionsCapitation students (local + Foreign) also taken

Intake 6 (regular – 3, diploma -1, sponsor-1, foreign -1)

Passed out 12Cost : 8 Lakhs

Orthopaedic Graduates from 1998 to 2007

11 12

15 16

0

5

10

15

20

KU NAMS IOM BPKIHS

PG Orthopaedic Training – Nepal ScenarioGovernment & Non Government ParticipationCourse Objectives similarDuration of training variable Training experience ununiform except for

truamaEvaluation systems not tested nor reviewedStudent / Teacher ratio 1:1Teachers: making use of available manpower

often lacking experience.

Training Process – Documentation

Core logbookTo maintain records of the acquisition of skillsTo indicate the levels of competence expected

& achieved

Thesis

Training Program – Common Patterns

IOMBPKIHSKUNAMS

Group discussionsCase PresentationsJournal ClubsPractical Learning

EROPDOT

Clinical ResearchHours / Duties / Time off No Hours 80-90 hrs/week

Training Program – Special AspectsKU – Additional Pediatric & Rehabilitation

ExposureBPKIHS

Community orthopaedicsLink with AIIMS & other leading Indian

Institutions

EvaluationsFormative Evaluation

Applied Basic SciencesClinical PresentationsAnnual Examinations

Dissertation (Thesis)Final Examination

Written : I, II & IIIPractical

Examiners

ExaminationsPaper setting as per guidelines of universityChairman – appointedWritten papersPractical

OSCEShort and long casesTable viva

Examinations – ShortcomingsUniformity lacking – Specially in

implementationPre-tests of examinations ?Validity to need and training ? Bias – competitive / institutional

Roles of Non-Orthopaedists

Initial evaluation/primary care/emergency care

TransportDefinitive care

Health Assistant (HA)Course Duration : 2 ½ years to 3 years11 centers and 40 intake in each centerCourse content:

Basic Science Basic Medicine Basic Surgery Basic epidemiology Maternal Child Health

Job Posting : Health PostJob Responsibility

Immunization First Aid Surgery Preventive Health Referral

Community Medical Assistant (CMA)Course Duration : 15 monthsCourse content:

Basic Science Basic Medicine First Aid Surgery Basic epidemiology Maternal Child Health

Job Posting : Sub Health PostJob Responsibility

Immunization First Aid Preventive Health Referral

Community Based Rehabilitation (CBR) Worker -(HRDC)

Stationed in the fieldHRDC need basedPrimary selection and intensive 3 months long

training with annual 6 weeks refreshers.Goals – preventive, facilitative, screening,

referral, Rx

Physiotherapy and Rehabilitation (PRT)Trainee- (HRDC)

Pre requirement – High SchoolTraining

Didactic/PracticalCommunity Need basedFollow up care / rehabilitation needs of

patients emphasized

Other Non-Orthopaedist Workers

Compounder/DresserPlaster cast technicianAmbulance Driver/attendantTraditional practitioners, including bone-

setters, barbers

Conclusions: Orthopaedists1. Curriculum needs to have a practical focus, instead of trying to

be “complete”.2. Uniformity in training experience should be a continuous target.3. Cost effective non-operative treatment methods need to be

promoted. 4. Technically, market driven orthopaedic practices, may give

wrong message to trainee.5. Case material for training can be pooled from all the available

institutions to strengthen a broad exposure6. Areas that need strengthening

1. Evaluations Process2. Research and Publications3. Availability of special courses in weaker areas.

Conclusions: Non-Orthopaedists

1. Important but largely neglected manpower2. Very simple and basic training can be cost effective.3. Serious complications/fatalities would be

prevented.4. Curriculum design and urgent implementation is

the need of the day