Musculoskeletal Training of Orthopaedists and Non-orthopaedists – Experiences in Nepal
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Transcript of 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