Musculoskeletal Training of Orthopaedists and Non-orthopaedists

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Musculoskeletal Training of Orthopaedists and
Non-orthopaedists Experiences in Nepal

• Ashok K. Banskota MD, FACS

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Training of Orthopaedists

• Under 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)

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Trends in Post Graduate Program Development

• IOM, (TU) MBBS ? Higher Studies
• 1979 ? 1982 (PG) ? 1998 (Ortho)
• KU 1994 ? 1999 (Ortho)
• BPKIHS 1994 ? 1998 (Ortho)
• NAMS (PG Institute) ? 2003 (Ortho)

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Course Duration
IOM (TU 4 yrs BPKIHS 3 yrs KU 3 yrs NAMS
3 yrs
Pre Requirement 1yr House officer, Post MBBS NMC
Registration

• ALL

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Global Objectives

• Meet increasing specialist manpower need
• Produce a skilled orthopaedic specialist of at
  least minimum international standards
• Provide a training experience with an adequate
  knowledge base of the applied basic sciences,
  trauma care principles and management of common
  orthopaedic disorders.

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Candidate Selection Criteria

• Slated Criteria
• All
• Entrance Examination for pre qualifiers
• Interview

• Special Circumstances
• Accommodating diploma Holders (NAMS)
• Scholarships (Foreigner)
• Manpower needs of training institutions (KU)
• BPKIHS (meeting National manpower needs)

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Costs of Training

• University Expenses
• Student monthly stipend
• Training institution logistic expenses
• Expenses for Special courses / meetings

• IOM
• KU
• BPKIHS
• NAMS

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Challenges in Orthopaedic Care Nepal

• Specialist needs enormous
• 90 orthopaedists / 26 million
• No uniformity in standards of practice
  trainees from different backgrounds
• Practice opportunities limited enormous input
  required throughout the country

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Kathmandu University Ortho Residency (1999)

• MS B B Hospital Hospital and Rehabilitation
  Center for Disabled Children (HRDC)
• Initiated to meet growing needs
• compliment of case load / institutional base /
  preceptors
• Controversies (now resolved)
• 1999-2006 11 graduates
• 10 Lakhs

Pre-Residency University Program E X A M Registrar
1 year 3 years E X A M 1 year
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IOM TU PG Ortho (1998)

• TUTH Venue
• Foreign nationals / Paying
• 4 years course
• Intake initially 2/year now 4/year
• Criteria Entrance Exam
• Passed out 15
• Cost 10 Lakhs

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BPKIHS Ortho 1998

• Medical University 3 year Program
• Central Government of India collaboration
• Apex institute for manpower training
• Intake initially 2/year now 4/year
• (foreign nationals)
• Total passed out 16
• Cost 10 14 Lakhs

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NAMS Ortho (2003)

• Bir Hospital (PG Institute) Valley Group of
  Hospitals
• Accommodation of Diploma Holders in Government
  Positions
• Capitation students (local Foreign) also taken
• Intake 6 (regular 3, diploma -1, sponsor-1,
  foreign -1)
• Passed out 12
• Cost 8 Lakhs

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PG Orthopaedic Training Nepal Scenario

• Government Non Government Participation
• Course Objectives similar
• Duration of training variable
• Training experience ununiform except for truama
• Evaluation systems not tested nor reviewed
• Student / Teacher ratio 11
• Teachers making use of available manpower often
  lacking experience.

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Training Process Documentation

• Core logbook
• To maintain records of the acquisition of skills
• To indicate the levels of competence expected
  achieved
• Thesis

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Training Program Common Patterns

• Group discussions
• Case Presentations
• Journal Clubs
• Practical Learning
• ER
• OPD
• OT
• Clinical Research
• Hours / Duties / Time off
• No Hours 80-90 hrs/week

• IOM
• BPKIHS
• KU
• NAMS

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Training Program Special Aspects

• KU Additional Pediatric Rehabilitation
  Exposure
• BPKIHS
• Community orthopaedics
• Link with AIIMS other leading Indian
  Institutions

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Evaluations

• Formative Evaluation
• Applied Basic Sciences
• Clinical Presentations
• Annual Examinations
• Dissertation (Thesis)
• Final Examination
• Written I, II III
• Practical
• Examiners

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Examinations

• Paper setting as per guidelines of university
• Chairman appointed
• Written papers
• Practical
• OSCE
• Short and long cases
• Table viva

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Examinations Shortcomings

• Uniformity lacking Specially in implementation
• Pre-tests of examinations ?
• Validity to need and training ?
• Bias competitive / institutional

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Training of Non-Orthopaedists
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Roles of Non-Orthopaedists

• Initial evaluation/primary care/emergency care
• Transport
• Definitive care

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Health Assistant (HA)

• Course Duration 2 ½ years to 3 years
• 11 centers and 40 intake in each center
• Course content
• Basic Science
• Basic Medicine
• Basic Surgery
• Basic epidemiology
• Maternal Child Health
• Job Posting Health Post
• Job Responsibility
• Immunization
• First Aid Surgery
• Preventive Health
• Referral

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Community Medical Assistant (CMA)

• Course Duration 15 months
• Course content
• Basic Science
• Basic Medicine
• First Aid Surgery
• Basic epidemiology
• Maternal Child Health
• Job Posting Sub Health Post
• Job Responsibility
• Immunization
• First Aid
• Preventive Health
• Referral

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Community Based Rehabilitation (CBR) Worker
-(HRDC)

• Stationed in the field
• HRDC need based
• Primary selection and intensive 3 months long
  training with annual 6 weeks refreshers.
• Goals preventive, facilitative, screening,
  referral, Rx

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Physiotherapy and Rehabilitation (PRT)Trainee-
(HRDC)

• Pre requirement High School
• Training
• Didactic/Practical
• Community Need based
• Follow up care / rehabilitation needs of patients
  emphasized

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Other Non-Orthopaedist Workers

• Compounder/Dresser
• Plaster cast technician
• Ambulance Driver/attendant
• Traditional practitioners, including
  bone-setters, barbers

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Conclusions Orthopaedists

• Curriculum needs to have a practical focus,
  instead of trying to be complete.
• Uniformity in training experience should be a
  continuous target.
• Cost effective non-operative treatment methods
  need to be promoted.
• Technically, market driven orthopaedic practices,
  may give wrong message to trainee.
• Case material for training can be pooled from all
  the available institutions to strengthen a broad
  exposure
• Areas that need strengthening
• Evaluations Process
• Research and Publications
• Availability of special courses in weaker areas.

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Conclusions Non-Orthopaedists

• Important but largely neglected manpower
• Very simple and basic training can be cost
  effective.
• Serious complications/fatalities would be
  prevented.
• Curriculum design and urgent implementation is
  the need of the day

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THANK YOU