Training of Surgeons for Practice in Rural Setup

R.D. Prabhu

(Based on the paper presented at ASICON-2002 Kolkata during a symposium on “Post graduate Surgical Training; Need for Restructuring”)
Shree Dutta Hospital, Shimga-577201

It is very distressing to see the current health care status of India. Dr. R.G. Takwale, ex V.C. Of Indira Gandhi NATIONAL Open University (IGNOU) remarked “Not more than 30% of Indian population has any access to basic surgery”1. Now the Human Development Report 2001 of Government of India, reports that “Not more than 20% of the population has any access to the allopathic medicine leave alone basic surgical services like life saving caesarean section or life saving repair of typhoid perforation”2. That only means that the contribution of the surgical fraternity of India to the national health care activity is less than 20%! Obviously, something is grossly wrong some where in our surgical health care delivery system, and I believe that, that there is something wrong, most probably, the fault in the training. We do not create the kind of surgeons that our country needs.

I have always believed that the surgical training in a country should create a surgeon, primarily for that country. Unfortunately our system of medical education and training does not do that; the surgeons coming out of the medical schools are better suited to work in western hospitals. In 1988, the World Federation for Medical Education in Health Policy, while planning for “Health for All by the Year 2000”, came out with Edinburgh declaration, which states: “The aim of medical education is to produce doctors who will promote the health of all people Educational programme contents must reflect

  • national health priorities.
  • availability of affordable resources.

Our education gives very little impor1ance to the availability of affordable resources. We apply to India what is recommended, available and affordable in developed countries; the use of costly procedures and liberal use of expensive investigations and equipment with scant regard to the economic status of the common man, are examples of this. Disregard to the Edinburgh declaration probably is one of the important reasons of our failure to achieve the goal- “Health for All by 2000 AD.”. Therefore it is about time that educationists wake up and realise that there is a need for change in the surgical training programme so that we improve the quality of surgical care to suite our country best.

W.H.O., defines Quality health care as proper performance of interventions

  • that are known to be safe,
  • that are affordable to the society in question.
  • that have the ability to produce an impact on mortality, morbidity, disability and malnutrition. Quality of health care also requires
  • that the service should be generated at the point of demand

It is possible to change the surgical training to achieve all this; but there are two areas of resistance for such changes:

First The Universities, medical colleges and the teachers. They always resist any change in the existing programmes. They must co-operate in the interest of the nation.

Second We the surgeons ourselves. Many amongst us are so used to the western protocols and practices that they refuse to see the relevance for any changes. Some time ago Banoo Koya of Pune had said “We are happy with excellent health care of 5%, mediocre care of 15% but we are not at all concerned with the health care of the remaining 80%…”. We persist and insist that we all must aim for the excellent health care no matter if 80% of our people are unable to afford it. Surgical fraternity must dispel this thinking and the training must aim to remove this discrepancy; we must accept our share of the responsibility in the nation’s health care and be able to offer surgical care to 100% of our population.

The changes that are needed are not difficult at all.

  • Curriculum for Master of Surgery (M.S.) : It must be such that it creates a True (master) General Surgeon. We need specialists too; but they can be trained through M.Ch. Courses in each subject. Small towns and communities cannot sustain a team of specialists. There, a general surgeon who can manage basic problems from other branches of surgery is more suitable to offer secondary and some tertiary surgical care. After all, the originators of every surgical specialty were general surgeons. We all must accept that a properly trained general surgeon can learn about and safely master the technical skills of simple procedures from almost all specialty branches of surgery. Mamitu Gashe, who was a patient herself in the famous Hamlin Fistula Hospital in Ethiopia, was first assisting at fistula repairs and later became such a skilled operator and a popular guide hereself, that she shared the honour bestowed by the Royal College of Surgeons of England in recognition of the contribution made by such trained helpers4. Trained surgeon has the advantage of being well-versed in basic surgical techniques common to all specialities. However, to make him a safe surgeon he must be so trained that he realises what is possible in his place and what needs to be referred to a better equipped centre.
  • The Surgery taught must be affordable. Affordability primarily depends upon economic status of the community. What is affordable in a rich state like Punjab may not be affordable in Orissa or Bihar. However, in general terms the affordability depends on, (a) surgical procedure, (b) hospital cost and (c) cost of investigations and drugs.

    1. Simple surgery is affordable, feasible and effective too. Students must be taught time tested simple procedures in preference to new techniques whose effectiveness is yet to be proved. Old techniques that do not require costly equipment, like the modified Freyer’s prostatectomy, which, though specialists consider outdated, are still relevant in rural hospitals. Costly equipment only increases the cost of surgery.
    2. We must have more affordable hospitals in rural India. Krishnan from Thiruvananta-puram had shown how 80% of hospital beds in India are in city hospitals, away from the point of demand of 70% of the Indian population. We need to change this. It is said that about 50% of surgeons trained each year go for self-employment1. If those who go for self-employment also know how to organise affordable hospitals with basic amenities, they may become motivated to go to small towns to set up their practice and this may slowly increase the total rural bed strength. So organisation of small hospitals must be taught to the students.
    3. Training must also stress on clinical diagnosis and rational use of investigative procedures and drugs. This will surely further reduce health care expenses since it is said that 10-20% of the cost of treatment is for investigations and costly drugs.
  • To be able to reduce the mortality, morbidity and disability, a rural surgeon needs to be able to manage life-threatening emergencies from all branches of surgery, including those from I Obstetrics and Gynaecology. He is the first I surgeon at the point of demand, and he must I be able to act immediately to save lives and reduce morbidity by whatever means available to him. For example, a ruptured ectopic gestation, a Caesarean section delivery in an I obstructed labour, intussusception in children, a pneumothorax, a compound fracture and so on, have a better prognosis if treated soon. If the patient cannot be managed at the rural hospital the surgeon must be able to see that the patient is revived and stabilised enough for being transported to a higher centre. This training is very vital for India since we have poorly organised or non-existing system of referrals and even poorer transport system for seriously ill patients.
  • Train the surgeon to practice at the point of demand. For this he should be trained to overcome the constraints of surgery and lack of infrastructure in rural India. These may be in the form of lack of anaesthetist, lack of qualified nurses and technicians, lack of laboratory and investigative facilities, blood bank, etc. The best place to gain this experience is a rural hospital and the best person to guide the candidate is the practising rural surgeon. Training in a rural hospital under a practising rural surgeon must form an important part of post-graduate surgical training of the MS candidate.

Such a training programme is practical and feasible also. In fact the present rural surgeons or the surgeons in rural India had all this training in their own way and are functioning with admirable efficiency. But formal education will make them work even more efficiently. National Human Development Report 2001 has reported on page 86, “….Association of Rural Surgeons of India (launched in 1993) is providing viable models of rural health care that is accessible and affordable to a common man.” We in Association of Rural Surgeons of India (ARSI) have already put in to practice what has been narrated until now. ARSI and IGNOU together have launched a distant education course in rural surgery, called “CRS” -certificate in rural surgery, for the currently practising rural surgeons or for those who aspire to be one. This course has been developed by teaching faculty of medical colleges and rural surgeons and is already appreciated by the candidates undergoing training. To some all this may appear to be a retrograde step; but it is in fact a step in the right direction in the interest of our nation. The education will have satisfied the Edinburgh declaration and more important, such surgeons will be able to offer quality surgery that satisfies WHO definition also. Such a training will then give us a surgeon who

  • Is safe,
  • Gives affordable service,
  • Reduces mortality, morbidity, disability, and
  • Is available near the point of demand.

And that is what our country needs at present to take affordable surgery to the door steps of majority of our population.

References :
  • Inaugural address by Prof. R. G. Takwale, Vice Chancellor, Indira Gandhi National Open University, New Delhi, at the 3rd National Conference of Rural Surgeons of India, New Delhi, 1995.
  • National Human Development Report 2001 , Planning Commission, Government of India, March 2002. page 86
  • Quality in Health Care -a lecture by Dr. V.L. Sateesh, RMO, National Institute of Mental Health and Neuro Sciences, Bangalore, 2001.
  • Hamlin Fistula Welfare and Research Trust leaflet. Addis Ababa Fistula Hospital, Ethiopia.