|Year : 2019 | Volume
| Issue : 4 | Page : 225-227
Vascular education and training in India TRAIL SO FAR AND THE PLAUSIBLE FUTURE
Kalkunte R Suresh
Chief Editor – IJVES, Director – JIVAS, Bengaluru, Karnataka, India, India
|Date of Submission||20-Nov-2019|
|Date of Acceptance||20-Nov-2019|
|Date of Web Publication||20-Dec-2019|
Kalkunte R Suresh
Chief Editor – IJVES, Director – JIVAS, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Suresh KR. Vascular education and training in India TRAIL SO FAR AND THE PLAUSIBLE FUTURE. Indian J Vasc Endovasc Surg 2019;6:225-7
Just over a year back, I had ventured to outline, in this column, the evolution of vascular surgery as an independent specialty in India. Perhaps, it is apt to recall some of the landmarks that resulted in the recognition of this superspecialty.
The Madras Medical College had MCh program in vascular surgery since 1985. But, the specialty of vascular surgery was not listed as separately by the MCI and in 2001, there were efforts by CTVS to include vascular surgery within its folds, thus denying its recognition. Thanks to the efforts by few VSI members, while I was the secretary of VSI, their efforts were thwarted, and all need to peruse part of the minutes of THAT MCI meeting:
“Medial Council of India – No. MCI-6(1) 2001-Med/5890: 118th Session”
“Of the Medical Council of India will be held on 21stand 22ndJune, 2001, at 11.00 am at the Council Office, Aiwan – E – Ghalib Marg, Kotla Road, New Delhi-110002……….
39. Representation for continuance of the course by nomenclature of M. Ch. (Vascular Surgery) – compliance from Vascular Society of India regarding.
“………. The Postgraduate Committee considered the letter dated 29-11-2000 from Vascular Society of India for inclusion of Vascular Surgery as a separate super speciality course in the Regulations of the Council on Postgraduate Medical Education 2000……….
The Committee agreed to the proposal to include Vascular Surgery as a separate speciality under M. Ch. in the schedule to the Postgraduate Medical Education Regulation, 2000, as it will help in developing the speciality in other medical institutions particularly in Govt. institutions where the treatment facilities for poor may be enhanced.
Accordingly, the Postgraduate Committee decided to recommend the inclusions of separate M. Ch. course in Vascular Surgery in the schedule to the Postgraduate Regulations for consideration and approval by the General Body of the Council.”
Thus, the new, independent specialty of peripheral vascular surgery was born. India is ahead of countries such as the USA and UK in having a specialty board in vascular surgery. The initial fellowship programs by NBE transformed into 3-year DNB in 2008.
Some aspects of DNB (I am not fully aware of methodology/curriculum of MCH) in peripheral vascular surgery:
1. Equivalence of DNB and MCh: Significant confusion exists in spite of the following notification (extracted from the NBE website), which clearly states the two are equal
“MINISTRY OF HEALTH AND FAMILY WELFARE (Department of Health and Family Welfare) NOTIFICATION, New Delhi, the 3rd August, 2016, S.O. 2672(E).—In exercise of the power conferred by sub-section (2) of section 11 of the Indian Medical Council Act, 1956 (102 of 1956), the Central Government after consulting the Medical Council of India, hereby makes the following further amendments in theFirst Schedule of the Act, namely:……
(ii) The following Diplomate National Board (DNB), Super Specialty Courses (three years courses at the Post MD/MS level) shall be inserted, namely:
Diplomate National Board (Peripheral Vascular Surgery): This shall be recognised medical qualification when granted by National Board of Examinations, New Delhi, on or after December 2009.”
But, some of the MCI-recognized institutions continued to play truant, and another notification (quoted below from the NBE website) was issued to correct “… nonrecognition of DNB degree by MCI-approved Medical Colleges”
“No.V.11012/1/2014-MEPI; Government of India; Ministry of Health and Family Welfare
Medical Council of India
Dwarka, New Delhi 110077
Sub: Regarding Issue of DNB Qualifications- Grievance of Candidates – Reg.
With reference to the above cited subject, kindly find enclosed copies of representation dated 19.04.2017; 13.04.2017 and 01.04.2017 received from Association of National Board Accredited Institutions; National Board of Examinations and Dr. Shaji Alex respectively.
2. The Ministry vide Public Notice dated 22.08.2014 and the letter dated 10.12.2014 had declared the letter No. MCI-12(1)/2014-Med. Misc./101884 dated 09.04.2014 relating to the amendment in Teachers' Eligibility Qualification Regulations, 1988 void ab- initio. However, the Ministry is still receiving grievances from candidates regarding non-recognition of DNB degree by MCI approved medical colleges.
3. It is therefore requested to issue an advisory for the medical colleges to comply with the existing regulations regarding DNB qualifications.
I have been informed that vascular surgeon with DNB needs one-year experience as a “registrar” (I could not find any documentation) in a government college to be able be appointed in a teaching institution, if the hospital he/she is trained in has less than 500 beds! This is obviously ludicrous because none of the medical colleges, outside Tamil Nadu, have vascular departments. In fact, many of the vascular surgeons in teaching institutions have been trained in NBE-recognized institutions!
Another interesting note in the notification issued by the Central Government is quoted below: “Note: - The FNB qualifications shall not be treated as a recognised medical qualification for the purpose of teaching faculty. [No. V.11025/19/2014-MEP] ALI R. RIZVI, Jt. Secy.”
As a corollary, does this mean DNB in vascular surgery should be treated as a “a recognised medical qualification for the purpose of teaching faculty”? Confusing play of words, to say the least.
2. Equivalence in DNB and MCh exit exams:
The curriculum, the examiners, and the type of exams are fairly similar in the two. But, an MCh graduate is allowed to take DNB exam and not the other way around. This is extremely prejudiced and unjustifiable to DNB candidates. Hopefully, with amalgamation of the health education systems, this will be corrected. The “Vascular Specialty Board” of NBE should push this agenda vigorously.
3. The change in the nomenclature of DNB:
A “Vascular Specialists Board” was constituted by the NBE earlier this year with several vascular surgeons, along with the executive director and members of NBE. There were multiple suggestions which were discussed and accepted by the NBE:
- A very important change suggested and accepted was to change the nomenclature from “DNB Peripheral Vascular Surgery” to “DNB Vascular and Endovascular Surgery.” This has not yet found its way into NBE website.
- The curriculum uploaded into the NBE website was accepted with some changes that will be updated in future. The curriculum contains extensive training in open surgery, endovascular procedures, vascular medicine, diabetic foot/wound care, etc.
- The logbook format prescribed in the website should be followed
- Several rotations were recommended – including in other vascular departments across the country and other specialties related to vascular diseases. Interdepartmental meetings within the training hospitals were also encouraged.
Some thoughts for the future of vascular education and training
The steady growth of vascular surgical training programs across the country is indeed encouraging. With it comes the responsibility of offering a comprehensive training program with as little variation as possible across the teaching institutions. It is unlikely that every institution can offer a trainee all that is required to provide care to these complex patients, right after the completion of the training program, especially if they chose to practice in areas where awareness of vascular diseases is lacking and the infrastructure may be inadequate. Due to paucity of vascular surgeons across India, it is important that the outgoing trainees are able to establish themselves in smaller or at least in tier two cities. We should device ways to increase the skill sets of every trainee.
Another aspect is to increase awareness among general surgical postgraduates, and this might translate into more surgeons seeking vascular training. If the existing vascular department can offer a short rotation to these trainees from medical colleges within their states, it would create awareness and also, hopefully, early referral of patients with vascular diseases.
VSI can and should play an important role through “Academic Council for Vascular Education and Training”
An organization under the VSI banner to promote the above goals – if one such already exists, it should probably have vascular program directors as members from both teaching and nonteaching institutions. Its function should be well defined and initially, its approach can be as follows:
I. Curriculum/syllabus for vascular training:
- Periodically review the existing vascular curriculum/syllabus and suggest changes that would include the evolving diagnostic and therapeutic procedures
- Suggest methods/changes in the accreditation of vascular training programs
- Create a large question bank, with the help of vascular surgeons/specialists across India as per the categories of examination papers described in the syllabus
- Create a list of potential examiners from a pool of vascular surgeons – at present, this list is limited to the number of senior vascular surgeons. We do have a large pool of our younger colleagues who have experience and capabilities of being examiners.
- Suggest various vascular departments/surgeons with whom the vascular trainees can “rotate” to further their experience, especially if any modality is lacking at their training center.
- Perhaps, develop password-protected extensive E-library available to all VSI members, especially to those in vascular training, through VSI website
- Identify the fields and methods for “hands-on” skills training on simulators. This is further outlined below:
This list is not exhaustive and can and should be modified and updated as the needs arise.
II. Development of “hands-on” training and skills program.
1. Training in indirect noninvasive vascular evaluation
- Use of vascular lab for arterial assessment of limbs – to measure segmental pressures, plethysmography, analysis of waveforms, assess functional significance of arterial disease – severity, location, and impact on distal perfusion; appropriate use of CW Doppler and interpretation; assessment; questionable claudication – treadmill exercise testing; structured exercise program for claudicators; and arterial and venous flow assessments – a shortlist that all trainees should be able offer to their patients.
- Use in venous diseases – though not common, a working knowledge and hands-on experience will be useful
2. Training in direct noninvasive vascular imaging
- Duplex/Color Doppler ultrasound remains the cornerstone of noninvasive vascular diagnostic testing. Duplex ultrasound imaging demonstrates the morphologic anatomy of the lesion, location, surface characteristics, length, and severity. Ability to evaluate peripheral arterial and venous diseases, cerebrovascular diseases and to perform abdominal visceral assessment and mapping of dialysis access and venous conduits should be developed.
The combination of the above two yields near-complete vascular (arterial/venous), anatomical, physiological, morphological, and pathological details. Structured hands-on experience will be invaluable and should be the requirement of all the vascular trainees. This will also encourage them to learn detailed anatomy and physiology of the vascular system. They should be proficient in using the equipment, protocol-based evaluation for screening, and preprocedure and postoperative surveillance
3. Comprehensive training in the development of vascular skills in invasive procedures
- Gradual decrease in “open” vascular procedures has resulted in many trainees having limited exposure to these time-tested procedures. Perhaps, the time has come to resort to mannequin-/model-based training in several open procedures – a role reversal from earlier endovascular skills development. The available open surgical models can be expensive, but with innovative thinking, low-cost models can be created
- Simulator-based endovascular skills training: Now, these trainees learn these skills by direct observation and assisting in the procedures. The simulator training can prepare them for “real” procedures, which is known to enhance their skills and confidence. But, these are quite expensive, though few are available in India with the industry.
4. Imparting the above to vascular trainees
The above are well recognized and recommended as an integral part of vascular training in the USA, Canada, and Europe. Can we take this “leap” in India? It appears difficult but not impossible. There are already few departments conducting courses in Duplex/noninvasive vascular evaluation. Perhaps, some of these can offer intensive, structured, short-term courses for entry-level trainees? Can these be recognized by the VSI to offer such courses? Also, there are several “live” workshops and these can include basic courses for the beginners?
We could also, with the help of the industry, obtain simulators, models for both open surgical and endovascular training, and conduct courses to provide a “head start” to junior trainees and advanced techniques to the 2nd- and 3rd-year students.
VSI's midterm conferences, aimed toward educating the trainees, have had a significant impact and well attended. Can this be converted to hands-on training, instead of numerous didactic lectures which have become repetitious. The “competition sessions” can be retained, and the rest can be converted to more practical sessions, with limited lectures on the practical aspects of open and endovascular procedures. Perhaps, it is time to emerge from the established norms and relook and refurbish our midterm conferences aiming entirely toward hands-on training. It is for the VSI Executive Committee to consider these suggestions.
The thoughts and suggestions presented above are from the existing training methodologists in the USA and Europe; many of these are my own thoughts. These may or may not reflect the opinions of the Editorial Board or VSI Executive Committee.