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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.
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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 demand3
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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.
- 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.
- 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.
- 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.
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- 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.
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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.
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And that is what our country needs at present to take affordable
surgery to the door steps of majority of our population.
Reference :
- 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.
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