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

1. Musculoskeletal Training of Orthopaedists and Non-orthopaedists – Experiences in Nepal Ashok K. Banskota MD, FACS

4. 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)

5. 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)

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

7. 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.

8. 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)

9. Costs of Training • University Expenses • Student – monthly stipend • Training institution logistic expenses • Expenses for Special courses / meetings • IOM • KU • BPKIHS • NAMS

10. 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

11. 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

12. 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

13. 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

14. 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

17. 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 1:1 • Teachers: making use of available manpower often lacking experience.

18. Training Process – Documentation Core logbook • To maintain records of the acquisition of skills • To indicate the levels of competence expected & achieved Thesis

19. Training Program – Common Patterns • IOM • BPKIHS • KU • NAMS • Group discussions • Case Presentations • Journal Clubs • Practical Learning • ER • OPD • OT • Clinical Research • Hours / Duties / Time off • No Hours 80-90 hrs/week

20. Training Program – Special Aspects • KU – Additional Pediatric & Rehabilitation Exposure • BPKIHS • Community orthopaedics • Link with AIIMS & other leading Indian Institutions

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

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

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

24. Training of Non-Orthopaedists

27. Roles of Non-Orthopaedists • Initial evaluation/primary care/emergency care • Transport • Definitive care

28. 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

29. 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

30. 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

31. Physiotherapy and Rehabilitation (PRT)Trainee- (HRDC) • Pre requirement – High School • Training • Didactic/Practical • Community Need based • Follow up care / rehabilitation needs of patients emphasized

32. Other Non-Orthopaedist Workers • Compounder/Dresser • Plaster cast technician • Ambulance Driver/attendant • Traditional practitioners, including bone-setters, barbers

33. 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.

34. 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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