In India, we are currently at the doorstep of a urological revolution. The advent and growth of new subspecialties has resulted in a rapid explosion of urological knowledge and skills. While this may be beneficial in selected institutions, most urologists in peripheral centers who cater to the majority of the Indian population need to be well versed in general urological skills covering a wide array of these new subspecialties.
Clearly, in India, there is no escaping the need to have a core competency in the management of common urological diseases. The original Indian residency program was designed at the time when urology was quite a limited specialty. There was no endourology, no laparoscopy, no lithotripsy, and no robotics. Reconstructive and pediatric urology were in their infancy. Microsurgery for male infertility was not developed.
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Urology at that time essentially involved open surgery for stone and malignancy. With the emergence of new modalities of treatment, there is also a greater amount of time required to train the budding urologists in these skills. The current three-year urology residency may not provide the right foundation for this in these changing times. There is no doubt that a solid foundation in general surgery is essential for specialization in any surgical branch-but are three years necessary for it?
One would think not. An intensive one to two-year general surgery rotation with more time available later on for urology would be good enough to develop the basics and then build on it to make a comprehensively trained general urological surgeon.
EXISTING TRAINING SCHEDULES
In the United States in , a third of the urology residency programs 41 of were of five years duration including a two-year pre-urological general surgery training. Over the next 12 years there has been an overwhelming trend of conversion to a one-year general surgery training followed by a four-year urology stint. In fact, in all US urology programs but one required a four-year clinical urology training.
In all others general surgery training is incorporated within the framework of a urology residency program. In fact, in three countries, namely, Estonia, Italy and Ukraine general surgery training is foregone altogether in favor of a purely urological training program. The mean time spent in general surgery training in European countries is A large number of residents, even in leading institutions of our country rue a deficiency of practical operating experience in our urology residency programs.
This lack of proper practical training is distressing - although not uniquely Indian. In a survey of laparoscopic training during residency, Duchene et al. Nevertheless, it is likely that Indian data on this aspect of our residency programs would present an alarming picture. Most of our institutions still lack a structured policy regarding the number and type of surgical procedures to be performed by residents in training.
Surgeries are allotted to residents in a relatively random fashion and the most important factor in this is the amount of trust and rapport a resident has been able to develop with the members of the faculty. Although this is not necessarily improper, it does introduce a discrepancy in the surgical exposure between two residents in the same or different departments. In our current residency system, by the time a resident comes into a situation where he would start getting some surgical freedom, it is time to go.
By increasing the number of years to be spent in the same department, the independent surgical exposure would definitely be enhanced and would go a long way in producing urologists who are more technically skilled than those coming out of residency programs today.
Clinical and even basic science research is a vital component of a residency training program. Not only does it enrich the individual during training and thereafter, but also ensures growth and development of our specialty in the future. In the current three-year program, residents are often left performing a desperate balancing act between inpatient care, operating room duties, emergency calls and preparation for examinations leaving very little room and I dare say, inclination for research.
This is not only detrimental for the individual but also for the institution since the reputation of the institution and its stature in scientific circles is determined to a large extent by the publications emerging from it. This is indeed quite paltry as compared to the publications from institutions in the United States in these journals during the same time period.
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Though the reasons for this vast gap may be many, a general lack of time and facilities for urological research in India is definitely quite glaring. A six-year program with a dedicated research year would provide a greater opportunity to perform high quality research during the training period by ensuring a more rational time allocation to this aspect of residency training thereby resulting in an increase in the number of urological publications coming out of Indian academic institutions.
I would concede that the current MBBS curriculum does not offer enough exposure to subspecialties like urology and that makes it difficult for medical students to choose a path that would lead to a direct five to six-year course after MBBS. This doesn't however mean that the current three-year course in urology is adequate.
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It stresses on the fact that there is a need to change the way medical education is conducted at the undergraduate level. In order to assist the medical student in making a decision regarding the specialty to pursue after graduation, a structured curriculum needs to be formulated and implemented at the undergraduate level so as to ensure adequate exposure to subspecialties like urology.
The present portal of entry into a urological residency in India is fraught with uncertainty. After MBBS, at every stage, the prospect of a daunting entrance examination looms ahead. For an aspiring urologist, completion of a general surgery residency is just a means to an end.
Even these examinations are not standardized. While some institutions ask pure urology, others want to test the candidates on their general surgery knowledge. Still others even put questions from biochemistry and gynecology in their entrance examinations.
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The candidates end up either riding two horses at the same time with a high chance of falling or have to forego some examinations altogether. Clearly, such a system causes an undue amount of stress and anxiety in the minds of these young surgeons and is counterproductive to our medical system. Authors of published original research with the highest impact, as judged democratically by the readers, will be invited by the Chief Editor to write a Frontiers Focused Review - a tier-climbing article. This is referred to as " democratic tiering ".
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