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|NI FEATURE: TIMELESS REVERBERATIONS - COMMENTARY
|Year : 2016 | Volume
| Issue : 4 | Page : 602-603
Training neurologists in India: Past, present and future
M Gourie-Devi MD (Medicine), DM (Neurology), DSc (Honoris Causa), FAMS, FIAN, FNASc
Emeritus Professor of Neurology, Department of Neurology, Institute of Human Behaviour and Allied Sciences (IHBAS), New Delhi; Chairperson, Department of Neurophysiology and Senior Consultant Neurologist, Sir Ganga Ram Hospital, New Delhi, Former Director and Professor of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
|Date of Web Publication||5-Jul-2016|
Prof. M Gourie-Devi
Emeritus Professor of Neurology, Department of Neurology, Institute of Human Behaviour and Allied Sciences (IHBAS), New Delhi; Chairperson, Department of Neurophysiology and Senior Consultant Neurologist, Sir Ganga Ram Hospital, New Delhi, Former Director and Professor of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Gourie-Devi M. Training neurologists in India: Past, present and future. Neurol India 2016;64:602-3
I am grateful to the Editor of Neurology India for asking me to contribute to the novel section of 'Timeless reverberations'. Through this narrative, I wish to share some ideas and thoughts about neurology education in India culled from personal experience, initially as a postgraduate student (the first batch of postgraduates of DM in Neurology-1966 to 1968) and subsequently as mentor of more than 100 neurology trainees. Establishment of neurology services (neurosurgery and neurology) in the early 1950s in Chennai (Madras), Mumbai (Bombay), Vellore, Kolkata (Calcutta) and New Delhi and later in Bangalore, Chandigarh, Lucknow, Pune and many other cities, was a major milestone in the history of development of neurological services in India. Further advances in diagnostic facilities including neuroradiology, neuropathology, biochemistry and other allied disciplines, provided a firm footing for patient care. To fulfill the felt need of manpower in the superspecialities, training program leading to the degree of DM for medical disciplines and MCh for surgical disciplines was initiated in the country. Cardiology and neurosurgery took the lead and soon neurology followed. In the 1960s, DM course in neurology commenced in Madras, Vellore and All India Institute of Medical Sciences (AIIMS), New Delhi. I was lucky to be enrolled in the first batch at AIIMS under the tutelage of (late) Prof. Baldev Singh, respectfully called as 'Papa' neuron. DM in neurology which started as a two year course, later on was increased to 3 years, to enable the trainee to keep pace with the rapid advances and to acquire knowledge and the necessary skills. Since education is an organic entity, response to the ever changing health care challenges and societal needs is essential and mandatory. Over the last five decades, the emphasis has been on clinical neurology with stress on bed side discussion coupled with training in clinical neurophysiology and allied disciplines of neuroradiology, neuropathology and behavioral sciences. Exposure to basic sciences of neurochemistry, genetics, neurophysiology is limited to very few institutes, and in others, it is either very limited or nonexistent. Recollection triggers memories of the combined seminars we had at AIIMS in the department of Physiology with the PhD scholar of physiology presenting the basic science and DM neurology student, the clinical aspects of a specified topic with the eminent Physiologist, (late) Dr. BK Anand, Professor of Physiology and (Late) Professor Baldev Singh directing the discussion. Indeed an unforgettably rich experience. Another major initiative was the organization of 5 courses in Neurobiology, a brain child of Prof. PN Tandon, Professor of Neurosugery AIIMS, by the Department of Science and Technology in the 1990s, which were held at AIIMS and National Institute of Mental Health and Neurosciences in Bangalore. Lectures were delivered by eminent neuroscientists of the country covering a wide range of topics focusing on cutting edge research to the postgraduate students of neurology and neurosurgery drawn from institutes across the country. The broad objective was to inculcate interest in basic neurosciences and to encourage them to pursue clinical and translational research. It is fervently hoped that these novel initiatives will serve as models and be adapted by training institutes and also become a collaborative national effort.
Neurology training and thereafter
In the early 1980s, under the aegis of Neurological Society of India, a workshop was held to formulate the eligibility, duration and course content for DM in Neurology and MCh in Neurosurgery. While there was consensus on MBBS with a 5 year course and MS with a 3 year course for MCh in Neurosurgery, for DM in Neurology there was agreement only on MD with a 3 year course but disagreement on MBBS at the entry level. Thus, it was left to the institutes to take the final decision. The National Institute of Mental Health and Neurosciences at Bangalore is the only institute which admits candidates with MBBS or MD for DM Neurology program and the experience over three decades has convincingly demonstrated that the candidates of both the streams are comparable in their skills and knowledge. Diplomate of the National Board of Examination in Neurology (DNB in Neurology) is also offered in some hospitals in the country. The bedrock of training program is directed towards creating a human resource of clinicians, teachers and researchers. In the current scenario, ethical dimensions in conducting research on humans requires emphasis. The essence of autonomy, nonmaleficience, beneficence and justice, the four pillars of bioethics, has to be communicated to the residents through didactic lectures and case studies.
The demands on the current trainees is tremendous due to rapid advances in Clinical Neurology and the emergence of subspecialties of epilepsy, cerebrovascular disorders, movement disorders, clinical neurophysiology, neuromuscular disorders, cognitive neurology, neurocritical care, etc. The current trend in the USA is that most residents (74%) do a fellowship in a subspecialty of their choice along with training in patient oriented clinical research or research in basic sciences., It is also of interest that nearly half of all residents in the USA wished to pursue academics. In India, although the majority continue to function as general neurologists, the recent trend is also to do fellowship program in a subspecialty either at institutions in the country or abroad, which offer advanced training in the area of interest. The candidate with this focused training feels empowered to offer special services to the patients either in the government or private sector. Unlike the scenario in the USA, the general impression in India is that most residents, after training, choose to work in corporate hospitals or nursing homes and only a minority show interest in pursuing a career in institutions and in carrying out the three roles of clinical practice, teaching and clinical research. Perhaps the decision is dictated by market forces and also by limited availability of faculty posts in prestigious institutions.
Burden of neurological disorders in India and Neurology manpower
Based on community based surveys in different regions of the country, it is estimated that 30 million people have neurological disorders. This figure is not inclusive of neuroinfections, metabolic disorders, traumatic injuries and rare disorders since these diseases have not usually been included in the surveys. The country is facing a public health crisis in providing neurology services particularly at the district, taluk and primary levels. With a pathetic small number of 1200 neurologists (data provided by Indian Academy of Neurology), the approximate ratio is 1 neurologist for a population of 1,000,000 which is in stark contrast to that of 1 for 26000 population in the USA and 1 for 53000 in Canada. Currently, there are only 90 institutes providing training to 200 candidates (DM in Neurology and DNB in Neurology: Source-Indian Academy of Neurology); there is thus an urgent need to enhance the number of teaching institutions to provide training and to maintain high standards of teaching and training programs. It is obvious that with just 200 neurologists being trained annually, there is a huge gap between the service providers and the requirement of neurology services. Therefore, attempt should be made to bridge the gap through innovative strategies to provide Neurology care for common neurological disorders in the rural and remote areas. The future neurologists in India, in addition to acquiring skills and competence in advances in Neurology, have also to cater to the needs of the community at large. The concept of “Neurology as a public health issue” needs to be emphasized in the training programs and the residents should be exposed to assessment and management of neurological disorders in the rural setting and acquire leadership qualities to function as nodal neurologists for training medical officers working at different tiers of the pyramid of health care delivery systems.
In conclusion, it may be stated that while over the last few decades, major initiatives have taken place in the country to develop a robust program for training neurologists, the need of the hour is to ensure that designing the content of the training should be a dynamic process, keeping in view the national demands and the international scenario. The three cornerstones, skill based learning, communication skills and clinical research need to be emphasized in the training program. The Indian Academy of Neurology should constitute an Advisory Committee to review and refine the training program every few years, amalgamating the new advances and the changing demands.
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