Medical Council of India (MCI) is an autonomous regulatory authority responsible for setting the standards of undergraduate as well as Postgraduate Medical Education besides certifying the availability of adequate infrastructure, clinical teaching material, and the trained workforce in the training institutes. Specifically, the Postgraduate Medical Education is governed by the MCI Postgraduate Medical Education Regulations, 2000 with the goal of producing competent specialists who are expected to master most of the competencies to enable them to carry out their professional duties ethically. Each discipline is expected to define competencies clearly to be brought to the notice of the new entrants so that they spend all their efforts in acquiring those competencies during the 3-year course of study. All training medical institutes, with the exception of some autonomous central institutes which are deemed universities, need an affiliation with a university for the conduct of the certifying examination for the award of MS/MD degree.
More importantly, however, the universities are responsible for the development of an enabling and dynamic curriculum that is responsive to the changing demands of the community. However, with few exceptions, the curriculum, if developed, is not available publically for scrutiny by the society and worse still, may not have been changed ever since it was designed by the affiliating university's board of studies. Moreover, in a majority of the training institutes, the infrastructure development has not kept pace with the changing times. Additionally, there is no provision to test the quality of training or the trainers either by the MCI or the affiliating university. Training of the residents is left to the whims and fancies of the department faculty and perhaps largely, the head of the department, who may or may not have the will, belief or resources to keep pace with the changing technology or learning resources. It is a common observation that although the equipment is physically present, it may not be functional, or in the worst case, access to equipment may be restricted. In the absence of a standard curriculum, modern equipment, learning environment, and a peer-reviewed quality assurance, the graduating ophthalmologists expectedly come out of our training institutes with hugely variable competencies. I am sure, the ophthalmology leadership in the country is fully aware of this.
In the current issue of the journal, the authors have stirred up a hornet's nest by reflecting on the training standards and the expectations of the ophthalmologists who trained 2–10 years before they were recruited for this survey. In an update on a much smaller survey done in the past, the authors of the present study managed to get a fairly large sample size (no = 531) of ophthalmologists representing all regions of India to answer questions on their perceptions of at least two important competencies, the clinical examination skills and the surgical skills in their training program. I applaud the authors for undertaking this painstaking study and exposing the truth with warts and all. The first step before taking a course correction is admitting that all is not well with ophthalmology training in India.
To bring out a clear perspective on ophthalmology training in our country, 241 medical institutions are certified by the MCI for running the MS Ophthalmology course with an annual intake of 1026 students. A total of 118 Government Medical Colleges and 123 private trust medical colleges are certified to run the MS Ophthalmology course. Twice as many seats (683:343) are available every year in the Government Medical Colleges compared to the private institutions. Besides 120 medical colleges also run a DO course (66 government; 54 trust). Twice as many seats exist in the Government institutes for DO 242 versus 113 for the trust institutes. In January 2017, 147 DNB seats were available in 66 specialist eye hospitals and two multispecialty hospitals practically all in the private sector the so-called “corporate hospitals.” On a rough estimate, nearly, 1500 newly minted Ophthalmologists become available every year to practice in India.
Given that nearly 60% of the ophthalmologists come out of government medical institutes, the critical question that has been addressed albeit to a limited extent is whether the clinical skill training is perceived to be better in the government medical institutions or the private trust institutions? Are the doctors who are trained in the National Board of Examination (NBE) accredited institutions for DNB degree better trained? As expected, the government institutes fared badly on the basic clinical skills such as the slit lamp examination, gonioscopy, applanation tonometry, indirect ophthalmoscopy, and the biomicroscopic fundoscopy. Times have changed and expectedly uniform poor performance across the training institutes on refraction reflects the students' own indifference rather than the opportunities and the training material. Likewise, the evaluation skills for children including the squint and vision assessment were poorly performing primarily because of students' indifference.
As far as the surgical skills are concerned, the emphasis appears on extracapsular cataract extraction and small incision cataract surgery. It is really unfortunate that nearly 50% of the trainees did not perform independently or under supervision, phacoemulsification, squint, and trabeculectomy. It is a paradox that while the trainee ophthalmologists from the western world flock to India for training in phacoemulsification, our own trainees are deprived of this opportunity.
That they did not get to see or assist posterior segment procedures, corneal grafting, or the laser procedures reflect on the lack of infrastructure and the trained faculty in the training institutes. This calls for a serious introspection by the authority to allow such institutes to keep training the ophthalmologists for the nation.
I would have loved the authors to dissect their data to compare the surgical skills training in government versus the private sector institutes to have a clearer perspective on this critical aspect of training. The residency programs in the western world are far more competitive, structured, regulated, and peer-reviewed. Excellent modules are available from the International Council of Ophthalmology and NBEs for emulation by the training institutes in India. It is high time they shed their inertia.
About the author
Prof. Amod Gupta is an Emeritus Professor and an Ex- Professor of Ophthalmology at the Post Graduate Institute of Medical Education and Research, Chandigarh. He was the Dean at the PGI from 2010 to 2014. He headed the Department of Ophthalmology at the PGI from 1989 to 2015 and raised the Advanced Eye Centre at the PGI, Chandigarh in 2006. He has been at the forefront of clinical research in Ophthalmology and especially in the field of retinal and uveal diseases. He has published more than 350 original research papers in peer-reviewed journals which have been extensively cited. Teaching is his passion. Earthy humor is his style. His involvement in residency training has been deep and intensive, and he has an insight into what works and what doesn’t. His recent initiative of “Teaching the Teachers” by the WisdomTree approach has been well appreciated. There is none better than Prof Gupta to ponder over the status of residency training in India. The father figure that he is, he has every right to rap on our knuckles and show us the right path.
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