Postgraduate surgical training in India

Postgraduate surgical training is supposed to be one of the toughest stages of training in medicine. While there is no doubt that surgical trainees in India get good experience in open surgery during their tenure, consultant surgeons are reluctant to train surgical postgraduate students in laparoscopic surgery.

Medical training in India commences with the MBBS of five and a half years, inclusive of a year of internship. Thereafter, candidates who clear an entrance exam can enter a three-year postgraduate training programme.

During the first year, most of the surgical trainee’s time will be taken up in attending to ward patients, writing clinical notes and doing other paperwork. During the second year of training, s/he may get hands-on surgical practice, often in emergency operation theatres under supervision of a third-year trainee or senior resident doctor. In routine operations, senior and junior consultants hardly ever allow trainees to do basic laparoscopic surgeries like cholecystectomies, appendicectomies, diagnostic laparoscopies, etc., other than holding the camera port for the consultants during these procedures. None of the government medical colleges in India has a laparoscopic set-up for emergency theatres. So the surgical candidate will not do any laparoscopic surgeries even during emergencies. Third year trainees will get limited opportunities. Overall, three valuable years of training are completed without any significant, hands-on laparoscopic training.

It does not end here. After post graduation, there is a three-year posting as senior residents (SR). SRs operate independently in emergency theatres, assisting and performing all open surgeries in routine theatres. But here again, they hardly get to perform laparoscopic surgery independently, as the bulk of these surgeries are performed by consultants. For the sake of training, they will get a few laparoscopic cholecystectomies in the final days of their senior residency. So, after six years of training, surgeons are sent out into this modern era of laparoscopic surgery without proper exposure to laparoscopic techniques. There is no fixed curriculum that stipulates a minimum number of laparoscopic procedures be assigned to candidates during their postgraduate studies or senior residency.

Why are consultants so apathetic towards their students? The answer, obvious to most trainees, is that the consultants themselves learned laparoscopy after the age of 40, so they do not want trainees to master it at a young age. Indeed, younger consultants are keener to train students in laparoscopic procedures than their older counterparts are. The introduction of just a few laparoscopic procedures in the last six months of their training will not let trainees become expert in any of the procedures.

As trainees in general surgery, we wish to ask our consultants: If we do not get hands-on experience in laparoscopic technology during postgraduate studies and senior residency, who will give us guided training once we graduate?

The answer is: no one. There are few laparoscopic training centres in India giving hands-on experience to beginners. These are generally in private hospitals, and they are very costly. A few surgeons try to learn the procedures on their own in some small hospitals. Some lucky chaps get training outside the country.

The surgical curriculum must state the year-wise goal of a surgical trainee, including the number of laparoscopic and open surgical procedures which the candidate must perform and assist in before completing postgraduate studies and during senior residency. There should be a performance evaluation before the trainee can be promoted to the next year. Surgical trainees should not get a senior residency merely on the basis of interviews; they should also have references from their tutors on their performance.

Compared to European or US surgical trainees, Indian candidates perform negligible numbers of laparoscopic surgeries. The new world is getting trained on simulators, which we can only dream of, in a third world country like ours. Yet, with the variety of cases available, we can get adequate exposure if we are given the opportunity.