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Neurosurgical Training in India
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Anil Nanda, M.D., M.P.H. Professor and Chairman, Department of Neurosurgery Louisiana State University Health Sciences Center—Shreveport
Neurosurgical Training in India Anil Nanda and Ashish Sonig
That is, the protean work of the protoplasm in which the great Self resides cannot be detected by the body’s eye; to know its work, mind’s eye is necessary, along with the body’s eye. For acquiring efficiency in Surgery alone, the dissection of dead body, nay, the “Avagharshana” which brings into view the layer of epidermis and the dermis, the number and branches of blood-vessels and nerves that lie embedded in muscles etc, is only necessary (8). Sushruth, 600 BC (Sanskrit)
1. Ka ya-cikitsa (Sanskrit: internal medicine) 2. Kauma rabhrtyam (Sanskrit: pediatrics) 3. S´alya-cikitsa (Sanskrit: surgery) 4. S´a la kya tantra (Sanskrit: ophthalmology and ear⫺nose⫺throat) 5. Bhu ta vidya (Sanskrit: psychiatry) 6. Agadatantram (Sanskrit: toxicology) 7. Rasayana (Sanskrit: immunity and rejuvenation)
INTRODUCTION
T
he history of Indian neurosurgery is intimately related to the concepts of totemism (12, 26) and therianthropy. The former is a belief that every human has a spiritual linkage to all forms, including animals. The latter refers to the metamorphosis of human form, mostly gods to animals. Entwined between these two didactic terms is “Ganesha,” the all-encompassing cosmic deity of the ancient Hindu pantheon. The product of a mythological xenograft (18), Ganesha is an elephant-headed god with a human body. He was created by Lord Shiva, who is considered to be the master of the Siddha system of medicine (14), one of the oldest systems of medicine known to mankind. The Siddha system was practiced by the ancient Indus valley civilization, Bharatvarsha (4), known as India. According to the Hindu religion, the fundamental tenet of the faith is the belief in the One god, Brahman, The Universal soul. Brahman (29) devised the Indian system of medicine, Ayurveda (29) and divided it into eight parts (10). The “Astanga Ayurveda,” or eight sections of Ayurveda (20), are as follows:
Key words 䡲 India 䡲 Neurosurgical 䡲 Training Abbreviations and Acronyms AIIMS: All India Institute of Medical Sciences CMC: Christian Medical College (United States Medical Licensing Examination) DNB: Diplomate of National Board program MCh: Magister Chirurgiae MCI: Medical Council of India NIMHANS: National Institute of Mental Health and Neuro-Sciences PGIMER: Postgraduate Institute of Medical Education and Research
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8. Vajikaranam (Sanskrit: aphrodisiacs and improving health of progeny)
FROM CELESTIAL ART TO ANCIENT NEUROSURGERY According to Hindu mythology, after its creation, the art of Ayurveda was then passed to the Aswini Kumars (the celestial twin sons of the Sun God). The celestial knowledge of Ayurveda was then propagated to sages and rishis (Saints), the first being Saint Bharadwaja (29). He, in turn, taught this to his pupil Atreya followed by Susruth, who published his treatise on shalyachikitsa (surgery), Sushruth samhita (3, 21) sometime between 700 and 600 BC. In his treatise, he gave a detailed account of the Vatavyadhi (diseases of the nervous system) and common neurological disorders along with their remedies. He described sciatica, glossopharyngeal neuralgia, and brachlagia (6) and gave an apt description of convulsions, which he called “Apatantrakah” (Sanskrit) (7):
Department of Neurosurgery, Louisiana State University Health Sciences Center—Shreveport, Shreveport, Louisiana, USA To whom correspondence should be addressed: Anil Nanda, M.D., M.P.H. [E-mail: [email protected]] Citation: World Neurosurg. (2013) 79, 5/6:615-620. http://dx.doi.org/10.1016/j.wneu.2013.03.001 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2013 Elsevier Inc. All rights reserved.
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Symptoms: The patient lies with his eyes closely shut, or stares with a sort of fixed or vacant gaze, the eyes remaining fixed or immovable. The patient loses all perception, and groans. Respiration becomes difficult, or symptoms of temporary asphyxia and unconsciousness set In. Consciousness and a normal condition of the organism return with the passage of time Susruth also devised his own dissection techniques to analyze structures not visible to the naked eye. He immersed cadavers in a special grass called “kush;” as they slowly decomposed, the minutest of vessels would swell (9): . . . . with Kusa grass and place it at the edge of the water of a rivulet. After three days take it out carefully, and gradually take off the successive layers of the epidermis and dermis and of the muscles beneath by gently and lightly rubbing it over with a soft brush. Thus the smallest and the thinnest arteries, which have by this time swelled and obtained a distinct existence are made palpable everywhere even to the minutest. The saga of Ancient Indian surgery and neurosurgery continued for centuries, with reports of lord Buddha’s physician Jivaka performing trephination (19). Similar neurosurgical procedures were performed mainly for the elite up until the 10th century AD (14).
THE INTRODUCTION OF MODERN NEUROSURGERY IN INDIA General surgeons performed neurosurgery before independence. In 1835 the first medical schools (19) were established in the eastern and southern regions of India, Calcutta (Kolkata) and Chennai, respectively. Lt. Col. F. J. Anderson and Provat Sanyal pioneered neurosurgical operations at Calcutta Medical College. In Southern India, Dr. Balakrishna Rao started neurosurgical procedures at Madras Medical College. A decade later Grant Medical College and its associated Sir Jamsetjee Jeejebhoy Group of Hospitals was established in the western region of India and the city of Bombay (Now Mumbai).
THE FOUNDING FATHERS OF INDIAN NEUROSURGERY Since its independence on 15th August 1947, India has made prodigious progress in nuclear, space, and medical technologies. These developments were led by visionaries in their respective fields. The field of neurosurgery enjoyed similar progress. Its list of visionaries is long and impressive.
Vellore. Dr. Chandy worked for nearly 21 years at CMC, Vellore and trained 25 neurosurgeons (2). For his contributions, he was awarded the Padma Bhushan, one of the highest civilian awards given by the Indian government, in 1964. Dr. Jacob Chandy died on June 23, 2007. His life and work was published recently in Neurosurgery Journal (2).
Dr. Balasubramaniam Ramamurthi In 1950, Dr. Ramamurthi set up the Department of Neurosurgery at the Madras Medical College Government General Hospital after completing his neurosurgical training from Newcastle in Tyne, England (11). He later founded the Institute of Neurology, Madras, in the 1970s. Along with his colleagues in neurology and neurosurgery, he performed the first stereotactic surgeries in India. Their work was internationally acclaimed. For his phenomenal contribution to the growth of neurosurgery, Dr Ramamurthi was awarded the Padma Bhushan and the Dhanvantari Award (one of the highest awards for a physician). In 1987 he was appointed the President of the World Federation of Neurosurgeons (27). He was also the founding editor of Neurology India, the first Indian journal to publish neurology and neurosurgery literature. In addition to the programs established by Drs. Chandy and Ramamurthi, in 1951 Dr. Ram G. Ginde started the Department of Neurosurgery at Seth G. S. Medical College and the associated King Edward Memorial Hospital in Bombay19.
THE BIRTH OF THE NEUROLOGICAL SOCIETY OF INDIA (NSI) The NSI was the brainchild of four eminent figures: Drs. J Chandy, B. Ramamurthi, S. T. Narasimhan, and B Singh. Dr. Baldev Singh was from the State of Punjab in northern India and was trained in neurology in the United Kingdom. He also trained in electroencephalography under Dr. Gibbs in Chicago and joined Dr. Chandy in Vellore (11). All branches of the neurosciences were brought under the purview of the Neurosurgical Society of India. The society had its first meeting in March of 1952 at Hyderabad, during which its members decided to publish their own journal, Neurology India. The society has grown since the days of its inception and over the years, the NSI has stratified into several subsocieties, including:
y Indian Society of Pediatric Neurosurgery—founded in the year 1989 during the Annual Conference of the International Society for Pediatric Neurosurgery in Mumbai (5), along with its affiliated journal, Journal of Pediatric Neurosciences;
y The Indian Society for Stereotactic and Functional Neurosurgery; and
y The Skull Base Surgery Society of India, founded on February 7, Dr. Jacob Chandy Dr. Chandy obtained his medical education at the Madras Medical College, Madras (2, 22). He later pursued his dream of becoming a neurosurgeon by training under Dr. Wilder Penfield at the Montreal Neurological Institute in Canada and in Chicago with Theodore Rasmussen. Upon his return to India, Chandy joined Christian Medical College in Vellore and in 1949 established the first neurosurgery department in India. In 1957 Wilder Penfield laid the cornerstone for the Department of Neurological Sciences, and Dr. Chandy started the first neurosurgical training program at Christian Medical College (CMC),
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1998, as a professional medical society In addition, the NSI has included the Association of Neurological Nurses as a section. All of these sections and subsections of the NSI are affiliated with the World Federation of Neurosurgical Societies.
OVERVIEW OF NEUROSURGICAL RESIDENCY TRAINING IN INDIA Residency programs in India are different from those in most parts of Europe and North America. An Indian student can enter a medical
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Medical graduate Degree: MBBS
Option 1
Option 2
6 years training in a government owned hospital, acrredited by Medical council of India Degree: MCh in Neurosurgery
3 years of training in General Surgery Degree: DNB or MS in General Surgery AND
Or 6 years training in a private/trust owned hospital, acrredited by National Boards Degree: DNB in Neurosurgery
3–4 years of dedicated training in Neurosurgery in a government owned hospital, acrredited by Medical Council of India. Degree: MCh in Neurosurgery Or 3–4 years of dedicated training in Neurosurgery in a private/trust owned hospital, acrredited by National Boards
medical and surgical training in India. Each year, 59 such institutes offer 190 neurosurgical training positions. MCh students must complete certain prerequisites before graduation. All MCh programs conduct their own examinations, which include both a written and an oral evaluation of a candidate by the invited faculty. Exam content varies from institution to institution. For example, at the National Institute of Mental Health and Neurosciences, a premiere federal government institute in Bangalore, candidates for graduation is required to resect a glioma under the supervision of invited faculty (Figure 2). Candidates also are expected to submit a dissertation defending their research work.
Degree: DNB in Neurosurgery
Diplomate of National Board Program The extension of neurosurgical services to its population of 1.3 billion is one of the biggest challenges India faces today. Currently India has a very high patient to doctor ratio, or 1:1700 (1). The ratio is even greater in neurosurgery. To increase the number of practicing neurosurgeons in the country, the Indian government established the autonomous National Board of Examinations in 1975. The board’s objective was to start training programs in private and semiprivate hospitals, relieving the MCI of this responsibility. The National Board of Examinations awards the qualification Diplomate of National Board (DNB) neurosurgery upon successful completion of the course. As with the MCh program, a candidate can enter a DNB program in neurosurgery after the completion of his or her Bachelor’s of Surgery and Bachelors of Medicine course or general surgery residency. To earn the DNB degree, a candidate must pass the DNB final exam. First, an eligible candidate must complete a theory examination to qualify for oral examination. A candidate unsuccessful in the first attempt of orals is permitted one more attempt. The board thus ensures uniform standards of neurosurgical training across India.
Figure 1. The MCh (Magister chirurgiae) program is the oldest and most highly regarded in neurosurgery. The Medical Council of India (MCI) regulates MCh training standards. National boards were formed to allow privately owned, trust-governed, and some government-owned, hospitals to start DNB residency programs. The MCI and National boards ensures the uniformity in training and certification process. The government of India gives equal recognition to MCh and DNB programs.
school immediately after graduating from a high school; there are no requirements for a pre-med or a bachelor’s program. The duration of an Indian graduate medical education is 4.5 years, and a student has to pass both a written and an oral examination before entering a year of compulsory internship. Thus the total duration of training is 5.5 years. The internship includes rotations in all medical specialties and exposes the student to the environment of first-year residency. These specialty rotations during internship are in addition to the mandatory clinical clerkships during the graduate medical curriculum. After a student successfully completes the internship, he or she is awarded the degree of Bachelor’s of Surgery and Bachelors of Medicine. If an Indian medical student wishes to pursue neurosurgery, he or she has two options (Figure 1). First, the student could enter a general surgery residency program for 3 years, followed by neurosurgical training lasting between 3 and 4 years. Second, the student could enroll in a 6-year neurosurgical training program, which includes a rotation in general surgery. Entrance into any program is based on written exams, which are highly competitive⫺only the top 0.1% of examinees gains admission.
FEDERAL GOVERNMENT AND NEUROSURGICAL TRAINING Magister Chirurgiae (MCh) Program Upon completion of a neurosurgical residency, the degree of MCh is awarded by those institutes that are endorsed by the Medical Council of India (MCI), which is the highest organization that accredits
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India’s federal government oversees the standards of medical education and quality in some hospitals. By an act of Parliament, these hospitals have been conferred the status “Institute of National Importance” (16). This special recognition ensures adequate funds for research, medical education, and the maintenance of health ser-
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After completion of stipulated training years AND successful submission of dissertation, a candidate is eligible to appear for the certification/board exam
The board exam is conducted by a panel of four neurosurgeons and one neurologist and it has four components
Written exam
Paper I Applied and basic neurological sciences
Paper II Neuroradiology, Neuropathology, Electrophysiology and other diagnostic aspects
Paper III Neurosurgery proper
Paper IV Recent advances in neurosurgery
Figure 2. This chart shows the “Exit” exam process of a neurosurgical candidate for the MCh (Magister chirurgiae) degree at NIMHANS (National Institute of Mental Health and Neurosciences, Bangalore). A candidate must pass all components of the examination; failure of any one
vices. These programs offer only MCh degrees to their candidates. The Institutes of National Importance are as follows:
y All India Institute of Medical Sciences, Ansari Nagar, New Delhi; y Post Graduate Institute of Medical Education and Research, Chandigarh;
y Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala; and
y National Institute of Mental Health and Neuro-Sciences (24). As Institutes of national importance, these hospitals have autonomy in the selection process for neurosurgical training. Each institute has its own examination, and candidate selection is determined on the basis of his or her performance (Figure 3).
HOSPITAL RANKINGS Hansa, a full-service global market research agency with a presence in 77 countries, recently ranked all hospitals in India (13). Hansa conducted the research survey in association with The Week, a popular Indian magazine (23). Hospitals in the top 16 cities of Delhi, Lucknow, Ludhiana, Jaipur, Chennai, Coimbatore, Kochi, Thiruvananthapuram, Bangalore, Hyderabad, Kolkata, Mumbai, Ahmedabad, Pune, Nagpur, and Indore were included. The inclusion criteria specified that hospitals must have completed at least 2 years of operation and have a minimum of 100 beds. The data from 917 experts—328 general ខphysicians, 442 specialists, and 147 pathologists/radiologists—was taken into account (28). The hospitals were ranked in the following order (23):
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Clinical assessment
Operative performance
Viva-voice
Candidate interacts with actual cases and a discussion follows on work-up and management
The candidate performs surgery, usually glioma resection, in front of the board members
The candidate is assessed during viva voice on every aspect of neurosurgery
component will disqualify the candidate from the certification process. After a failure, a candidate must appear again for the entire process after a minimum period of 6 months.
1. National Institute of Mental Health and Neurosciences (NIMHANS) NIMHANS, established in 1942, was ranked first for the second time consecutively. Frontal leucotomies were some of the first psychoneurosurgical procedures performed at NIMHANS. The Neurosurgery department was started by Dr. R. M. Varma, who received his neurosurgical training from Bristol, United Kingdom. NIMHANS is the only federal government institute that is dedicated exclusively to neurosciences. It received its academic autonomous status from the University Grants Commission on November 14, 1994. Other departments at NIMHANS that aid neurosurgery include neuroanesthesia, neurochemistry, neuroimaging & interventional radiology, neurology, neuromicrobiology, neuropathology, neurophysiology, neurovirology, neuronursing, and psychiatric and neurological rehabilitation. More than 4000 cases are performed annually in six operation theaters at the Neuro Centre, and three theaters at the neurotrauma facilities. The faculty consists of three professors, four additional professors, five associate professors, and five assistant professors. The Medical Council of India has increased the annual resident intake to 14, making the neurosurgical training program at NIMHANS one of the largest in the world. 2. The All India Institute of Medical Sciences (AIIMS) The first Prime Minister of India, Jawaharlal Nehru, envisaged the creation of a medical Institute. In 1952 the foundation stone of the AIIMS was laid, and in 1956 an act of parliament declared it an Institute of National Importance, meant to serve as a hub of excellence in all aspects of medical education. Inspired by Dr. B. Ramamurthi, Dr. P. N. Tandon established the Department of Neurosurgery. The department experienced a mod-
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After successful completion of MBBS course and one year of compulsory internship, a candidate is eligible to appear for the entrance exam.
Over 10,000 candidates appear for the written exam (multiple choice questions) for 3 positions in MCh neurosurgery course (6-year duration).
On the basis of their performance, the candidates are given absolute scores and a rank order list is made accordingly.
The scores obtained are specific for the exam and cannot be used to secure admission in other institutes or subsequently.
Once candidate is selected, he/she undergoes an internal departmental assessment at 6 months and at 18 months. Only after a good assessment is a candidate allowed to finish the stipulated 6 years of training. Figure 3. The admission process of neurosurgical residency program at AIIMS (The All India Institute of Medical Sciences). More than 10,000 medical students appear for the entrance exam of AIIMS; only three students are selected for a 6-year neurosurgical training course. The pattern of the exam is very similar to that of the United States Medical Licensing Examination except that a candidate is given an absolute score. Only top scores will ensure a neurosurgical residency spot at AIIMS. A candidate becomes eligible to appear for final examination for the award of MCh degree at the end of 5 years, 5.5, or 6 years of training. However, a candidate can graduate only after the completion of mandatory 6 years of training. After passing the written and oral components of the examination, the degree of MCh (neurosurgery) is awarded.
erate beginning in 1965, only operating on 50 patients. However, today nearly 3000 operations are performed each year by surgeons at AIIMS, and the institute receives 1500 trauma cases annually. In addition, more than 250 patients are treated with gamma knife radiosurgery each year. Currently AIIMS has 17 faculty members and an annual intake of 11 residents.
3. The Sree Chitra Tirunal Institute for Medical Sciences and Technology In 1973 the Royal Family of Travancore donated the building and land for a medical institute. Three years later, the Sree Chitra Tirunal Medical Center formally opened. Under an act of parliament, the Sree Chitra Tirunal Medical Center was declared an Institute of National Importance, and it was renamed the Sree Chitra Tirunal Institute for Medical Sciences and Technology. The neurosurgery
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department has eight faculty positions and trains four residents annually.
4. Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh The PGIMER opened in 1962. After an act of parliament in 1967, it became autonomous, functioning under the Ministry of Health and Family Welfare, Government of India. The institute was envisaged by Jawaharlal Nehru and Sardar Prartap Singh Kairon, then the chief minister. Dr Des Raj Gulati started the Department of Neurosurgery in January of 1962, and by 1968 the PGIMER faculty was training its first neurosurgery resident.
5. CMC, Vellore Dr. Jacob Chandy started the Department of Neurosurgery at Christian Medical College in 1949. Five years later, he trained the first neurosurgery resident, Dr. R.N. Roy from Calcutta. Dr. Roy went on to become the head of the Department of Neurosurgery at Bangur Institute of Neurology, Kolkata (2). CMC Vellore received its accreditation from Madras University in 1957 for specialty training in neurosurgery. Dr. K.V. Mathai became the first resident who completed accredited training. Currently CMC, Vellore has four accredited training positions for neurosurgery.
NEUROSURGERY AND CURRENT CHALLENGES IN CONTEMPORARY INDIA In 1991 India faced a serious economic crisis. Its government instituted several economic reforms, and the foreign reserves grew from a mere $600 million in 1991 to $294.5 billion (17) in 2012, more than that of most developed nations. In 2007 India recorded its highest gross domestic product growth rate of 9%, becoming the second-fastest growing economy behind China. This economic boom has translated into better infrastructure in government-owned hospitals whereas the economic reforms have allowed development of the health industry in the private sector. It would be perverse not to acknowledge the contribution of private industry in the growth of neurosurgery in India. There are several factors fueling the expansion of Indian hospital industry, including, the rising coverage of health insurance, economic growth, and growth of the middle class. Moving forward, the Indian hospital industry will need to eliminate the deficit in hospital beds. Currently the global average in developed nations is three beds per 1000 people. To match the average, India must add 3 million beds in the years to come. Per the recent market report (15) “Indian Hospital Services Market Outlook,” the hospital industry will be worth $81.2 billion dollars in India by 2015. Economic reforms in India have resulted in better city infrastructure and better reimbursement of doctors. Thus, many doctors who trained abroad are returning. They bring with them medical advances and internationally recognized credentials. The lower cost of healthcare compared with some other nations has transformed India into a preferred medical tourism destination. According to one recent estimate, medical tourism in India has become a $35.69
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billion industry (25). The future of neurosurgery in India is bright. With a booming economy, the boon of medical tourism, and the return of well-trained doctors to the country, Indian neurosurgery will reach a new pinnacle in the 21st century.
ACKNOWLEDGMENT We thank Katie Matza, editorial consultant, Department of Neurosurgery, LSU Health Sciences Center–Shreveport, for editorial assistance.
11. Doshi PK: History of stereotactic surgery in India. In: Lozano AM, Gildenberg PL, Tasker RR, eds. Textbook of Stereotactic and Functional Neurosurgery. Berlin, Heidelberg: Springer Berlin Heidelberg; 2009:155-169 Available at: http://link.springer.com/ content/pdf/10.1007%2F978-3-540-69960-6_12. Accessed January 17, 2013.
21. Misra BK: Susruta: the father of surgery. World Neurosurg 75:231-232, 2011.
2. Abraham J, Mathai KV, Rajshekhar V, Narayan RK: Jacob Chandy: pioneering neurosurgeon of India. Neurosurgery 67:567-575; discussion 575-576, 2010.
12. Goldenweiser AA: Totemism. Science 33:529-530, 1911.
3. Banerjee AD, Ezer H, Nanda A: Susruta and ancient Indian neurosurgery. World Neurosurg 75:320323, 2011.
13. Hansa Research–Market Research Solutions, Custom Search Solutions, Global Market Research: Available at: http://www.hansaresearch.com/. Accessed February 2, 2013.
24. Press Information Bureau English Releases: Available at: http://pib.nic.in/newsite/erelease.aspx?relid⫽ 75998. Accessed February 21, 2013.
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4. Barrow IJ: From Hindustan to India: naming change in changing names. South Asia: Journal of South Asian Studies 26:37-49, 2003. 5. Bhagwati SN: Development of pediatric neurosurgery in India. J Pediatr Neurosci 6:S4-S10, 2011. 6. Bhishagratna KK: The Sushruta Samhita Nidana Sthanam. In: The English translation of the Sushruta Samhita, First. Vol. II. Calcutta: Bharat Mihir Press; 1963:14. 7. Bhishagratna KK: The Sushruta Samhita Nidana Sthanam. In: The English translation of the Sushruta Samhita, First. Vol. II. Calcutta: Bharat Mihir Press; 1963:12. 8. Bhishagratna KK: Introduction. In: The English translation of the Sushruta Samhita, First. Vol. II. Calcutta: Bharat Mihir Press; 1963:VI.
14. Hegde T, Saratchandra P: Evolution of neurosurgical techniques. In: Ramamurthi R, Sridhar K, Vasudevan MC, eds. Textbook of Operative Neurosurgery, Vol. 1. New Delhi: B I Publications Pvt Limited; 2005:3-19. 15. Indian Hospital Services Market Outlook: Available at: http://www.rncos.com/Report/IM381.htm. Accessed February 21, 2013. 16. Institutions of National Importance. Available at: http://mhrd.gov.in/instiutions_imp. Accessed February 21, 2013. 17. International Reserves and Foreign Currency Liquidity - INDIA: Available at: http://www.imf.org/ external/np/sta/ir/IRProcessWeb/data/ind/eng/curind. htm#I. Accessed January 18, 2013. 18. Kahan BD: Ganesha: the primeval Hindu xenograft. Transplant Proc 21:1-8, 1989.
9. Bhishagratna KK: Introduction. In: The English translation of the Sushruta Samhita, First. Vol. II. Calcutta: Bharat Mihir Press; 1963:XIV.
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22. Nadkarni TD, Goel A, Pandya SK: Neurosurgery in India. J Postgrad Med 2002;48:332. 23. Nambisan K: Best hospitals in India. The Week 5264, 2012.
25. Qadeer I, Reddy S: Medical tourism in India: progress or predicament? Economic and Political Weekly: 2010 Available at: http://www.epw.in/ special-articles/medical-tourism-india-progress-orpredicament.html.Accessed 18 January 2013. 26. Stanley HM: Totemism. Science 9:877-878, 1899. 27. Tandon PN: Prof. B. Ramamurthi: contributions to Indian neurosurgery (a personal tribute). Neurol India 52:18-20, 2004. 28. THE WEEK-HANSA Research Survey: Available at: http://english.manoramaonline.com/cgi-bin/ MMOnline.dll/portal/ep/home.do?thisPage⫽%2Fep% 2Ftheweek%2Fcontent%2FprintArticle.jsp%3FBV_ID% 3D%2540%2540%2540%26com.broadvision.session. new%3DYes%26articleTitle%3DTHE%2BWEEKHANSA%2BResearch%2BSurvey%26language%3 Denglish%26contentOID%3D13007935. Accessed February 2, 2013. 29. Verma V: Introduction to Ayurvedic concepts. In: Ayurveda, A Way of Life, Vol 1. Boston: Red Wheel/ Weiser, LLC; 1995.
Citation: World Neurosurg. (2013) 79, 5/6:615-620. http://dx.doi.org/10.1016/j.wneu.2013.03.001 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2013 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2013.03.001
Anil Nanda, M.D., M.P.H. Professor and Chairman, Department of Neurosurgery Louisiana State University Health Sciences Center—Shreveport
Neurosurgical Training in India Anil Nanda and Ashish Sonig
That is, the protean work of the protoplasm in which the great Self resides cannot be detected by the body’s eye; to know its work, mind’s eye is necessary, along with the body’s eye. For acquiring efficiency in Surgery alone, the dissection of dead body, nay, the “Avagharshana” which brings into view the layer of epidermis and the dermis, the number and branches of blood-vessels and nerves that lie embedded in muscles etc, is only necessary (8). Sushruth, 600 BC (Sanskrit)
1. Ka ya-cikitsa (Sanskrit: internal medicine) 2. Kauma rabhrtyam (Sanskrit: pediatrics) 3. S´alya-cikitsa (Sanskrit: surgery) 4. S´a la kya tantra (Sanskrit: ophthalmology and ear⫺nose⫺throat) 5. Bhu ta vidya (Sanskrit: psychiatry) 6. Agadatantram (Sanskrit: toxicology) 7. Rasayana (Sanskrit: immunity and rejuvenation)
INTRODUCTION
T
he history of Indian neurosurgery is intimately related to the concepts of totemism (12, 26) and therianthropy. The former is a belief that every human has a spiritual linkage to all forms, including animals. The latter refers to the metamorphosis of human form, mostly gods to animals. Entwined between these two didactic terms is “Ganesha,” the all-encompassing cosmic deity of the ancient Hindu pantheon. The product of a mythological xenograft (18), Ganesha is an elephant-headed god with a human body. He was created by Lord Shiva, who is considered to be the master of the Siddha system of medicine (14), one of the oldest systems of medicine known to mankind. The Siddha system was practiced by the ancient Indus valley civilization, Bharatvarsha (4), known as India. According to the Hindu religion, the fundamental tenet of the faith is the belief in the One god, Brahman, The Universal soul. Brahman (29) devised the Indian system of medicine, Ayurveda (29) and divided it into eight parts (10). The “Astanga Ayurveda,” or eight sections of Ayurveda (20), are as follows:
Key words 䡲 India 䡲 Neurosurgical 䡲 Training Abbreviations and Acronyms AIIMS: All India Institute of Medical Sciences CMC: Christian Medical College (United States Medical Licensing Examination) DNB: Diplomate of National Board program MCh: Magister Chirurgiae MCI: Medical Council of India NIMHANS: National Institute of Mental Health and Neuro-Sciences PGIMER: Postgraduate Institute of Medical Education and Research
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8. Vajikaranam (Sanskrit: aphrodisiacs and improving health of progeny)
FROM CELESTIAL ART TO ANCIENT NEUROSURGERY According to Hindu mythology, after its creation, the art of Ayurveda was then passed to the Aswini Kumars (the celestial twin sons of the Sun God). The celestial knowledge of Ayurveda was then propagated to sages and rishis (Saints), the first being Saint Bharadwaja (29). He, in turn, taught this to his pupil Atreya followed by Susruth, who published his treatise on shalyachikitsa (surgery), Sushruth samhita (3, 21) sometime between 700 and 600 BC. In his treatise, he gave a detailed account of the Vatavyadhi (diseases of the nervous system) and common neurological disorders along with their remedies. He described sciatica, glossopharyngeal neuralgia, and brachlagia (6) and gave an apt description of convulsions, which he called “Apatantrakah” (Sanskrit) (7):
Department of Neurosurgery, Louisiana State University Health Sciences Center—Shreveport, Shreveport, Louisiana, USA To whom correspondence should be addressed: Anil Nanda, M.D., M.P.H. [E-mail: [email protected]] Citation: World Neurosurg. (2013) 79, 5/6:615-620. http://dx.doi.org/10.1016/j.wneu.2013.03.001 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2013 Elsevier Inc. All rights reserved.
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Symptoms: The patient lies with his eyes closely shut, or stares with a sort of fixed or vacant gaze, the eyes remaining fixed or immovable. The patient loses all perception, and groans. Respiration becomes difficult, or symptoms of temporary asphyxia and unconsciousness set In. Consciousness and a normal condition of the organism return with the passage of time Susruth also devised his own dissection techniques to analyze structures not visible to the naked eye. He immersed cadavers in a special grass called “kush;” as they slowly decomposed, the minutest of vessels would swell (9): . . . . with Kusa grass and place it at the edge of the water of a rivulet. After three days take it out carefully, and gradually take off the successive layers of the epidermis and dermis and of the muscles beneath by gently and lightly rubbing it over with a soft brush. Thus the smallest and the thinnest arteries, which have by this time swelled and obtained a distinct existence are made palpable everywhere even to the minutest. The saga of Ancient Indian surgery and neurosurgery continued for centuries, with reports of lord Buddha’s physician Jivaka performing trephination (19). Similar neurosurgical procedures were performed mainly for the elite up until the 10th century AD (14).
THE INTRODUCTION OF MODERN NEUROSURGERY IN INDIA General surgeons performed neurosurgery before independence. In 1835 the first medical schools (19) were established in the eastern and southern regions of India, Calcutta (Kolkata) and Chennai, respectively. Lt. Col. F. J. Anderson and Provat Sanyal pioneered neurosurgical operations at Calcutta Medical College. In Southern India, Dr. Balakrishna Rao started neurosurgical procedures at Madras Medical College. A decade later Grant Medical College and its associated Sir Jamsetjee Jeejebhoy Group of Hospitals was established in the western region of India and the city of Bombay (Now Mumbai).
THE FOUNDING FATHERS OF INDIAN NEUROSURGERY Since its independence on 15th August 1947, India has made prodigious progress in nuclear, space, and medical technologies. These developments were led by visionaries in their respective fields. The field of neurosurgery enjoyed similar progress. Its list of visionaries is long and impressive.
Vellore. Dr. Chandy worked for nearly 21 years at CMC, Vellore and trained 25 neurosurgeons (2). For his contributions, he was awarded the Padma Bhushan, one of the highest civilian awards given by the Indian government, in 1964. Dr. Jacob Chandy died on June 23, 2007. His life and work was published recently in Neurosurgery Journal (2).
Dr. Balasubramaniam Ramamurthi In 1950, Dr. Ramamurthi set up the Department of Neurosurgery at the Madras Medical College Government General Hospital after completing his neurosurgical training from Newcastle in Tyne, England (11). He later founded the Institute of Neurology, Madras, in the 1970s. Along with his colleagues in neurology and neurosurgery, he performed the first stereotactic surgeries in India. Their work was internationally acclaimed. For his phenomenal contribution to the growth of neurosurgery, Dr Ramamurthi was awarded the Padma Bhushan and the Dhanvantari Award (one of the highest awards for a physician). In 1987 he was appointed the President of the World Federation of Neurosurgeons (27). He was also the founding editor of Neurology India, the first Indian journal to publish neurology and neurosurgery literature. In addition to the programs established by Drs. Chandy and Ramamurthi, in 1951 Dr. Ram G. Ginde started the Department of Neurosurgery at Seth G. S. Medical College and the associated King Edward Memorial Hospital in Bombay19.
THE BIRTH OF THE NEUROLOGICAL SOCIETY OF INDIA (NSI) The NSI was the brainchild of four eminent figures: Drs. J Chandy, B. Ramamurthi, S. T. Narasimhan, and B Singh. Dr. Baldev Singh was from the State of Punjab in northern India and was trained in neurology in the United Kingdom. He also trained in electroencephalography under Dr. Gibbs in Chicago and joined Dr. Chandy in Vellore (11). All branches of the neurosciences were brought under the purview of the Neurosurgical Society of India. The society had its first meeting in March of 1952 at Hyderabad, during which its members decided to publish their own journal, Neurology India. The society has grown since the days of its inception and over the years, the NSI has stratified into several subsocieties, including:
y Indian Society of Pediatric Neurosurgery—founded in the year 1989 during the Annual Conference of the International Society for Pediatric Neurosurgery in Mumbai (5), along with its affiliated journal, Journal of Pediatric Neurosciences;
y The Indian Society for Stereotactic and Functional Neurosurgery; and
y The Skull Base Surgery Society of India, founded on February 7, Dr. Jacob Chandy Dr. Chandy obtained his medical education at the Madras Medical College, Madras (2, 22). He later pursued his dream of becoming a neurosurgeon by training under Dr. Wilder Penfield at the Montreal Neurological Institute in Canada and in Chicago with Theodore Rasmussen. Upon his return to India, Chandy joined Christian Medical College in Vellore and in 1949 established the first neurosurgery department in India. In 1957 Wilder Penfield laid the cornerstone for the Department of Neurological Sciences, and Dr. Chandy started the first neurosurgical training program at Christian Medical College (CMC),
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1998, as a professional medical society In addition, the NSI has included the Association of Neurological Nurses as a section. All of these sections and subsections of the NSI are affiliated with the World Federation of Neurosurgical Societies.
OVERVIEW OF NEUROSURGICAL RESIDENCY TRAINING IN INDIA Residency programs in India are different from those in most parts of Europe and North America. An Indian student can enter a medical
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Medical graduate Degree: MBBS
Option 1
Option 2
6 years training in a government owned hospital, acrredited by Medical council of India Degree: MCh in Neurosurgery
3 years of training in General Surgery Degree: DNB or MS in General Surgery AND
Or 6 years training in a private/trust owned hospital, acrredited by National Boards Degree: DNB in Neurosurgery
3–4 years of dedicated training in Neurosurgery in a government owned hospital, acrredited by Medical Council of India. Degree: MCh in Neurosurgery Or 3–4 years of dedicated training in Neurosurgery in a private/trust owned hospital, acrredited by National Boards
medical and surgical training in India. Each year, 59 such institutes offer 190 neurosurgical training positions. MCh students must complete certain prerequisites before graduation. All MCh programs conduct their own examinations, which include both a written and an oral evaluation of a candidate by the invited faculty. Exam content varies from institution to institution. For example, at the National Institute of Mental Health and Neurosciences, a premiere federal government institute in Bangalore, candidates for graduation is required to resect a glioma under the supervision of invited faculty (Figure 2). Candidates also are expected to submit a dissertation defending their research work.
Degree: DNB in Neurosurgery
Diplomate of National Board Program The extension of neurosurgical services to its population of 1.3 billion is one of the biggest challenges India faces today. Currently India has a very high patient to doctor ratio, or 1:1700 (1). The ratio is even greater in neurosurgery. To increase the number of practicing neurosurgeons in the country, the Indian government established the autonomous National Board of Examinations in 1975. The board’s objective was to start training programs in private and semiprivate hospitals, relieving the MCI of this responsibility. The National Board of Examinations awards the qualification Diplomate of National Board (DNB) neurosurgery upon successful completion of the course. As with the MCh program, a candidate can enter a DNB program in neurosurgery after the completion of his or her Bachelor’s of Surgery and Bachelors of Medicine course or general surgery residency. To earn the DNB degree, a candidate must pass the DNB final exam. First, an eligible candidate must complete a theory examination to qualify for oral examination. A candidate unsuccessful in the first attempt of orals is permitted one more attempt. The board thus ensures uniform standards of neurosurgical training across India.
Figure 1. The MCh (Magister chirurgiae) program is the oldest and most highly regarded in neurosurgery. The Medical Council of India (MCI) regulates MCh training standards. National boards were formed to allow privately owned, trust-governed, and some government-owned, hospitals to start DNB residency programs. The MCI and National boards ensures the uniformity in training and certification process. The government of India gives equal recognition to MCh and DNB programs.
school immediately after graduating from a high school; there are no requirements for a pre-med or a bachelor’s program. The duration of an Indian graduate medical education is 4.5 years, and a student has to pass both a written and an oral examination before entering a year of compulsory internship. Thus the total duration of training is 5.5 years. The internship includes rotations in all medical specialties and exposes the student to the environment of first-year residency. These specialty rotations during internship are in addition to the mandatory clinical clerkships during the graduate medical curriculum. After a student successfully completes the internship, he or she is awarded the degree of Bachelor’s of Surgery and Bachelors of Medicine. If an Indian medical student wishes to pursue neurosurgery, he or she has two options (Figure 1). First, the student could enter a general surgery residency program for 3 years, followed by neurosurgical training lasting between 3 and 4 years. Second, the student could enroll in a 6-year neurosurgical training program, which includes a rotation in general surgery. Entrance into any program is based on written exams, which are highly competitive⫺only the top 0.1% of examinees gains admission.
FEDERAL GOVERNMENT AND NEUROSURGICAL TRAINING Magister Chirurgiae (MCh) Program Upon completion of a neurosurgical residency, the degree of MCh is awarded by those institutes that are endorsed by the Medical Council of India (MCI), which is the highest organization that accredits
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India’s federal government oversees the standards of medical education and quality in some hospitals. By an act of Parliament, these hospitals have been conferred the status “Institute of National Importance” (16). This special recognition ensures adequate funds for research, medical education, and the maintenance of health ser-
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After completion of stipulated training years AND successful submission of dissertation, a candidate is eligible to appear for the certification/board exam
The board exam is conducted by a panel of four neurosurgeons and one neurologist and it has four components
Written exam
Paper I Applied and basic neurological sciences
Paper II Neuroradiology, Neuropathology, Electrophysiology and other diagnostic aspects
Paper III Neurosurgery proper
Paper IV Recent advances in neurosurgery
Figure 2. This chart shows the “Exit” exam process of a neurosurgical candidate for the MCh (Magister chirurgiae) degree at NIMHANS (National Institute of Mental Health and Neurosciences, Bangalore). A candidate must pass all components of the examination; failure of any one
vices. These programs offer only MCh degrees to their candidates. The Institutes of National Importance are as follows:
y All India Institute of Medical Sciences, Ansari Nagar, New Delhi; y Post Graduate Institute of Medical Education and Research, Chandigarh;
y Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala; and
y National Institute of Mental Health and Neuro-Sciences (24). As Institutes of national importance, these hospitals have autonomy in the selection process for neurosurgical training. Each institute has its own examination, and candidate selection is determined on the basis of his or her performance (Figure 3).
HOSPITAL RANKINGS Hansa, a full-service global market research agency with a presence in 77 countries, recently ranked all hospitals in India (13). Hansa conducted the research survey in association with The Week, a popular Indian magazine (23). Hospitals in the top 16 cities of Delhi, Lucknow, Ludhiana, Jaipur, Chennai, Coimbatore, Kochi, Thiruvananthapuram, Bangalore, Hyderabad, Kolkata, Mumbai, Ahmedabad, Pune, Nagpur, and Indore were included. The inclusion criteria specified that hospitals must have completed at least 2 years of operation and have a minimum of 100 beds. The data from 917 experts—328 general ខphysicians, 442 specialists, and 147 pathologists/radiologists—was taken into account (28). The hospitals were ranked in the following order (23):
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Clinical assessment
Operative performance
Viva-voice
Candidate interacts with actual cases and a discussion follows on work-up and management
The candidate performs surgery, usually glioma resection, in front of the board members
The candidate is assessed during viva voice on every aspect of neurosurgery
component will disqualify the candidate from the certification process. After a failure, a candidate must appear again for the entire process after a minimum period of 6 months.
1. National Institute of Mental Health and Neurosciences (NIMHANS) NIMHANS, established in 1942, was ranked first for the second time consecutively. Frontal leucotomies were some of the first psychoneurosurgical procedures performed at NIMHANS. The Neurosurgery department was started by Dr. R. M. Varma, who received his neurosurgical training from Bristol, United Kingdom. NIMHANS is the only federal government institute that is dedicated exclusively to neurosciences. It received its academic autonomous status from the University Grants Commission on November 14, 1994. Other departments at NIMHANS that aid neurosurgery include neuroanesthesia, neurochemistry, neuroimaging & interventional radiology, neurology, neuromicrobiology, neuropathology, neurophysiology, neurovirology, neuronursing, and psychiatric and neurological rehabilitation. More than 4000 cases are performed annually in six operation theaters at the Neuro Centre, and three theaters at the neurotrauma facilities. The faculty consists of three professors, four additional professors, five associate professors, and five assistant professors. The Medical Council of India has increased the annual resident intake to 14, making the neurosurgical training program at NIMHANS one of the largest in the world. 2. The All India Institute of Medical Sciences (AIIMS) The first Prime Minister of India, Jawaharlal Nehru, envisaged the creation of a medical Institute. In 1952 the foundation stone of the AIIMS was laid, and in 1956 an act of parliament declared it an Institute of National Importance, meant to serve as a hub of excellence in all aspects of medical education. Inspired by Dr. B. Ramamurthi, Dr. P. N. Tandon established the Department of Neurosurgery. The department experienced a mod-
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After successful completion of MBBS course and one year of compulsory internship, a candidate is eligible to appear for the entrance exam.
Over 10,000 candidates appear for the written exam (multiple choice questions) for 3 positions in MCh neurosurgery course (6-year duration).
On the basis of their performance, the candidates are given absolute scores and a rank order list is made accordingly.
The scores obtained are specific for the exam and cannot be used to secure admission in other institutes or subsequently.
Once candidate is selected, he/she undergoes an internal departmental assessment at 6 months and at 18 months. Only after a good assessment is a candidate allowed to finish the stipulated 6 years of training. Figure 3. The admission process of neurosurgical residency program at AIIMS (The All India Institute of Medical Sciences). More than 10,000 medical students appear for the entrance exam of AIIMS; only three students are selected for a 6-year neurosurgical training course. The pattern of the exam is very similar to that of the United States Medical Licensing Examination except that a candidate is given an absolute score. Only top scores will ensure a neurosurgical residency spot at AIIMS. A candidate becomes eligible to appear for final examination for the award of MCh degree at the end of 5 years, 5.5, or 6 years of training. However, a candidate can graduate only after the completion of mandatory 6 years of training. After passing the written and oral components of the examination, the degree of MCh (neurosurgery) is awarded.
erate beginning in 1965, only operating on 50 patients. However, today nearly 3000 operations are performed each year by surgeons at AIIMS, and the institute receives 1500 trauma cases annually. In addition, more than 250 patients are treated with gamma knife radiosurgery each year. Currently AIIMS has 17 faculty members and an annual intake of 11 residents.
3. The Sree Chitra Tirunal Institute for Medical Sciences and Technology In 1973 the Royal Family of Travancore donated the building and land for a medical institute. Three years later, the Sree Chitra Tirunal Medical Center formally opened. Under an act of parliament, the Sree Chitra Tirunal Medical Center was declared an Institute of National Importance, and it was renamed the Sree Chitra Tirunal Institute for Medical Sciences and Technology. The neurosurgery
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department has eight faculty positions and trains four residents annually.
4. Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh The PGIMER opened in 1962. After an act of parliament in 1967, it became autonomous, functioning under the Ministry of Health and Family Welfare, Government of India. The institute was envisaged by Jawaharlal Nehru and Sardar Prartap Singh Kairon, then the chief minister. Dr Des Raj Gulati started the Department of Neurosurgery in January of 1962, and by 1968 the PGIMER faculty was training its first neurosurgery resident.
5. CMC, Vellore Dr. Jacob Chandy started the Department of Neurosurgery at Christian Medical College in 1949. Five years later, he trained the first neurosurgery resident, Dr. R.N. Roy from Calcutta. Dr. Roy went on to become the head of the Department of Neurosurgery at Bangur Institute of Neurology, Kolkata (2). CMC Vellore received its accreditation from Madras University in 1957 for specialty training in neurosurgery. Dr. K.V. Mathai became the first resident who completed accredited training. Currently CMC, Vellore has four accredited training positions for neurosurgery.
NEUROSURGERY AND CURRENT CHALLENGES IN CONTEMPORARY INDIA In 1991 India faced a serious economic crisis. Its government instituted several economic reforms, and the foreign reserves grew from a mere $600 million in 1991 to $294.5 billion (17) in 2012, more than that of most developed nations. In 2007 India recorded its highest gross domestic product growth rate of 9%, becoming the second-fastest growing economy behind China. This economic boom has translated into better infrastructure in government-owned hospitals whereas the economic reforms have allowed development of the health industry in the private sector. It would be perverse not to acknowledge the contribution of private industry in the growth of neurosurgery in India. There are several factors fueling the expansion of Indian hospital industry, including, the rising coverage of health insurance, economic growth, and growth of the middle class. Moving forward, the Indian hospital industry will need to eliminate the deficit in hospital beds. Currently the global average in developed nations is three beds per 1000 people. To match the average, India must add 3 million beds in the years to come. Per the recent market report (15) “Indian Hospital Services Market Outlook,” the hospital industry will be worth $81.2 billion dollars in India by 2015. Economic reforms in India have resulted in better city infrastructure and better reimbursement of doctors. Thus, many doctors who trained abroad are returning. They bring with them medical advances and internationally recognized credentials. The lower cost of healthcare compared with some other nations has transformed India into a preferred medical tourism destination. According to one recent estimate, medical tourism in India has become a $35.69
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billion industry (25). The future of neurosurgery in India is bright. With a booming economy, the boon of medical tourism, and the return of well-trained doctors to the country, Indian neurosurgery will reach a new pinnacle in the 21st century.
ACKNOWLEDGMENT We thank Katie Matza, editorial consultant, Department of Neurosurgery, LSU Health Sciences Center–Shreveport, for editorial assistance.
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Citation: World Neurosurg. (2013) 79, 5/6:615-620. http://dx.doi.org/10.1016/j.wneu.2013.03.001 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2013 Elsevier Inc. All rights reserved.
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