Dr Ramesh Singh Bhandari
Super specialty training has been found to be one way of improving the quality and safety of surgical services being provided. It’s a very well established fact that super specialization increases the standards of care of any surgical or medical discipline. Surgical gastroenterology is relatively a new specialty being developed in our country. However, the paths towards development of this specialty and its training has not been an easy task. Besides the improvement in patient care under the specialty services, it also improves the level of training as well as the quality of research being done in this field.
M.Ch. stands for Magister of Chirurgieae. It is a 3 years postdoctoral system developed by the Indian medical system and has also been adopted in the same format in our country. It is considered as one of the highest degree in the surgical field. Similarly, its counterpart in medicine is called as D.M or Doctorate of Medicine. M.Ch. in surgical gastroenterology is a three years curriculum based learning program dealing with the disorders of gastrointestinal (GI) tract, which includes overall aspects of upper GI tract, Hepatopancreatobiliary (HPB) and Colorectal disorders. Subsequently, at the completion of course a specialist in surgical gastroenterology is produced.
The M.Ch in surgical gastroenterology course first started in India as a distinct specialty training in 1984 by Madras Medical College, Chennai. Following, this post doctoral training system for producing specialist in surgical gastroenterology was adapted by many other big centers in India and by now there are more than a dozen of tertiary level academic institutions in India offering M.Ch training in surgical gastroenterology. Nepal also adopted the similar system to start training and to produce specialist surgical gastroenterologist. In Nepal, Department of GI and General Surgery, Maharajgunj Medical College, Institute of Medicine, Tribhuvan University enrolled first batch in 2008 and it was in 2011 the first M.Ch. graduate of surgical gastroenterology specialty was produced. For the first few batches the university enrolled only one candidate every year and subsequently after the approval from the Nepal Medical Council, total two candidates were accepted every year. After the starting of this super specialty training in Institute of Medicine, few other government institutions (NAMS, BPKIHS) and one private institution (COMS, Chitwan) started this specialty training. Depending upon the approval from the medical council of Nepal, the numbers of candidate being enrolled varied each year. Recently, one more private institution (KMC) has also received an approval to start this training program. In all of these academic institution, the minimum eligibility criteria to be enrolled into this training program is that the trainee should have completed 3 years of general surgery training or its equivalent and has been registered as a general surgeon in Nepal Medical Council. A graduate in M.Ch. surgical gastroenterology is registered in Nepal Medical Council as specialist in surgical gastroenterology.
In contrary to the Indian Medical system, the practice in developed world is more focused on developing the organ-based specialization rather covering the overall aspects of gastrointestinal tract. However, in countries like ours, we do need specialty trainings but broad based to deal with wider range of disorders and to serve the larger population. Having said this, the availability of fellowships and short term training in high volume centers of India and other developed countries, general surgeons in our country are also being able to train themselves in organ based specialties like HPB, Upper GI and Colorectal surgery.
In Indian and Nepalese medical system, Master of Surgery (M.S) in general surgery is a three years post graduate surgical training to produce general surgeons who can deal with different areas of general surgery. Traditionally, gastrointestinal surgery, urosurgery, neurosurgery, cardiothoracic vascular surgery, pediatric surgery, plastic surgery, breast thyroid and endocrine surgery all have been a part of the general surgery training. Important and basic areas of all of these specialties are covered in the general surgery training. Importantly, even in general surgery training, major area of training component included belongs to gastrointestinal surgery while remaining part is comprised by components of above-mentioned specialties. A postgraduate in general surgery is expected to perform all the basic and intermediate procedures with limited major ones of all of the above specialties. However, as the other specialties expect the gastrointestinal surgery had long been very well defined and developed, the major bulk of the work of a general surgeon is mostly of gastrointestinal tract, breast and thyroid surgery. Only the limited basic to intermediate procedure of other specialties are left out for a general surgeons to carry out unless the general surgeon is working in those dedicated specialties. Thus, many general surgeons in the past and even in current times have themselves trained to perform even complex gastrointestinal surgery besides performing the procedures of other specialties including the breast thyroid and endocrine surgery.
However, the development of super specialty training in surgical gastroenterology created a kind of debate among the general surgeons in developing separate super specialty of gastrointestinal surgery and separating it from the general surgery. Some still believe that there is not much difference between general surgeon and a surgical gastroenterologist. But the initiation and subsequent development with establishment of the M.Ch surgical gastroenterology training programs within the country and production of trained surgical gastroenterologist, the demarcation between a general surgeon and a surgical gastroenterologist is being well defined. Similarly, in many western countries, as the other specialty are so well established, the general surgery is mostly limited to gastrointestinal tract, breast thyroid endocrine surgery, retroperitoneal surgery and some areas not covered by other specialties. In these developed western countries, after completion of general surgery training they go for organ specific training like HPB, upper GI and colorectal surgery. This training system is different from our training system, which we have adopted from the Indian Medical system of M.Ch surgical gastroenterology training. Because the general surgery training itself incorporates the large bulk of gastrointestinal surgery, the M.Ch. in surgical gastroenterology training is more focused on the complex and advanced areas of the upper gastrointestinal tract, hepatobiliarypancreatic and colorectal surgery components which otherwise is not included in general surgery training. This includes both the benign and malignant disorders of these areas.
Besides the improved patient care, M.Ch. in surgical gastroenterology training is committed to provide the highest level of training in this field to train the future teachers of surgical gastroenterology specialty as well as improving the standards and quality of publications and research conducted in the field of gastrointestinal surgery. Over these years, as the surgical gastroenterology has been able to stand out as a separate specialty, it is now being one of the most sought super specialty by the general surgery graduates.
-(Dr Bhandari is Professor of Gastrointestinal Hepatopancreatobiliary and Liver Transplant, TUTH).
