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Astrocyte

Astrocyte is a multi-disciplinary medical journal published quarterly. An independent and authoritative window to current medical thought and research, it is a responsive forum for practice changing continuing education; reflections, scrutiny, and constructive debate; and crystal ball gazing. The mission to instill knowledge, inspire introspection and ignite human minds in the pursuit of clinical excellence.

RNI: MAHENG13637

ISSN: 2349-0977

volume1 issue3 Oct 2014

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Editorial Of Divinity, Retro Dynamics and Basic Edicts in Physician-Patient Relationship

Original ContributionsCorrelative Imaging in Congenital Heart Disease

Special ReportsTelemedicine for Reach, Education, Access, and Treatment: Structural Analysis of the Pilot Data

Medical EducationsDevelopment of Post Graduate Program in Emergency Medicine in India: Current Status, Scope and Career Pathways

Medicine And Society Approach of Physiotherapy Students Towards Community Placement: Perceptive Obstacles

Editorial Of Divinity, Retro Dynamics and Basic Edicts in Physician-Patient Relationship

Original Contributions Prevalence of Modifiable and Non-Modifiable Risk Factors and Lifestyle Disorders among Health Care Professionals�

Kangaroo Mother Care in Low Birth Weight Babies: Measures to Mitigate Challenges in Implementation�

Practice Changing Continuing Education Correlative Imaging in Congenital Heart Disease�

Special Report Telemedicine for Reach, Education, Access, and Treatment: Structural Analysis of the Pilot Data�

Medical Education Development of Post Graduate Program in Emergency Medicine in India: Current Status, Scope and Career Pathways

Astrocyte

Astrocyte ¦ Oct-Dec 2014 ¦ Volume 1 ¦ Issue 3218

New FrontiersMedical Education

introduCtion

Emergency medicine (EM) is a recognized medical specialty in over 60 countries, and this is growing in low and middle-income countries. Recent epidemiologic and demographic, public health data highlight the growing need for EM services that can include management of trauma, acute care and pediatric emergencies. Many low-and middle-income countries are devising EM training programs to address the needs of local communities who increasingly desire these services on a round-the-clock basis to help stabilize and dispose of patients as per their medical needs.

The International Federation for Emergency Medicine (IFEM) defines EM as a field of practice based on the knowledge and skills required for the prevention, diagnosis and management of acute and urgent aspects of illness and injury affecting patients of all age groups with a full spectrum of episodic undifferentiated physical and behavioral disorders. IFEM further encompasses an understanding of the skills needed to develop EM services and includes the need for prehospital and in-hospital emergency medical systems to manage patients properly.[1]

Currently in India, a few hospitals have well-structured EM departments, but they often still want for formally qualified EM faculty. Medical emergencies are usually managed by

residents pooled from other various specialties, such as General Surgery or Medicine, and initial assessment and a plan-of-care for the patient can vary depending on which specialty doctor is called when a patient presents. External issues such as lack of infrastructure, manpower, and equipment and training facilities further compound the challenge of managing emergency care.

As the establishment of Emergency Department (ED) in various public and private hospitals is increasing in India, the need for physicians specifically trained in EM is also accelerating. Developing a comprehensive and recognized EM program for training physicians in India must occur simultaneously to meet demand for emergency care services.

CurrEnt status of EMErgEnCy MEdiCinE in india

In India, EM is a nascent specialty and there are very few formally trained emergency physicians, and most EM physicians are concentrated in institutes that have supported EM’s growth. In many of the hospitals the services provided are called “Casualty Centers” and often are staffed by junior physicians who usually do not have specialty qualification in EM. Additionally medically staffed ambulances, which provide pre-hospital care, are often privately owned and operate on a fee-for-service basis that is often not coordinated within the operational or catchment area.

The milestones that have been achieved in the field of EM and EM Services in India till date are given in Table 1.[2,3]

Emergency medicine was recognized as a separate specialty by Medical Council of India on July 21, 2009. The first

Development of Post Graduate Program in Emergency Medicine in India: Current Status, Scope and Career Pathways

Manish Jain, Bipin Batra, Elizabeth G. Clark1, Tamorish Kole2

National Board of Examinations, Medical Enclave, Ansari Nagar, 2Max Healthcare, 2, Press Enclave Road, Saket, New Delhi, 1Kerala Institute of Medical Sciences, Trivandrum, Kerala, India

Recent epidemiologic and demographic public health data highlight the growing need for emergency medicine (EM) services in India and highlight its importance as a recognized medical specialty. Developing a comprehensive and recognized EM program for training physicians in India is of utmost priority and should not be neglected at any point of time. This review article attempts to highlight the development of a post-graduate program in EM in the country.

Key words: Emergency medicine, development, postgraduate program

Abstract

Address for correspondence: Dr. Manish Jain, National Board of Examinations, Medical Enclave, Ansari Nagar,

New Delhi - 110 029, India. E-mail: Manish.mjonline@gmail.com

Access this article online

Quick Response Code:Website: www.astrocyte.in

DOI: 10.4103/2349-0977.157766

Jain, et al.: Post Graduate Program Development of Emergency Medicine in India

Astrocyte ¦ Oct-Dec 2014 ¦ Volume 1 ¦ Issue 3 219

program of MD-EM was started in Sri Ramachandra Medical College and Research Institute, Chennai with an initially six seats being approved by the Government of India as per provisions of IMC Act. At present various universities in India offer 48 seats in MD-EM at 24 Institutions across India as shown in Table 2.[4]

Of the total 23,075 seats offered for Post Graduate Medical Courses, MD-EM comprises only 48 seats out of them.[4] A descriptive figure showing the number of PG seats offered in some of the other disciplines is shown in Figure 1. On the comparison, it is found that EM offers only 0.21% of the total PG Medical seats available in the country. A subject wise comparison the number of seats being offered in EM as compared to other disciplines is as follows:• General medicine: 2.05%• General surgery: 2.26%• Anesthesia: 3.09%• Orthopedics: 4.95%• Radiology: 6.28%• Psychiatry: 11.54%• Pulmonary medicine: 14.59%.

In addition to above, certain foreign universities like George Washington University, Washington and UpState Medical University, New York have also been running PG training programs in EM in the country.

sCoPE of EMErgEnCy MEdiCinE in india

The scope for growth of EM in India is quite large and this relatively new service line needs to be carefully managed in order to fully take-off and meet the needs of the Indian population. India has a significant requirement for EM services due to the high prevalence of infectious diseases, symptoms resulting from chronic diseases such as complications from diabetes, cardiovascular disease, and traumatic injury. At present, the lack of an appropriate referral system in India results in many patients presenting at secondary and tertiary care emergency care centers, and as a result these EDs are crowded and over-burdened with problems, which can be better managed at out-patient care settings. Better coordination of care and explaining to the public what truly

Table 2: MD-EM in India: Current Status

Name of Medical College/Medical Institution State Annual intake (seats)

Kamineni Institute of Medical Sciences, Narketpally

Andhra Pradesh

2

Narayana Medical College, Nellore Andhra Pradesh

2

P.E.S. Institute Of Medical Sciences and Research, Kuppam

Andhra Pradesh

2

Sri Venkateswara Institute of Medical Sciences, Tirupati

Andhra Pradesh

2

Gauhati Medical College, Guwahati Assam 2B.J. Medical College, Ahmedabad Gujarat 2Government Medical College, Surat Gujarat 2Medical College, Baroda Gujarat 1Smt. N.H.L.Municipal Medical College, Ahmedabad

Gujarat 2

JJM Medical College, Davangere Karnataka 3JSS Medical College, Mysore Karnataka 2Kempegowda Institute of Medical Sciences, Bangalore

Karnataka 2

S S Institute of Medical Sciences and Research Centre, Davangere

Karnataka 3

St. Johns Medical College, Bangalore Karnataka 1Vydehi Institute Of Medical Sciences and Research Centre, Bangalore

Karnataka 2

Academy of Medical Sceiences, Pariyaram, Kannur

Kerala 2

Amrita School of Medicine, Elamkara, Kochi Kerala 2Government Medical College, Kozhikode, Calicut Kerala 2Jubilee Mission Medical College and Research Institute, Thrissur

Kerala 2

Mahatma Gandhi Missions Medical College, Navi Mumbai

Maharashtra 2

Padmashree Dr. D Y Patil Medical College, Pimpri, Pune

Maharashtra 2

Padmashree Dr. D.Y.Patil Medical College, Navi Mumbai

Maharashtra 2

SRMC, Chennai Tamil Nadu 2Vinayaka Missions Kirupananda Variyar Medical College, Salem

Tamil Nadu 2

SRMC: Sri Ramachandra Medical College and Research Institute

Table 1: Milestones Achieved in the Field of EM and EM Services in India

Year Milestone1971-1988 MCI recommendations on postgraduate Medical Education

1971 (revised up to 1988), showed that Accidental and EM was a recognized MD degree. It was listed as the 24th specialty

1994 First Academic EM Department setup at CMC Vellore1994 SRMC Chennai started a formal Emergency Department on

23rd August, 1994. It later became the first institute in India to offer the MD in EM

1997 Apollo Hospital, Hyderabad, started a formal Emergency Department. It later became the first institute to start UK-affiliated EM programs and an easy access number 1066 for ambulance service

2000 SEMI registered as a nonprofit2006 Vinayaka Mission University, Salem started MD-EM program

which later expanded to other affiliated medical colleges2007 An American-supported program for EM training started

at two hospitals in Kerala with Indo-US EM partnership, which later extended to 7 sites

2009 EM was recognized as an MD discipline and was added as the 30th discipline for MD on 21st July, 2009

2013 National Board of Examinations introduced DNB-EM2014 First batch of DNB-EM constituting of 45 seats in 14

institutions across the country was placed in various accredited institutions

2014 Indian College of EM formedMCI: Medical Council of India, SRMC: Sri Ramachandra Medical College and Research Institute, EM: Emergency Medicine, SEMI: Society for Emergency Medicine in India, DNB-EM: Diplomate of National Board Emergency Medicine

Jain, et al.: Post Graduate Program Development of Emergency Medicine in India

Astrocyte ¦ Oct-Dec 2014 ¦ Volume 1 ¦ Issue 3220

CarEEr Pathways in EMErgEnCy MEdiCinE

Emergency Medicine as a career choice offers many benefits to doctors wishing to pursue this specialty. The economic opportunities are strong for an EP in a secondary or tertiary care setting. Remuneration for EPs is high compared with other specialties (MD/MS) as shown in Table 3.[9]

Launch of DNB-emergency medicine 2013The National Board of Examinations assessed the following aspects of EM before approving a post graduate program in EM:• Global trends and current status of EM• Emergency medicine in India: Current status• Emergency medicine in India: Career pathways for

graduates• An approach to curriculum for EM in Indian context• Program development in EM, accreditation for faculty

development.

An expert committee also recommended the significant impact of the DNB EM program on the quality of emergency medical care services to the public at-large. They also supported the development of career pathways for medical graduates with a 3-year Post Graduate DNB EM program and called for the implementation by the National Board of Examinations on a priority basis.[10]

The National Board of Examinations at present offers 66 seats in DNB-EM at 20 institutions across India as shown in Table 4 (as in November 2014).

constitutes a medical emergency needs support from all levels of government as well as the hospital and doctors who provide care.

The experience of International EM suggests that the development of EM goes through three stages called the “EM development pyramid” as shown in Figure 2.[5-8]

Stage-I or primary development consists of academic and clinical EM and patient care systems development. This will result in upgrading the present causality departments into well-equipped and autonomously functioning ED manned by trained emergency physicians (EP).

Stage-II or secondary development involves administrative and managerial training, financial and economic systems development, reimbursement and systems analysis.

Stage-III or tertiary development looks at macro issues such as health legislation, health policy, public health systems/agendas, patient safety and acute healthcare as a human right.

Development of these three stages overlap, and ideally should run concurrently. Though the development of EM has broad similarities all over the world, blind adoption without validation in the Indian population will be unsatisfactory, given India’s unique epidemiology, geography, and cultural and economic diversity.

Figure 1: Total number of postgraduate seats in Medical Council of India recognized colleges.

Figure 2: Emergency medicine development pyramid.

Table 3: Pay Offered to EP

Place PayMetro cities (Mumbai, Chennai, Bangalore, New Delhi, Kolkata, Hyderabad)

6.25–15.60 lakhs/annum

Nonmetro major cities (Bhubaneswar, Ahmedabad, Madurai, Pondicherry, Guwahati, Ludhiana)

5.75–8.76 lakhs/annum

United Kingdom 75000 GBP/annumUnited Arab Emirates 900,000 AED/

annumEP: Emergency physicians

Jain, et al.: Post Graduate Program Development of Emergency Medicine in India

Astrocyte ¦ Oct-Dec 2014 ¦ Volume 1 ¦ Issue 3 221

skills in other aspects of EM, which they may not currently possess with a proposed faculty training program

• The need for a post graduate program in EM is strong, and this program has a potential to offer approximately 1000 Post Graduate seats per annum in the country

• The introduction of EM can help make healthcare services more accessible and inclusive for patients and create job opportunities in the field of EM including new roles for doctors, nurses and allied health professionals.

suMMary

• Need of nurturing as a “specialty of medicine”• Adopting minimum standards to ensure effective and

quality delivery of services to patients• Program development to follow international standards

and be adapted to local needs• Introduction of faculty training and development programs

is critical• Commitment to creating free standing Departments of EM• This program has a potential to offer approximately 1000

post graduate seats per annum in India• The introduction of EM can help make healthcare services

more accessible and inclusive for patients and create job opportunities in the field of EM including new roles for doctors, nurses and allied health professionals.

rEfErEnCEs1. Available from: http://www.ifem.cc/About_IFEM.aspx. [Last accessed

on 2014 Dec 04].2. Alagappan K, Cherukuri K, Narang V, Kwiatkowski T, Rajagopalan A.

Early development of emergency medicine in Chennai (Madras), India. Ann Emerg Med 1998;32:604-8.

3. David SS, Vasnaik M, Ramakrishnan TV, Emergency medicine in India: why are we unable to 'walk the talk'? Emerg Med Australas. 2007 Aug;19(4):289-95.

4. Available from: http://www.mciindia.org/InformationDesk/CollegesCourses Search.aspx. [Last accessed on 2014 Dec 08].

5. Mulligan T. ED Development in Netherlands, Emergency Physicians Monthly; July 20, 2010.

6. Das AK, Gupta SB, Joshi SR, Aggarwal P, Murmu LR, Bhoi S, et al. White paper on academic emergency medicine in India: INDO-US Joint Working Group (JWG). J Assoc Physicians India 2008;56:789-98.

7. Subhan I, Jain A. Emergency care in India: The building blocks. Int J Emerg Med 2010;3:207-11.

8. Rajavelu P, Rajagopala A. Need for Epidemiology for Indian EM: An Evidence Based Approach, EMS India.

9. Available from: http://www.emergencymedicine.in. [Last accessed on 2014 Dec 04].

10. Emergency Medicine-Programme Development by NBE: Report of Consultative Meeting.

rECoMMEndations

• Emergency medicine as a discipline needs nurturing as a medical specialty

• Both public and private sector hospitals must adopt minimum standards for establishing and managing Departments of EM and the establishment of minimum standards shall ensure effective and quality delivery of services to the patients as monitored by key performance indicators

• Program development of Indian EM training must be customized to the local burden of disease

• Emergency medicine programs in India must adopt global best practices as is appropriate to serve the local community

• Introduction of training and development programs for faculty and residents of EM is a highly important need because there are very few physicians specifically trained as EPs

• For EM to progress in India, academic institutions must commit to creating free standing Departments of EM, with dedicated faculty focused on developing a career in EM. This faculty, initially arising from diverse medical fields, can develop their faculty skills by sharing acute care knowledge from their respective fields while developing

How to cite this article: Jain M, Batra B, Clark EG, Kole T. Development of post graduate program in emergency medicine in India: Current status, scope and career pathways. Astrocyte 2014;1:218-21.

Source of Support: Nil. Conflict of Interest: None declared.

Table 4: DNB - EM in India: Current Status

Hospital/Institute State Number of seats

Ananthapuri Hospitals and Research Institute Kerala 2Apollo Hospital Karnataka 4Apollo Hospital Tamil Nadu 4Apollo Hospital Andhra Pradesh 2Apollo Super Specialty Hospital Tamil Nadu 2Bangalore Baptist Hospital Karnataka 4Deenanath Mangeshkar Hospital and Research Centre

Maharashtra 4

Fortis Hospital Uttar Pradesh 3Jehangir Hospital Maharashtra 3Kerala Institute of Medical Sciences Kerala 4Lourdes Hospital Kerala 4Malabar Institute of Medical Sciences Ltd. Kerala 4Manipal Hospital Karnataka 4Max Super Specialty Hospital Delhi 3Max Super Specialty Hospital Delhi 2MES Medical College and Hospital Kerala 4Narayana Hrudayalaya Karnataka 4Pushpagiri Institute of Medical Sciences and Research Centre

Kerala 4

Yashoda Hospital Andhra Pradesh 3Yashoda Super Specialty Hospital Andhra Pradesh 2DNB-EM: Diplomate of National Board Emergency Medicine