Many still consider Emergency Medicine
a nascent specialty in India and hold pessimistic thoughts about choosing EM as
a full time career. However, EM continues to gain reputation among medical
students. A major portion of candidates still pick EM only as an afterthought for
reasons such as not matching in their desired field of interest, no
standardized exams for entry into EM, quick money and speedy promotion to a Department
Chief position almost immediately after the completion of training. Undoubtedly,
EM is getting popular but despondently, apex medical bodies in India have been
exceedingly sluggish towards the development of EM as an individual specialty
and it was only in July 2009, when EM was recognized as a standalone
specialty in India.
History of EM in India
EM started drawing attention among the
young physicians in 1990s when private hospitals began to develop ED’s. At that
time, there were only a few physicians who were passionate about this exciting
field and were trying hard to fight the existing systems. As expected, there
was quite a bit of resistance from other specialties that still continues to
exist. A number of short courses, fellowships and diplomas emerged in 1990s to
cater the need of the budding Emergency Departments. The issue that remained
was a palpable lack of recognition for these credentials both nationally and
internationally.
For those of you who are not familiar
with this concept of private versus government sector healthcare in India, let
me put it like this:
Private =
Early access to care but you need to pay for that, extremely low threshold of
admission
Government =
Lengthy waiting hours but care provided is free of cost, very high threshold of
admission
Medical Council of India alone cannot
be blamed for our slow progress but there are a multitude of issues that
interfere with the development of EM in India. For instance, most of the
Emergency Departments (Private and Government) strive hard to meet the set
standards to run a residency program especially when it comes to possessing
experienced teaching faculty. Our colleagues from Anesthesia, Critical Care,
Internal Medicine are often dragged to the Emergency Departments to book them
as teaching faculty during the Medical Council inspection. While these
physicians are exceptional in their particular fields of practice, they have
undergone minimal or no prior training in EM!!
Emergency Departments have
traditionally been referred as “Casualty” which is historically manned by
Casualty Medical Officers (C.M.O.) who are considered as traffic policemen
guiding patients to various specialties and keeping things relatively simple.
Abdominal Pain = Surgery
Fever = Internal Medicine
Fracture = Orthopedics
Isolated Head Trauma = Neurosurgery
The mindset was not focused on
evaluation and treatment but just the final disposition. With such a system,
the brunt used to fall on polytrauma victims who stayed in the “Casualty” for
prolonged hours without any definite disposition plan. Due to a sense of lack
of liability, patients used to get shunted through various departments with a
complete lack of communication among the consultants leading to frequent mishaps.
Current Status of Emergency Medicine
1. Government EDs
– These departments are always packed with innumerable patients with wide
spectrum of illnesses with an average daily footfall of 200-500 patients/day.
The treatment offered here is free
(or at minimal costs) but waiting times cannot be estimated, as the concept of
triage rarely exists. These EDs are manned by physicians, surgeons, orthopods
with Casualty Medical Officers who work as messengers among the specialists. There
is no accountability or requirement for any sort of prior training to work in a
Casualty. The junior physicians working here simultaneously prepare for Post-Graduate Medical Entrance Examinations in the hope of securing a
postgraduate position in established fields that are already well recognized by
the MCI. The situation in these
departments is no less than an everyday disaster! Only a few government hospital
EDs have a consultant available with some prior training in EM. Unfortunately,
nothing much has changed in the last two decades. The elite and influential
classes prefer to stay away from government institutes and the underprivileged people
have no other choice.
This is the current scenario that
prevails in a majority of the government run hospitals. Some of these government
centers also run the recognised EM
Residency programs.
2. Private EDs – In this sector, public needs to pay a fee for any sort of treatment (Yes,
even for an EMERGENCY). Payment for laboratory tests and procedures is required
before services are rendered and you are evaluated with minutes or seconds of
arrival. In critical circumstances, a private hospital may perform initial
stabilization in terms of ABC at a nominal fee, but then families must decide
whether to pay for further services or transport a critically ill patient to a
government hospital.
Private sector recognized the need to
provide Emergency Care 24X7 in early 2000s and they began to provide protocol based Emergency Care. They now prefer to employ physicians who are trained in life
support courses in addition to having some sort of basic EM training (1-3
years) but might expect them to seek expert consultation for almost every
patient and handover ill patients to the qualified and more reliable ICU
physicians at the earliest. The hospital management and physicians from other
specialties find it hard to trust the clinical acumen of partially trained Emergency
Physicians manning the EDs with credentials not recognised by national bodies. However,
this perception changes dramatically with time if satisfactory teaching is
delivered to the residents. Many private hospitals also run unaccredited (unaccredited program does not equal to
incompetent trainees) training programs to employ a bunch of residents and
provide minimal or no academic training. Most of the private centers have a
consultant available 24X7 to liaise with in-patient specialties and maintain the flow in the ED. These centers are able to manage minor and major injuries well,
but they rely profoundly on specialists-on-call from other departments for decision-making.
Only a few of these private centers are truly academically oriented.
3. Also, in
the past several years small hospitals
and clinics have rapidly developed across India. These sites lack
multidisciplinary support and trained Emergency Physicians and end up shunning
patients to private hospitals (sometimes miles away) due to concerns about
medico-legal issues and violence by the families in case of a mishap.
It has now been more than 7 years
since the recognition of EM as an individual specialty and we are certainly drifting
in the right direction. Joint efforts are required to make giant strides rather
than slow and steady development without meeting the needs of over 1.25 billion
people. EM still needs to go a long way and conquer rural sectors to make 24X7
standardized emergency care to everyone and also minimize the unnecessary burden on
specialists for trivial issues.
EM credentials in India
At the time of this writing, Medical
Council of India (MCI) and National
Board of Examinations (NBE) are two
major bodies that oversee post-graduate training in India. Only these two
credentials i.e. MD by MCI and DNB by NBE are nationally recognised in India.
· MCI is the
body that awards M.D. but offers a limited number of post-graduate positions in
University based teaching programs. Of
the total about 23,000 seats offered for Post Graduate Medical Courses, MD-EM
comprises only 73 seats.
· On the other
hand, NBE awards DNB (Diplomate of National Board) and again offers a limited
number of seats in hospital-based training programs. The National Board of Examinations at present
offers 66 seats in DNB-EM at 20 institutions across India (November 2014).
EM is still counted as one of the
least recognised specialties in India (others being Family Medicine, Palliative
Care etc.) but there are more than half a dozen diploma,
fellowships and residency programs which are offered to medical students. Here
is a list of these programs:
- MD
Emergency Medicine – 3 years (Nationally Recognized)
- DNB
Emergency Medicine – 3 years (Nationally Recognized)
- MRCEM
(by Royal College of EM, UK) – Eligible to enter FRCEM training
- Masters in Emergency
Medicine (i.e. MEM by Society of Emergency
Medicine in India) – 3 years
- Masters in Emergency
Medicine (MEM affiliated with
various North American Universities) – 3 years
- Fellowship
in Accident and Emergency Medicine (setup in 1994, first Academic EM
Department at Christian Medical College,
Vellore) – 2 years
- Diploma
in Emergency Medicine (St. John’s Medical College, Bangalore) – 1 year
- Royal
College of General Practitioners Diploma in EM – 1 year
Note- This may not be a complete list
of EM programs currently run in India
The matter that stems out with these
credentials is approval by the medical council. The training methods are diverse
with minimal focus on Academics (in majority of them) and completely different methods
to assess the candidates. While some programs strive hard and modify their
curricula based on residencies in the United States others utilize residents
only as a work force with self-directed learning through textbooks and social
media.
EM organizations in India
1.
SEMI (Society of Emergency Medicine in
India)
SEMI is the first Indian organization created for the
development of Emergency Medicine in India. It was founded in 1999 with its
first meeting conducted at EMCON 1999, the first Indian National Conference in
Emergency Medicine. The 18th EMCON was recently conducted at Madurai in
November 2016. SEMI has been making constant efforts to promote and uplift EM.
SEMI also runs a 3 year Masters in Emergency Medicine (MEM) Program at various
private hospitals in India.
2.
AAEMI
(American Academy of EM in India)
A group dedicated to promoting
Emergency Medicine in India, formed by physicians of Indian background since 2001.
3. INDUS-EM (INDUS
EMERGENCY & TRAUMA COLLABORATIVE)
All India Institute of Medical Sciences, New Delhi and University of
South Florida Emergency Medicine in USA founded INDUSEM in 2005. INDUSEM
gets the support of the State University of New York, Downstate Medical Center
and Baroda Medical College. INDUS EM group had published several white papers
pertaining to training and EM Academics.
In an
attempt to produce EM faculty, INDUS-EM encourages specialists from various
medical backgrounds (anesthesia, internal medicine, OBGYN) to take 12
online monthly tests based on Tintinalli’s textbook of EM followed by a board
review course to assess procedural competencies and check credentials (life
support courses, ECG courses and USG skills, ortho skills). This gives them a
taste of Emergency Medicine and puts them in place to teach Emergency Medicine.
Read more here.
Even with a
similar goal in their minds i.e. to nurture Emergency Medicine, there are
obvious elements of friction and blatant lack of interaction among these organizations.
This completely baffles the young EM advocates but more importantly hinders the
development of Emergency Medicine as a specialty.
Sub-Speciality Training – Is this the right time?
I believe it is a bit early to develop
sub-specialty training. First and foremost, we need to validate the existing
credentials and reach a final end point to ensure that we all stay on the same
page. Do you see a point specializing in EM Neurology if your General EM
credentials are questioned at the first place?
It is time to familiarize us with Core
EM topics and General Emergency Medicine first rather than getting into the
depths of EM Neurology or EM Cardiology. One of the major challenges ahead
would be to start working towards a “Rural EM” fellowship, which would
be immensely beneficial for the villages and small towns in India where a single doctor is expected to manage every possible pathology.
Another hitch - Brain Drain
EM is already entangled with several
internal regional and political issues and “brain drain” complicates it
further. A majority of Indian trainees in EM take the Royal College of EM exams
(Membership of RCEM Part A, B and C), which are entry-level exams in the UK to
pursue higher specialty training in EM. But in India, you will come across several
physicians employed as the Heads of the Emergency Departments (HOD/Chief) with MRCEM
qualification and a mere 3 years of training in EM. These posts offer alluring
salaries and are primarily offered by the private hospitals to flaunt their
Emergency Departments.
At the same time, an enormous number
of candidates migrate to Middle East, Singapore and the UK for various reasons
like understanding a global perspective of EM Healthcare systems, much higher
income and an opportunity to pursue higher training in Emergency Medicine. This
puts India at the back foot again by extracting a significant number of trainees
out of the system.
The route to United States still
remains unexplored as USMLE comes as a major barrier in addition to the
requirement of Standard Letters Of Recommendation, US Clinical experience and
issues with Visa. However, there are plenty of trainees who took up initially USMLE
but later changed their avenues and joined various local EM Programs.
Potential Solutions
By no means, I am an expert or a
policy maker and most of the material presented here is based solely on my past experiences and strong opinions. Every trainee considers his program as the best and belittles
other programs. I believe that nobody is perfect at this point of time and we
all have a long way to go. These are a few things that might help us to
ensure better Emergency Care in India:
1. Standardizing a robust criteria to pursue EM
To pursue MD or DNB (the two
nationally recognized credentials), candidates need to struggle and slog to
crack the All India Post Graduate Exams but despite of that “most of the
students get EM by fate, not by choice”. Unlike the US, there are no
interviews, LORs, Clinical Experience and contribution to the specialty type
questions asked. It is just based on the scores and ranks, which seems pretty unfair.
Candidates choose EM because they think “having something is better than
nothing” and it is certainly better than preparing for entrance exams for another
12 months!!
To accomplish a change at the
national level, there needs to be a total reform in the existing systems but to
begin with, at least the private hospitals must start scrutinizing candidates
before enrolling them for a EM course. Surprisingly, some programs enroll
candidates without any sort of screening or examinations. It is solely based on a candidate's ability to pay the annual fees.
2. Incorporating FOAMed
Emergency Medicine has been leading the FOAMed movement
and this can be a great learning resource. This is a boon for developing
nations where EM is still in the cradle. Since there is a sheer lack of local
educators in Emergency Medicine, FOAMed can take this responsibility off us until we have enough faculty. FOAMed fills
the gaps in our knowledge and keeps us up to date by levelling all the
differences. Understanding a core EM textbook still needs to be the skeleton around which FOAMed can revolve. Through FOAMed, we can interact with the world-class educators
from all over the world and listen to their thoughts, ask questions and learn from their experiences. Existing EM programs must make weekly CME attained
through podcasts mandatory for all the residents.
3. Setting a Common standard of training
With plenty of
EM training programs around, we need to lay minimum standards to call someone a
qualified Emergency Physician in India.
Who is a qualified Emergency Physician?
- Is it the MD/DNB candidates who are
frequently taught by Hospitalists, Surgeons, Orthopods, Anaesthetists and
Critical Care fellows lacking the EM Mindset?
- MRCEM qualified physicians who take
three exams (MRCEM Part A,B,C) with no fixed rotations in other specialties and
MRCEM is an entry level exam to pursue further training in the UK?
- MEM by SEMI or MEM affiliated with US
Universities – Only a few of these programs have managed to get trained faculty
from countries with stronger EM Healthcare systems countries to fulfill their training
requirements while others are struggling to run their academic schedules.
Questions have also been raised about the enrolling criteria for these
candidates.
- Others with 1 or 2 year of diplomas
and fellowships with similar issues pertaining to enrollment, academic and
assessment of trainees.
4. By
default but what we nationally recognize is MD and DNB but what about the other
programs? Is it okay to call all MD/DNB possessing candidates recognized despite
knowing the fact that plenty of them have serious issues in their training?
In the end, it all depends on an individual - if he/she is keen to learn, progress and strive hard to bring a change. We all know a few
exceptionally sound Emergency Medicine practitioners trained from the so called
unaccredited programs and at the same time, we also happen to know “EM
Physicians” from recognised training programs who struggle when it comes to
providing the basic Emergency Care although they have robust theoretical
background. We cannot paint everyone with the same brush.
As EM
Practitioners, we all have also dealt with MD/DNB possessing from every other specialty and time and again we have realized that all of them are not the
same. Furthermore, many MD/DNB providing institutes have serious flaws in terms of having the appropriate
teaching faculty, equipment and infrastructure to train the residents. Additionally, many candidates
possessing recognised credentials never took any entrance exams because MD residency spots are also available as management positions (paid seats).
Everyone possessing MD- Emergency Medicine cannot be considered as competent and all those with unrecognised credentials are not incompetent.
5. Is it
justifiable to sweep thousands of diploma and fellowship candidates in a go and
overlook their credentials and experience?
We need to be
mindful of people who are practicing EM since 15-20 years now. Can three years
of deficient training beat two decades of work experience (with a non-recognised EM qualification) in an Emergency Department?
If any
candidate meets the training duration laid down by a “National Emergency
Medicine Board” and also possesses the procedural skills, then he/she should be
allowed to take a board certification exam
(theory + practical) set by MCI/DNB (if you consider that as the gold
standard) to certify them as qualified Emergency Physicians. To many, this might sound like an unorthodox way
of obtaining a qualification but this is the only feasible temporary solution that I can
think of to generate enough EM faculties.
If the first world nations such as United States, United Kingdom and Australia can accept Primary Medical Credentials of an Indian Graduate after USMLE, PLAB and AMC respectively, then why are not we ready to accept post graduate credentials which are acquired from our own country (after unaccredited graduates take a National EM board certification exam).
6. Joining hands with developed EM systems
Many programs are on board with this idea, which are constantly
inviting US/UK based faculty in India to ensure Academics are taken care off.
This keeps the residents engaged and motivated in addition to finding the right
mentors.
7. Sponsoring exceptional candidates to train in developed systems
Apex government institutes can sponsor outstanding
candidates to get further training in developed EM systems and pursue super-specialization
with an agreement that they serve the home country for a fixed period of time
after returning back from the sabbatical.
8. Incorporating EM in undergraduate curriculum
EM should be instilled in the minds of budding physicians
at the outset not as an afterthought. As a specialty that emphasizes basic clinical skills, Emergency Medicine
must incorporated in the undergraduate medical curriculum. A core
curriculum that provides learning objectives, subject content list and
structured learning environment, needs to be planned.
This was just a collation of
my thoughts on EM in India and my objective was not to degrade or support any specific
program (recognized and unrecognized). I also acknowledge that some of my opinions would seem biased and unfair to each one of you. I would love to hear your thoughts and better solutions to combat this. Reaching a common ground is paramount to expedite our progress as a speciality. I cannot help but notice a clear sense
of animosity among various programs, which is not helping us in anyway but hampering
our movement. Our current situation looks similar to what happened in the US in early 1990s - The Rape of Emergency Medicine.
References:
- Arora P, Bhavnani
A, Kole T, Curry C. Academic emergency medicine in India and international
collaboration. Emergency Medicine Australasia. 2013 Aug 1;25(4):294-6.
- David SS, Selvaranjini
S, Thomas M. Incorporation of emergency medicine in the undergraduate
curriculum. Natl Med J India
1997;10:80-1.
- 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 Oct 1;1(3):218.
- Alagappan K, Cherukuri K, Narang V, Kwiatkowski T,
Rajagopalan A. Early development of emergency medicine in Chennai (Madras),
India. Annals of emergency medicine. 1998 Nov 30;32(5):604-8
- http://www.mciindia.org/InformationDesk/CollegesCoursesSearch.aspx
- Pal, Ranabir, et al. "The 2014 Academic College of Emergency Experts in India's INDO-US Joint Working Group (JWG) White Paper on" Developing Trauma Sciences and Injury Care in India"." International journal of critical illness and injury science 4.2 (2014): 114.
- Das, A. K., et al. "White paper on academic emergency medicine in India: INDO-US Joint Working Group (JWG)." Japi 56 (2008): 789-797.
- Subhan, Imron, and Anunaya Jain. "Emergency care in India: the building blocks." International journal of emergency medicine 3.4 (2010): 207-211.
Department of Emergency Medicine
