Training Rural Surgeons: The Viking Conference 2020 Presentation

This is the summary of the presentation at the Viking Surgeons Association annual conference 2020. The link to the conference is

The session is about how to train the Rural Surgeons.


The author is a Urologist and Laparoscopic Surgeon trained at a premiere medical college in India. He is working for over 3 decades in remote and rural areas of India and has helped 61 rural hospitals start Minimally Invasive Surgeries [MIS]. He believes that MIS is more relevant to the rural patients than the well to do urban patients.


The Association of Rural Surgeons of India [ARSI] took the initiative to do the necessary background work for starting the DNB course. ARSI prepared the curriculum and helped start the course with students spending time at one urban and one rural hospital during the 3-year course. Unlike the General Surgery students, they spent more time learning Obstetrics, Gynaecology, Orthopaedics, and other subjects relevant to the need. It worked very well and the students from the first few batches are doing excellent work in remote and rural areas.

Unfortunately, the Government changed the rules to prevent direct admission by the training institutions and then made it mandatory for students to clear the part 1 examinations before joining the course. The final nail in the coffin for the course was the rule that the teaching institutions could not simultaneously conduct General Surgery and Rural Surgery DNB course with the same staff. Now there is hardly any takers for the course.


The ARSI, the Association of Surgeons of India and other surgical societies offer travel fellowship to the members for upgrading their skills 2. It was appreciated and used when these programs started. However, over the years with inflation the amounts given hardly covered any significant portion of the costs involved and many of these programs are not active anymore.


There are many formal short training programs like the CeMAST 3, that offer excellent short-term courses. Unfortunately, most of them are relatively expensive for the rural surgeons and are situated in urban areas where stay adds significantly to the cost of training.


This is the form of training that was given at the 61 hospitals that started MIS. It catered to the felt need of the hospital. Surgeries were carried out with the local resources both in terms of equipment and human resource. There were no timelines to push them and they could learn at their own pace.


These were used to teach new skills for those who were interested in learning 4. Workshops to teach Gas Insufflation Less Laparoscopic Surgeries were arranged in Medical College 5,6.


While Lancet commission on Global surgery recommends a surgical coverage of 5,000 per 100,000 population, the rural surgeons managed to take the coverage from 239 to 3,739 within a year. The rural surgeons stayed on in rural areas.


Although the Informal training achieved desirable results the problem is that there are very few mentors. The NIHR _ GHRG project of the University of Leeds 7, helped to overcome the difficulty by helping the ARSI design a formal training program for rural surgeons. The first such training program was at Medical College, Kolkata 8.


In the innovative Proctorship program senior faculty from premiere medical colleges travelled to the rural hospitals for mentorship 9. However, unlike the earlier mentorship program this was more concentrated effort in a shorter time benefitting more trainees.


The ARSI and the International Federation of Rural Surgeons [IFRS]10, went a step further to get the Rural Surgery Research and Training Center of ARSI/IFRS 11, get accredited to the Martin Luther Christian University 12 and also plan for credentialing program.


The Lockdown helped in designing the Online courses using the zoom platform that could be used for didactic lectures, for patient consultations and case discussions and for supervision and guidance of minor surgical procedures 13.


In summary what seems to work well is the Informal Mentoring that was formalized by the University of Leeds project by validated training program, the innovative Proctorship program and University accreditation and credentialing by the Rural surgery association.

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J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is an urologist and laparoscopic surgeon trained at CMC Vellore. He is the Past President and Project Lead for the Project GILLS of the Association of Rural Surgeons of India, the Secretary of the International Federation of Rural Surgeons and board member of the G 4 Alliance. He is also an Adjunct Professor at Karunya University. He has over 400 publications in national and international Journals related to rural surgery and has won many innovations award like the EHA innovation award, Antia Finseth award, the Lockheed Martin award, the Millennium Alliance award, etc., He has few patents and the low cost equipment is listed in the WHO compendium of medical equipment for resource poor setting. He has helped many hospitals start Minimally Invasive Surgeries. The popular innovations that have made MIS possible in rural areas are the Gas Insufflation Less Laparoscopic Surgeries and the Laptop cystoscope. 

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