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1.  Scaling up specialist training in developing countries: lessons learned from the first 12 years of regional postgraduate training in Fiji – a case study 
In 1997, regional specialist training was established in Fiji, consisting of one-year Postgraduate Diplomas followed by three-year master’s degree programs in anesthesia, internal medicine, obstetrics/gynecology, pediatrics and surgery. The evolution of these programs during the first 12 years is presented.
Case description
A case study utilizing mixed methods was carried out, including a prospective collection of enrolment and employment data, supplemented by semi-structured interviews. Between 1997 and 2009, 207 doctors (113 from Fiji and 94 from 13 other countries or territories in the Pacific) trained to at least the Postgraduate Diploma level. For Fiji graduates, 29.2% migrated permanently to developed countries, compared to only 8.5% for regional graduates (P <0.001). Early years of the program were characterized by large intakes and enthusiasm, but also uncertainty. Many resignations took place following a coup d’etat in 2000. By 2005, interviews suggested a dynamic of political instability initially leading to resignations, leading to even heavier workloads, compounded by academic studies that seemed unlikely to lead to career benefit. This was associated with loss of hope and downward spirals of further resignations. After 2006, however, Master’s graduates generally returned from overseas placements, had variable success in career progression, and were able to engage in limited private practice. Enrolments and retention stabilized and increased.
Discussion and evaluation
Over time, all specialties have had years when the viability and future of the programs were in question, but all have recovered to varying degrees, and the programs continue to evolve and strengthen. Prospective clarification of expected career outcomes for graduates, establishment of career pathways for diploma-only graduates, and balancing desires for academic excellence with workloads that trainees were able to bear may have lessened ongoing losses of trainees and graduates.
Despite early losses of trainees, the establishment of regional postgraduate training in Fiji is having an increasingly positive impact on the specialist workforce in the Pacific. With forethought, many of the difficulties we encountered may have been avoidable. Our experiences may help others who are establishing or expanding postgraduate training in developing countries to optimize the benefit of postgraduate training on their national and regional workforces.
PMCID: PMC3543231  PMID: 23270525
Education; Medical; Postgraduate; Developing countries; Pacific Islands; Human resources for health; Professional satisfaction; Case study; Qualitative research; Medical migration; Mixed methods research
2.  Pediatric procedures in urology residency training: An analysis of the experience of Canadian urology residents 
We sought to determine if the exposure to pediatric urologic procedures by graduates of Canadian urological programs is congruent with the objectives of training (OTR) put forward by the Royal College of Physicians and Surgeons of Canada (RCPSC).
The Canadian T-Res (Resiliance Software Inc., Vancouver, BC) database for pediatric surgical procedures logged from 2003 to 2009 was interrogated. The number of cases logged for each of the A, B and C lists of procedures (least complex to most complex) as outlined in the RCPSC OTR in Urology were recorded for the 6 participating programs across the country.
A total of 48 residents submitted data to T-Res from the 6 participating programs. Of the A-list procedures, Canadian urology residents (PGY 1–5) from the 6 participating programs participated in an annual average of 53 hypospadias repairs, 30 orchidopexies for inguinal testes, 26 circumcisions, 7 hernia/hydrocele repairs, 7 pyeloplasties, 7 ureteral reimplants, 6 endoscopic injections for vesicoureteral reflux, 3 meatoplasties/meatotomies, 1 transurethral incision of ureterocele, 2 endoscopic procedures for stone management, and 1 transurethral incision of ureterocele, during the years in question. Of the B-list procedures, residents participated in an annual average of 1 transurethral resection of a posterior urethral valve, 3 continent diversions, 2 augmentation cystoplasties and 1 vesicostomy. Of the data available for the C-list procedures, residents participated in an annual average of less than 1 exstrophy repair and less than 1 pediatric renal transplant.
The RCPSC objectives set out by the specialty committee are a useful framework for guiding graduating residents on which procedures they might reasonably perform once they enter practice. Ongoing revisions to these objectives, which reflect changing trends in the management of core pediatric urology procedures, are supported by our study based on the number of cases in which residents participate. Improvements in the assessment of trainee surgical experience and competence, as it relates to the objectives of training in pediatric urology, are required as we migrate towards a competency-based model of postgraduate medical education.
PMCID: PMC4216286  PMID: 25408795
3.  The Impact of Postgraduate Training on USMLE® Step 3® and its Computer-Based Case Simulation Component 
The United States Medical Licensing Examination® (USMLE®) Step 3® examination is a computer-based examination composed of multiple choice questions (MCQ) and computer-based case simulations (CCS). The CCS portion of Step 3 is unique in that examinees are exposed to interactive patient-care simulations.
The purpose of the following study is to investigate whether the type and length of examinees’ postgraduate training impacts performance on the CCS component of Step 3, consistent with previous research on overall Step 3 performance.
Retrospective cohort study
Medical school graduates from U.S. and Canadian institutions completing Step 3 for the first time between March 2007 and December 2009 (n = 40,588).
Post-graduate training was classified as either broadly focused for general areas of medicine (e.g. pediatrics) or narrowly focused for specific areas of medicine (e.g. radiology). A three-way between-subjects MANOVA was utilized to test for main and interaction effects on Step 3 and CCS scores between the demographic characteristics of the sample and type of residency. Additionally, to examine the impact of postgraduate training, CCS scores were regressed on Step 1 and Step 2 Clinical Knowledge (CK) scores. Residuals from the resulting regressions were plotted.
There was a significant difference in CCS scores between broadly focused (μ = 216, σ = 17) and narrowly focused (μ=211, σ = 16) residencies (p < 0.001). Examinees in broadly focused residencies performed better overall and as length of training increased, compared to examinees in narrowly focused residencies. Predictors of Step 1 and Step 2 CK explained 55% of overall Step 3 variability and 9% of CCS score variability.
Factors influencing performance on the CCS component may be similar to those affecting Step 3 overall. Findings are supportive of the validity of the Step 3 program and may be useful to program directors and residents in considering readiness to take this examination.
PMCID: PMC3250543  PMID: 21879372
USMLE; Step 3; CCS; postgraduate training; graduate medical education
4.  Does general surgery residency prepare surgeons for community practice in British Columbia? 
Canadian Journal of Surgery  2009;52(3):196-200.
Preparing surgeons for clinical practice is a challenging task for postgraduate training programs across Canada. The purpose of this study was to examine whether a single surgeon entering practice was adequately prepared by comparing the type and volume of surgical procedures experienced in the last 3 years of training with that in the first year of clinical practice.
During the last 3 years of general surgery training, I logged all procedures. In practice, the Medical Services Plan (MSP) of British Columbia tracks all procedures. Using MSP remittance reports, I compiled the procedures performed in my first year of practice. I totaled the number of procedures and broke them down into categories (general, colorectal, laparoscopic, endoscopic, hepatobiliary, oncologic, pediatric, thoracic, vascular and other). I then compared residency training with community practice.
I logged a total of 1170 procedures in the last 3 years of residency. Of these, 452 were performed during community rotations. The procedures during residency could be broken down as follows: 392 general, 18 colorectal, 242 laparoscopic, 103 endoscopic, 85 hepatobiliary, 142 oncologic, 1 pediatric, 78 thoracic, 92 vascular and 17 other. I performed a total of 1440 procedures in the first year of practice. In practice the break down was 398 general, 15 colorectal, 101 laparoscopic, 654 endoscopic, 2 hepatobiliary, 77 oncologic, 10 pediatric, 0 thoracic, 70 vascular and 113 other.
On the whole, residency provided excellent preparation for clinical practice based on my experience. Areas of potential improvement included endoscopy, pediatric surgery and “other,” which comprised mostly hand surgery.
PMCID: PMC2689753  PMID: 19503663
5.  The underrepresented in graduate medical education and medical research. 
Public Health Reports  1984;99(1):53-58.
There is a perception that the career options open to medical school graduates who are members of minority groups are restricted. This perception relates especially to those postgraduate medical training programs that have not traditionally encouraged or had significant minority participation. Data were therefore sought to determine whether this perception was well founded. Recent reports show the strikingly low numbers of minorities on medical school faculties and in administrative positions in spite of efforts to fill such positions. Information on the specialties of practicing minority physicians is limited, but accurate figures are available on the participation of minorities in various specialty postgraduate training programs. For instance, during recent years, 50 to 60 percent of all black residents have been trained in internal medicine, pediatrics, general surgery, and obstetrics and gynecology. Further studies are needed to document or disprove the conception that minority physicians have less access than other physicians to certain careers in the delivery of health care and education. In the interim, efforts should be continued to encourage minority physicians not only to seek preparation for community primary care practice, but also for professional participation in academic careers of other specialties (and subspecialties), in biomedical and clinical research, and in health care administration. The ability to enter these diverse careers is most often determined by the opportunities available at the time of completion of medical school education. Therefore, those involved in graduate medical education should address the challenge of providing opportunities for the proportionate representation of minorities in all aspects of medical care and medical education.
PMCID: PMC1424521  PMID: 6422495
6.  The Underrepresented in Graduate Medical Education and Medical Research 
There is a perception that the career options open to medical school graduates who are members of minority groups are restricted. This perception relates especially to those postgraduate medical training programs that have not traditionally encouraged or had significant minority participation. Data were therefore sought to determine whether this perception was well founded.
Recent reports show the strikingly low numbers of minorities on medical school faculties and in administrative positions in spite of efforts to fill such positions. Information on the specialties of practicing minority physicians is limited, but accurate figures are available on the participation of minorities in various specialty postgraduate training programs. For instance, during recent years, 50 to 60 percent of all black residents have been trained in internal medicine, pediatrics, general surgery, and obstetrics and gynecology.
Further studies are needed to document or disprove the conception that minority physicians have less access than other physicians to certain careers in the delivery of health care and education. In the interim, efforts should be continued to encourage minority physicians not only to seek preparation for community primary care practice, but also for professional participation in academic careers of other specialties (and subspecialties), in biomedical and clinical research, and in health care administration. The ability to enter these diverse careers is most often determined by the opportunities available at the time of completion of medical school education. Therefore, those involved in graduate medical education should address the challenge of providing opportunities for the proportionate representation of minorities in all aspects of medical care and medical education.
PMCID: PMC2561654  PMID: 6492178
7.  Evolving residency requirements for ambulatory care training for five medical specialties, 1961 to 1989. 
Western Journal of Medicine  1989;151(6):676-678.
Recent changes in the patient population of teaching hospitals, spurred by technologic advances and economic forces, have jeopardized the traditional hospital-based model of residency training. In consequence, there has been increasing attention paid to the need for ambulatory care experience. A primary force in shaping the content of postgraduate medical education is "The Essentials of Accredited Residencies," published in the Directory of Graduate Medical Education Programs. We reviewed recommendations and requirements for ambulatory settings and outpatient experience as specified in the Directory during the years 1961 to 1988 and investigated pending changes in requirements for five major specialties: internal medicine, pediatrics, family practice, general surgery, and obstetrics and gynecology. Increases in the amount of time residents spend in ambulatory care training recently have been mandated in internal medicine and are under consideration in two other specialties, indicating probable major shifts in the locus of postgraduate medical training.
PMCID: PMC1026774  PMID: 2618049
8.  The development of postgraduate surgical training in Guyana 
Canadian Journal of Surgery  2010;53(1):11-16.
Like many developing countries, Guyana has a severe shortage of surgeons. Rather than rely on overseas training, Guyana developed its own Diploma in Surgery and asked for assistance from the Canadian Association of General Surgeons (CAGS). This paper reviews the initial results of Guyana’s first postgraduate training program.
We assisted with program prerequisites, including needs assessment, proposed curriculum, University of Guyana and Ministry of Health approval, external partnership and funding. We determined the outputs and outcomes of the program after 2 years, and we evaluated the impact of the program through a quantitative/qualitative questionnaire administered to all program participants.
Five residents successfully completed the 2-year program and are working in regional hospitals. Another 9 residents are in the training program. Twenty-four modules or short courses have been facilitated, alternating Guyanese with visiting Canadian surgical faculty members coordinated through CAGS. A postgraduate structure, including an Institute for Health Sciences Education and Surgical Postgraduate Education Committee, has been developed at the Georgetown Public Hospital Corporation (GPHC). An examination structure similar to Canada’s has been established. Hospital staff morale is greater, surgical care is more standardized and academic opportunities have been enhanced at GPHC. Four regional hospitals have welcomed the new graduates, and surgical services have already improved. Canadian surgeons have a greater understanding of and commitment to surgical development in low-income countries.
Guyana has proven that, with visiting faculty assistance, it can mount its own postgraduate training suitable to national needs and will provide a career path to encourage its own doctors to remain and serve their country.
PMCID: PMC2810022  PMID: 20100407
9.  What Is the Current Status of Global Health Activities and Opportunities in US Orthopaedic Residency Programs? 
Interest in developing national health care has been increasing in many fields of medicine, including orthopaedics. One manifestation of this interest has been the development of global health opportunities during residency training.
We assessed global health activities and opportunities in orthopaedic residency in terms of resident involvement, program characteristics, sources of funding and support, partner site relationships and geography, and program director opinions on global health participation and the associated barriers.
An anonymous 24-question survey was circulated to all US orthopaedic surgery residency program directors (n = 153) by email. Five reminder emails were distributed over the next 7 weeks. A total of 59% (n = 90) program directors responded.
Sixty-one percent of responding orthopaedic residencies facilitated clinical experiences in developing countries. Program characteristics varied, but most used clinical rotation or elective time for travel (76%), which most frequently occurred during Postgraduate Year 4 (57%) and was used to provide pediatric (66%) or trauma (60%) care. The majority of programs (59%) provided at least some funding to traveling residents and sent accompanying attendings on all ventures (56%). Travel was most commonly within North America (85%), and 51% of participating programs have established international partner sites although only 11% have hosted surgeons from those partnerships. Sixty-nine percent of residency directors believed global health experiences during residency shape future volunteer efforts, 39% believed such opportunities help attract residents to a training program, and the major perceived challenges were funding (73%), faculty time (53%), and logistical planning (43%).
Global health interest and activity are common among orthopaedic residency programs. There is diversity in the characteristics and geographical locations of such activity, although some consensus does exist among program directors around funding and faculty time as the largest challenges.
PMCID: PMC3792241  PMID: 23893360
10.  A retrospective review of general surgery training outcomes at the University of Toronto 
Canadian Journal of Surgery  2009;52(5):E131-E136.
Surgical educators have struggled with achieving an optimal balance between the service workload and education of surgical residents. In Ontario, a variety of factors during the past 12 years have had the net impact of reducing the clinical training experience of general surgery residents. We questioned what impact the reductions in trainee workload have had on general surgery graduates at the University of Toronto.
We evaluated graduates from the University of Toronto general surgery training program from 1995 to 2006. We compared final-year In-Training Evaluation Reports (ITERs) of trainees during this interval. For purposes of comparison, we subdivided residents into 4 groups according to year of graduation (1995–1997, 1998–2000, 2001–2003 and 2004–2006). We evaluated postgraduate “performance” by categorizing residents into 1 of 4 groups: first, residents who entered directly into general surgery practice after graduation; second, residents who entered into a certification subspecialty program of the Royal College of Physicians and Surgeons of Canada (RCPSC); third, residents who entered into a noncertification program of the RCPSC; and fourth, residents who entered into a variety of nonregulated “clinical fellowships.”
We assessed and evaluated 118 of 134 surgical trainees (88%) in this study. We included in the study graduates for whom completed ITER records were available and postgraduate training records were known and validated. The mean scores for each of the 5 evaluated residency training parameters included in the ITER (technical skills, professional attitudes, application of knowledge, teaching performance and overall performance) were not statistically different for each of the 4 graduating groups from 1995 to 2006. However, we determined that there were statistically fewer general surgery graduates (p < 0.05) who entered directly into general surgery practice in the 2004–2006 group compared with the 1998–2000 and 2001–2003 groups. The graduates from 2004 to 2006 who did not enter into general surgery practice appeared to choose a clinical fellowship.
These observations may indicate that recent surgical graduates possess an acceptable skill set but may lack the clinical confidence and experience to enter directly into general surgery practice. Evidence seems to indicate that the clinical fellowship has become an unregulated surrogate extension of the training program whereby surgeons can gain additional clinical experience and surgical expertise.
PMCID: PMC2769098  PMID: 19865542
11.  Postgraduate cadaver surgery: An educational course which aims at improving surgical skills 
Objective: To describe the postgraduate surgical skills training programme of the Flemish Society of Obstetrics and Gynaecology (VVOG*). Laparoscopic surgical techniques and indications have increased substantially during the past two decades. From surgeons it is expected that they keep up with all techniques and should be able to perform all relevant procedures. Learning new procedures in daily practice is hazardous and difficult to achieve. A training experience with cadaver surgery could improve the course and outcome of surgery on patients. We present the objective, structure, and outcome of the endoscopic postgraduate training course.
Structure: The overall objective of the endoscopic postgraduate training course is to refresh anatomical knowledge and improve general gynaecological laparoscopic surgical skills. The VVOG endoscopic training programme is based on black box training, followed by pig surgery. New is the possibility to perform surgical procedures on specifically prepared human cadavers. The course consists of an anatomical teaching session followed by lectures with videotaped procedures on the anatomical exploration of the pelvis, laparoscopic hysterectomy and pelvic lymphadenectomy. During the hands-on session the participant performs the surgical procedures in a controlled, nonthreatening and interactive way under the guidance of an experienced trainer.
Conclusions: All participants provided feedback on their experiences. The evaluation of the workshop revealed that this course is an opportunity to practise and improve clinical laparoscopic skills of gynaecological procedures and anatomy. Attending the course was regarded as of genuine additional value for surgical practice.
PMCID: PMC3987353  PMID: 24753929
Laparoscopy; endoscopy; surgery; training; skills; performance; postgraduate; VVOG; endogent
12.  The Impact of Japan's 2004 Postgraduate Training Program on Intra-Prefectural Distribution of Pediatricians in Japan 
PLoS ONE  2013;8(10):e77045.
Inequity in physician distribution poses a challenge to many health systems. In Japan, a new postgraduate training program for all new medical graduates was introduced in 2004, and researchers have argued that this program has increased inequalities in physician distribution. We examined the trends in the geographic distribution of pediatricians as well as all physicians from 1996 to 2010 to identify the impact of the launch of the new training program.
The Gini coefficient was calculated using municipalities as the study unit within each prefecture to assess whether there were significant changes in the intra-prefectural distribution of all physicians and pediatricians before and after the launch of the new training program. The effect of the new program was quantified by estimating the difference in the slope in the time trend of the Gini coefficients before and after 2004 using a linear change-point regression design. We categorized 47 prefectures in Japan into two groups: 1) predominantly urban and 2) others by the definition from OECD to conduct stratified analyses by urban-rural status.
The trends in physician distribution worsened after 2004 for all physicians (p value<.0001) and pediatricians (p value = 0.0057). For all physicians, the trends worsened after 2004 both in predominantly urban prefectures (p value = 0.0012) and others (p value<0.0001), whereas, for pediatricians, the distribution worsened in others (p value = 0.0343), but not in predominantly urban prefectures (p value = 0.0584).
The intra-prefectural distribution of physicians worsened after the launch of the new training program, which may reflect the impact of the new postgraduate program. In pediatrics, changes in the Gini trend differed significantly before and after the launch of the new training program in others, but not in predominantly urban prefectures. Further observation is needed to explore how this difference in trends affects the health status of the child population.
PMCID: PMC3813669  PMID: 24204731
13.  The RCCM 2009 Survey: Mapping Doctoral and Postdoctoral CAM Research in the United Kingdom 
Complementary and Alternative Medicine (CAM) is widely available in the UK and used frequently by the public, but there is little high quality research to sustain its continued use and potential integration into the NHS. There is, therefore, a need to develop rigorous research in this area. One essential way forward is to train and develop more CAM researchers so that we can enhance academic capacity and provide the evidence upon which to base strategic healthcare decisions. This UK survey identified 80 research active postgraduates registered for MPhils/PhDs in 21 universities and were either current students or had completed their postgraduate degree during the recent UK Research Assessment Exercise (RAE) 2001–2008. The single largest postgraduate degree funder was the university where the students registered (26/80). Thirty-two projects involved randomized controlled trials and 33 used qualitative research methods. The UK RAE also indicates a significant growth of postdoctoral and tenured research activity over this period (in 2001 there were three full time equivalents; in 2008 there were 15.5) with a considerable improvement in research quality. This mapping exercise suggests that considerable effort is currently being invested in developing UK CAM research capacity and thus inform decision making in this area. However, in comparative international terms UK funding is very limited. As in the USA and Australia, a centralized and strategic approach by the National Institute of Health Research to this currently uncoordinated and underfunded activity may benefit CAM research in the UK.
PMCID: PMC3136526  PMID: 19920088
14.  Career characteristics and postgraduate education of female dentist graduates of the College of Dentistry at King Saud University, Saudi Arabia 
The Saudi Dental Journal  2011;24(1):29-34.
The aims of this study were to investigate the number of female bachelor of dental surgery graduates who earned postgraduate education degrees from King Saud University, their specialties, degrees of qualification, and countries of graduation.
A questionnaire survey was conducted through face-to-face or phone interview among 677 female dentists who graduated from the College of Dentistry at King Saud University between 1984 and 2006.
Five hundred forty-five (81%) graduate female dentists responded, of whom 54% had completed postgraduate dental education. In the Saudi Board, 17% had obtained degrees in advanced restorative dentistry, 15% in pediatric dentistry, 14% in advanced general dentistry, 11% in orthodontics, 10% in prosthodontics, 8% in operative dentistry, 5% in endodontics, 5% in periodontics, 3% in oral and maxillofacial surgery, and 11% in other specialties. Fifty-nine percent had master’s degrees, 7% had doctorates, 32% had board certificates, and 2% had fellowship certificates.
More than half (54%) the female dentists surveyed had pursued postgraduate education. This investigation highlighted the different specialties enrolled by female dentists. Orthodontic post graduate program displayed the highest percentage of interest. Understanding the unavoidable social family needs and the demand for higher education by female dentists provides ideas as more programs should be planned to accommodate the needs of Saudi female dentists. This type of study should be repeated due to the increasing interest of female dentists in higher education.
PMCID: PMC3723372  PMID: 23960525
Postgraduate; Specialties; Qualification; Education; Dental; Career
15.  Factors Influencing Choice of Medical Specialty of Preresidency Medical Graduates in Southeastern Nigeria 
This study examined the determinants of specialty choice of preresidency medical graduates in southeastern Nigeria.
We used a comparative cross-sectional survey of preresidency medical graduates who took the Basic Sciences Examination of the Postgraduate Medical College in Enugu, southeastern Nigeria, in March 2007. Data on participants' demographics and specialty selected, the timing of the decision, and factors in specialty selection were collected using a questionnaire. Data were examined using descriptive and analytical statistics. P < .05 was considered significant.
The survey response rate was 90.8% (287 of 316). The sample included 219 men and 68 women, ranging in age from 24 to 53 years and with a mean age of 33.5 ± 1.1 (SD) years. Career choice was more frequently influenced by personal interest (66.6%), career prospects (9.1%), and appraisal of own skills/aptitudes (5.6%), and it was least affected by altruistic motives (1.7%) and influence of parents/relations (1.7%). The respondents selected specialties at different rates: obstetrics and gynecology (22.6%), surgery (19.6%), pediatrics (16.0%), anesthesiology (3.1%), psychiatry (0.3%), and dentistry (0.0%). Most (97.2%) participants had decided on specialty choice by the end of their fifth (of a total 16 years) postgraduate year. The participants significantly more frequently preferred surgery and pediatrics to other disciplines (P < .002, after Bonferroni correction for multiple comparisons).
Preresidency medical graduates in southeastern Nigeria were influenced by personal interest, career prospects, and personal skills/aptitude in deciding which specialty training to pursue. The most frequently chosen specialties were surgery and pediatrics. These findings have implications for Nigeria's education and health care policy makers.
PMCID: PMC3179211  PMID: 22942964
16.  e-Teaching in pediatric cardiology: A paradigm shift 
Training of postgraduate students has traditionally been done in person in a hospital setting with hands-on training with each faculty member imparting knowledge to 2 to 4 students per year. Supplementing their practical education with online instruction could make a significant difference in standardizing pediatric cardiology education in India.
To present the rationale, methods and survey results of a live e-Teaching methodology implemented for Pediatric cardiology trainees in association with the National Board of Examinations, India.
Materials and Methods:
Between March 2010 and March 2014, 310 e-classes were conducted in the Pediatric cardiac sciences by 24 e-teachers. Content of the e-Learning program was based on a 2-year pediatric cardiology curriculum and included twice-weekly live online video training sessions, a library of recorded sessions and online test quizzes for the students. A total of 231 students accessed the program at various times over the 4-year period.
In our study, requests for access to the e-lectures increased from 10/year the first year to 100/year by the fourth year with feedback surveys conveying a high satisfaction level from the students and a high need for this knowledge. The advantages of virtual live e-Learning included the fact that one teacher can teach multiple students in multiple geographic locations at the same time, obviating the issue of quality teacher shortage and the same content can be disseminated to all students undergoing specialist training so there is a national consensus on diagnostic and management approach among all trainees. Additionally, the e-classes can be recorded and replayed so they can be viewed repeatedly by the same group or new trainees.
This is the first sustained use of e-Teaching in a medical super-specialty in India. We believe that e-Teaching is an innovative solution that can be applied, not just to Pediatric Cardiology as we have done, but to all branches of specialist and super-specialist medical training in India and globally.
PMCID: PMC4322394
e-Learning; e-teaching; pediatric cardiology
17.  Emerging alternative model for cardiothoracic surgery training in India 
Medical Education Online  2013;18:10.3402/meo.v18i0.20961.
In India, cardiothoracic (CT) surgery training follows a 3+3-year model, where 3 years of general surgery residency with certification (MS/DNB) is required for entering 3 years of thoracic surgery residency (MCh/DNB). There are two certifying boards at the national level. One being the Medical Council of India (MCI), which oversees the major accreditation process involving the undergraduate and postgraduate medical education in India, and the other being the National Board of Examinations (NBE), which was formed for the purpose of establishing a uniform standard of postgraduate medical education. Recently, the latter body has come up with an alternative model for thoracic surgery residency in India. This model includes an integrated 6-year residency, with lesser emphasis on general surgical skills and greater exposure to CT surgery.
Changes to the current model of training for CT surgery is the need of the hour and should be initiated very soon by the MCI to meet the future demand for CT surgeons in India. An integrated training program is essential to create a new generation of cardiovascular specialists. Future directions to achieve this goal must include modifications to the undergraduate programs so as to infuse interest for CT surgery in the young minds of medical students.
PMCID: PMC3647042  PMID: 23651927
thoracic surgery; training; India
18.  A modified honours grading system and the selection of postgraduate trainees. 
The selection of medical graduates for postgraduate training has often been considered to be unreliable and arbitrary because of the quality of information made available by medical schools to program directors. Many faculties of medicine have changed from reporting graduate performance in percentage grades to using an honours/pass/fail grading system to ensure that clearly established criteria for competence have been met and to encourage excellence and minimize competition. Unfortunately, the honours/pass/fail grading system has not been able to give a clear statement of relative class standing to assist in postgraduate selection. This paper describes a modified honours grading system, which takes into account a student's grade, the relative weighting of a course and the number of honours grades awarded per course. The proposed system was found to rank students in a way similar to that of the traditional percentage grading system, with no significant loss in internal consistency. The modified honours grading system permits faculties that use honours/pass/fail grades to report student performance and class standing, thereby assisting program directors in the selection of medical students for postgraduate training.
PMCID: PMC1335319  PMID: 2018963
19.  The Strategic Planning Committee Report: The First Step in a Journey to Recognize Pediatric Hospital Medicine as a Distinct Discipline 
Hospital pediatrics  2012;2(4):187-190.
The field of pediatric hospital medicine (PHM) has experienced phenomenal growth over the past decade. Academic contributions by pediatric hospitalists include the creation of PHM core competencies,1 national collaborative PHM networks for both research (the Pediatric Research in Inpatient Settings network2) and quality improvement (the Value in Inpatient Pediatrics network3), a robust and well-attended annual scientific meeting,4 and an increasing number of divisions or sections of PHM in pediatric departments across the country. Many pediatricians are choosing to pursue careers in PHM,5,6 and several postgraduate training programs for PHM have emerged.7 Similar to other generalist pediatric fields,8-11 the question as to how best for PHM to evolve as a distinct discipline has arisen. Several training and/or certification options are feasible and have been examined by the pediatric hospitalists who constitute the Strategic Planning (STP) Committee. The objectives of this commentary are to (1) describe the work done to investigate these options to date, (2) provide a framework for evaluating them, and (3) describe next steps. This commentary will neither justify subspecialty status for PHM, which is currently still debated within the field, nor will it compare the development of PHM as a subspecialty with other generalist fields because such a comparison is premature.
PMCID: PMC4068346  PMID: 24313023
20.  Trauma care — a participant observer study of trauma centers at Delhi, Lucknow and Mumbai 
The Indian Journal of Surgery  2009;71(3):133-141.
Trained doctors and para-medical personnel in accident and emergency services are scant in India. Teaching and training in trauma and emergency medical system (EMS) as a specialty accredited by the Medical Council of India is yet to be started as a postgraduate medical education program. The MI and CMO (casualty medical officer) rooms at military and civilian hospitals in India that practice triage, first-aid, medico-legal formalities, reference and organize transport to respective departments leads to undue delays and lack multidisciplinary approach. Comprehensive trauma and emergency infrastructure were created only at a few cities and none in the rural areas of India in last few years.
To study the infrastructure, human resource allocation, working, future plans and vision of the established trauma centers at the 3 capital cities of India — Delhi (2 centres), Lucknow and Mumbai.
Setting and design
Participant observer structured open ended qualitative research by 7 days direct observation of the facilities and working of above trauma centers.
Material and methods
Information on, 1. Infrastructure; space and building, operating, ventilator, and diagnostic and blood bank facilities, finance and costs and pre-hospital care infrastructure, 2. Human resource; consultant and resident doctors, para-medical staff and specialists and 3. Work style; first responder, type of patients undertaken, burn management, surgical management and referral system, follow up patient management, social support, bereavement and postmortem services were recorded on a pre-structured open ended instrument interviewing the officials, staff and by direct observation. Data were compressed, peer-analyzed as for qualitative research and presented in explicit tables.
Union and state governments of Delhi, Maharashtra and Uttar Pradesh have spent heavily to create trauma and emergency infrastructure in their capital cities. Mostly general and orthopedics surgeons with their resident staff were managing the facilities. Comprehensively trained accident and emergency (AandE) personnel were not available at any of the centers. Expert management of cardiac peri-arrest arrhythmias, peripheral and microvascular repair were occasionally available. Maxillo-facial, dental and prosthodontic facilities, evenomation grading and treatment of poisoning — anti venom were not integrated. Ventilators, anesthetist, neuro and plastic surgeons were available on call for emergency care at all the 4 centers. Emergency diagnostic radiology (X-ray, CT scan, and ultrasound) and pathology were available at all the 4 centers. On the spot blood bank and component blood therapy was available only at the Delhi centers. Pre-hospital care, though envisioned by the officials, was lacking. Comprehensively trained senior A and E personnel as first responders were unavailable. Double barrier nursing for burn victims was not witnessed. Laparoscopic and fibreoptic endoscopic emergency procedures were also available only at Delhi. Delay in treatment on account of incomplete medico-legal formalities was not seen. Social and legal assistance, bereavement service and cold room for dead body were universally absent. Free treatment at Delhi and partial financial support at Lucknow were available for poor and destitute.
Though a late start, evolution of trauma services was observed and huge infrastructure for trauma have come up at Delhi and Lucknow. Postgraduate accreditation in Trauma and EMS and creation of National Injury Control Program must be mandated to improve trauma care in India. Integration of medical, non traumatic surgical and pediatric emergency along with pre-hospital care is recommended.
PMCID: PMC3452474  PMID: 23133136
Trauma Care; India; Trauma Centers; Participant observer
21.  Postgraduate specialties interest, career choices and qualifications earned by male dentists graduated from King Saud University 
The Saudi Dental Journal  2010;23(2):81-86.
Objectives: To study the career development of male graduates of King Saud University (KSU), College of Dentistry in terms of pursuit of postgraduate dental education, higher degrees or Board Certification, choice of universities and countries of study, and place of work after qualification.
Methods: A questionnaire survey was carried out through face to face or telephone interview among 666 KSU graduates of 1982–2004.
Results: 80% (532 graduates) response rate. (77%) finished postgraduate dental education. 17% specialized in Prosthodontics, 16% in Saudi Board Advanced Restorative Dentistry, 14% in Advanced General Dentistry, 10.5% in Orthodontics, 10% in Oral and Maxillofacial Surgery, 8.3% in Pediatric Dentistry, 7.7% in Endodontics, 6% in Periodontics, 5.5% in Operative Dentistry, 5% in other Specialties. 61% had a Master’s degree and 16% had a Doctorate degree. 23% had Board Certificates and 8% had a Fellowship Certificate. (78%) are working in the government, 15% at the university and 6% in private, and 19% in administrative positions.
Conclusion: Most of the dental graduates were motivated and eager to continue their postgraduate education to get either clinical specialty or academic degrees from nationally and internationally well recognized and known Universities and programs.
PMCID: PMC3723123  PMID: 23960503
Graduate; Dental; Specialty; Career; Education; Postgraduate
22.  A Public Health Approach to Pediatric Residency Education: Responding to Social Determinants of Health 
To evaluate the impact of a public health approach to pediatric residency education on learner knowledge, skills, attitudes, beliefs, and career choice.
Incorporating public health principles into traditional residency education can give pediatricians the population-oriented perspective to address social determinants of health.
The Community Health and Advocacy Training (CHAT) program is an educational intervention with a public health framework. From 2001–2007, 215 categorical pediatric residents and 37 residents in the CHAT program were evaluated by using an annual survey of community pediatrics exposure, knowledge, attitudes, and beliefs. American Board of Pediatrics (ABP) examination passage rates for both groups were also examined, as was career choice after graduation.
While interns in both the categorical and CHAT programs scored similarly on attitudes, beliefs, skills, and knowledge of community pediatrics, the postgraduate level-3 (PL-3) year CHAT residents scored higher in attitudes (P < .001) and skills (P < .05). Exposure to both didactic (P < .05) and practical (P < .001) community pediatrics curricular experiences were higher for CHAT residents than for categorical residents. No significant differences between ABP examination scores were found for the 2 groups, although 100% of CHAT graduates passed on the first try compared to 91% of categorical graduates during this time period. A greater percentage of CHAT graduates (82%) than categorical graduates (53%) reported pursuing careers in primary care.
With a public health approach to residency education, residents gain the knowledge, attitudes, and skills to address child health problems from a population perspective. Participation in such a curriculum still resulted in high passage rates on the ABP examination.
PMCID: PMC3184909  PMID: 22655145
23.  Physical Reality Simulation for Training of Laparoscopists in the 21st Century. A Multispecialty, Multi-institutional Study 
Simulation is the most effective and safe way to train laparoscopic surgeons in an era of limited work hours, lack of funding, and increasing malpractice costs. However, the costs associated with the use of virtual reality simulators are significant, and although very technically sophisticated they still lack tactile feedback. We are proposing a physical reality simulator, the LTS 2000, as a reliable and effective alternative to virtual reality. This study was carried out to establish how reliably the simulator was able to differentiate between different levels of laparoscopic experience and to analyze the detection of skills improvement after simulation and clinical training.
This study was carried out, between July 2002 and August 2003, in the departments of Surgery and Obstetrics and Gynecology at 2 separate institutions. We enrolled 40 individuals in the study who had experience ranging from postgraduate year-1 to full-time faculty level. Five postgraduate year-3 residents were subsequently retested after rotating on clinical services, performing advanced laparoscopic procedures to assess whether the simulator was sensitive enough to detect improvements in laparoscopic skills at the intermediate level. Six tasks were included in the test, and they were scored for speed and precision with the McGill system. Two scores were obtained: a coordination score and a suturing score combined in a total score. Other variables analyzed were handedness, specialty, number of laparoscopic procedures performed, and hours spent on the simulator.
Forty-five tests were performed. The number of subjects in each group based on level of experience was equally distributed. No difference occurred in scores between institutions, specialty, and right- or left-handed surgeons. A significant increase occurred in the coordination score and suturing score combined in the total score with increasing experience (P<0.05) at each level. Furthermore, the simulator was sensitive enough to detect a significant difference in all 3 scores between subjects who had practiced with the simulator before being tested (P<0.05). The scores of the 5 postgraduate year-3 participants doubled when tested, without reaching statistical significance due to the small sample size.
Our study shows that the LTS 2000 reliably and reproducibly detects different levels of laparoscopic expertise and progression of the learning curve. LTS 2000 as a model of physical reality simulation should be considered a reliable alternative to virtual reality simulation.
PMCID: PMC3015577  PMID: 15984696
Laparoscopy; Medical training; Virtual reality simulation; Physical reality simulation
24.  Providing after-hours on-call clinical coverage in academic health sciences centres: the Hospital for Sick Children experience 
An increasing number of admissions of patients requiring complex and acute care coupled with a decreasing number of pediatric postgraduate trainees has caused a shortage of house staff available to provide after-hours on-call coverage in the Department of Pediatrics at Toronto‚s Hospital for Sick Children. The Clinical Assistant program created to deal with this problem was short on staff, did not provide adequate continuity of care and was becoming increasingly unaffordable. The Clinical Departmental Fellowship program was created to address the problem of after-hours clinical coverage. The program is aimed at qualified pediatricians seeking additional clinical or research training in one of the subspecialty divisions in the Department of Pediatrics. We describe the hiring process, job description and evolution of the program since its inception in 1996. This program has been mutually advantageous for the individual fellows and their sponsoring divisions as well as the Department of Pediatrics and the Hospital for Sick Children. We recommend the introduction of similar programs to other academic medical departments facing staff shortages.
PMCID: PMC80296  PMID: 10951730
25.  Initial Experiences in Embedding Core Competency Education in Entry-Level Surgery Residents Through a Nonclinical Rotation 
Health care continues to expand in scope and in complexity. In this changing environment, residents are challenged with understanding its intricacies and the impact it will have on their professional activities and careers.
Embedding each of the competency elements in residents in a meaningful way remains a challenge for many surgery residency program directors.
We established a nonclinical rotation to provide surgery postgraduate year-1 (PGY-1) residents with a structured, multifaceted, largely self-directed curriculum into which each of the 6 core competencies are woven. Posttesting strategies were established for most curricular experiences to ensure to the greatest possible extent that each resident will have achieved an acceptable level of understanding of each of the competency areas before being given credit for the rotation.
By uniformly exceeding satisfactory scores on respective objective analyses, residents demonstrated an increased (at least short-term) understanding of each of the assessed competency areas.
Our project sought to address a prior lack of opportunity for our residents to develop a sound foundation for our residents in systems-based practice. Our new rotation addresses systems-based practice in several different learning environments, including emergency medical service ride-along, sentinel event participation, and hospice visits. Several research projects have enhanced the overall learning program. Our experience shows that a rotation dedicated to competency training can provide an innovative and engaging means of teaching residents the value of each element.
PMCID: PMC3186258  PMID: 22379529

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