Perspectives on Fellowship in Urology

Consultants Perspective: Dr. Joy N Chakraborty 

The speciality of Urology in India has started as a ‘Urology section’ of ASI in the year 1961 by Dr G M Phadke. In the same year, the first Urology Department was created in George’s Hospital (Bombay) with Dr B N Colabawalla as the chair. Since then, there has been a continuous evolution in the MCh curriculum as well as an increase in the number of MCh seats throughout India. In addition to MCh, DNB urology program also gained momentum since the last decade. Today, we have more than 100 institutions providing about 300 seats in urology.  The concept of fellowship comes from the assumption that the present 3-year MCH/ DNB course is inadequate to train the students in the different Urology subspecialties with in-depth knowledge and skill. Moreover, the various urology subspecialties have got progressively more enriched with newer knowledge, developments and techniques, which is impossible to acquire in a 3-year course. Here, we try to explore this topic in greater depth and insight.

The present situation of Urology fellowship in India 

Although a few urology fellowship programs have already been started in some tertiary care hospitals in India, they vary in uniformity in curriculum-designing, accreditation issues and quality control. Consequently, several of these Indian programs are far behind the European or American standards in several aspects, especially in the domain of research and publications. Here is a list of fellowship programs available in India at present.

Subject-wise drawbacks and advantages

  1.  Endourology fellowship: Most of the urology residents learn endourology procedures during the three-year residency program with the prospect of better financial sustainability throughout life. Further refinements happen in-practice. So, this fellowship may seem to be unnecessary in the Indian scenario unless combined with the learning opportunity in laparoscopy and robotics.
  2. Uro-oncology Fellowship: It is useful for those who want to pursue their career in pure uro-oncology practice. However, they must be placed in a suitable work-place. Also, both the laparoscopic and robotic experience is desirable. However, in the Indian scenario, several of those completing the fellowship still used to perform endo-urology to sustain financially. 
  3. Reconstructive urology fellowship: This branch is useful for the handful of dedicated urologists with a burning desire to devote to pure reconstructive urology. However, as the job prospects are limited to only a few specialized centres, most of the fellows who passed out resort to Endourology for sustenance.
  4. Female urology fellowship: This subspecialty (as a pure form) experience a few takers only due to the limited opportunity as a pure form as well as a bit difficult for male urologists (gender bias). Also, this subspecialty is shared by a section of the Gynecologists, further reducing its appeal to the newcomers. 
  5. Transplant Fellowship: Urologists as a pure transplant surgeon (without resorting to another subspecialty) are rare. Although this fellowship is demanding in terms of time, physical and mental workload, it gives poor remuneration and considerable professional risk in Indian scenario, if anyone opts to become a pure transplant surgeon. Mixing it with some other subspecialty is the usual rule to keep a balance.
  6. Laparoscopic Urology Fellowship: It is gradually losing its sheen over the last few years as Uro-oncology (with laparoscopic experience) and Robotics are more appealing to the present urologists. To make it more attractive, it must be combined with endo-urology (as done in AINU, Hyderabad).
  7. Paediatric Urology Fellowship: Only one centre is offering this fellowship in India. Also, this area is an overlapping zone between Paediatric surgeons and Urologists. Hence, only institutional practice (preferably teaching) is possible with this subspecialty, as sustenance as a pure Paediatric urologist is an issue in the Indian scenario.

Some other factors of importance in the implementation of fellowship programs in different subspecialties in Indian scenario are :

Institutional Drawbacks

  1. Lack of a structured and standardized training curriculum. The training program must have an accreditation from a University, autonomous authority and endorsed by USI or international body. These facts fail to instil a sense of worthiness, authenticity and confidence among the takers of fellowship positions.
  2. Lack of volume and infrastructure for training requirements: Sufficient work and technology are essential to meet the needs of the trainee. The learning outcome should specifically mention the number of cases they will perform under supervision as well as independently during the tenure. 
  3. Reliable research environment with protected time for research activities for the trainees with publication in reputed journals must be ensured. The number of publications the trainees would require the need to be specified in the learning objectives.
  4. The program director must be an official member of USI in good standing. He must show commitments for the clinical and academic education of the trainees. Also, there is a requirement of separate directors for different subspecialty, for example, one each for Endourology and laparoscopy with robotics. 
  5. Insufficient financial grant discourages prospective trainees. The program director must ensure adequate institutional funding for salary and fringe benefits for the trainees.
  6. There should be Formal Fellow evaluation for every six months, and remedial measures should be taken if necessary. The trainees must maintain an academic portfolio (including surgical e-logbook) for the assessment by USI. Besides, valid certification at the end of the program should be provided to the trainees jointly by the institute and USI. 

Trainee’s point of view

  1. Unlike European countries and Americas, most of the Indian urologists work in private practice, corporate sector and freelancing with cutting edge competition with their peers, general surgeons and even Ayush practitioners. The condition is made even worse with the growing number of MCh/DNB seats across India without proper planning, and there is a real concern for quality and supervision in several of the centres. Although the Government’s motivation is understandable (to provide the super speciality service at the district level with the false assumption of a shortage of urologists), the ultimate result is downgrading urology professionals and unhealthy competition among the peers. Thus, in the process of mimicking the western population-urologist ratio (without realising the Indian scenario), the ‘Urology’ is losing its brand value. Consequently, after spending 15 years in study altogether, most of the passed-out students first opt for Endourology (the bread-and-butter) for the lucrative nature of the practice, large caseload and a decent income to support their family rather than being enrolled in a fellowship program.
  1. Another concern is the asymmetrical growth of the subspecialties. There has been a recent surge in interest in Laparoscopy, Robotics and transplantation programs. Most of the premier institution’s work revolves around this due to more gratifying results, glamour and remuneration. Hence, some of the areas like Andrology, reconstructive urology or female urology remain neglected. 

Although trainee’s interest is the primary motivational factor here, glamour and remuneration package also play a significant role. Presently, placement opportunities with most of these subspecialties are limited only to the premier institutes. As a result, most of the post-fellowship candidates find their fellowship experience redundant if not suitably placed.

  1. Another point of importance is the inadequate salary package and the potential lack of learning opportunity in the fellowship program. Some centres try to exploit the candidates for paper-work and non-surgical works rather than following a strict curriculum (absent at present in India). This fact also acts as a deterrent for the fellowship aspirants.

What can be done to improve the situation?

Even though the ultimate goal of urology fellowship is to enhance the skill and in-depth knowledge in subspecialties, this seems to be far from sight with the present system of urology curriculum. Some factors need to be considered before prescribing recommendations. First, we need general urologists with good Endourology exposure as our country need more generalists. Secondly, as the urology practice in India is driven by free-market principle, cost-benefit analysis with judicial use of resources is a pertinent point. Thirdly, only a certain percentage of MCH/DNB students need to get subspecialty training to utilize their knowledge at the local level (with suitable placement opportunity). Fourthly, the trainees should consider the geographical location of their practice beforehand with carefully balancing their aspirations and family commitments. The necessary recommendations in that direction could be:

  1. Integration of all urology training (MCh and DNB) as well as subspecialty-fellowship programs, should be done nationwide with a uniform curriculum.
  2. All fellowship programs should be under the single umbrella of USI, who in turn should have clear-cut guidelines for awarding fellowship in collaboration with the training Institute. This fellowship certificate must have a legal validity from the NMC.
  3. Institutional requirements should be stricter in terms of infrastructure, the volume of subspecialty cases, hands-on experience, trainer’s experience, protected time for research activities and adequate funding for the trainees’ decent salary.
  4. Specific Institutes with high volume work on subspecialties should be identified and earmarked for fellowship programs.
  5. Urology can be converted into a broad specialty with five or six year training program.

Fortunately, we are moving gradually in that direction, keeping in mind the difference between Indian scenario from western practice. Formation of a Urology subspecialty group within USI has already been done. Curriculum designing and Institutional requirements have also been framed in some particular subspecialty. We can hope to move forward soon with a suitable subspecialty fellowship program.   

References:

  1. Gautam G. The current three-year postgraduate program in urology is insufficient to train a urologist. Indian journal of urology: IJU: journal of the Urological Society of India. 2008 Jul;24(3):336.
  2. Aron M. Urology training in India: balancing national needs with global perspectives. Indian journal of urology: IJU: journal of the Urological Society of India. 2009 Apr;25(2):254.
  3. Goel A. Urology in India: Numbers and practice. Indian Journal of Urology: IJU: Journal of the Urological Society of India. 2019 Oct;35(4):245.
Perspectives on Fellowship in Urology
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