Pain Fellowship and Training in India

Ruins of Nalanda University
Ruins of Nalanda University

Roy Porter in The Greatest Benefit to Mankind, states that before anaesthetics, antiseptics and antibiotics, medicine could do little for the sick except perhaps reduce pain with narcotics. This was the norm even when the ancient Egyptians used a combination of pulverized crocodile dung with herbs and honey to make contraceptive pessaries.

Since independence, our population has trebled; the life-spans have doubled; not to mention the corruption and scams where the “values” would not fit in a logarithmic scale. Healthcare has improved despite the mayhem, though modern treatments are still unaffordable to a vast majority. As it stands, there aren’t sufficient doctors who are trained enough to manage pain in India. Only a systematic education and training of doctors would help our population in the long run. The Indian Society for Study of Pain (ISSP), with tireless enthusiasm, has been vanguardist at its efforts to train doctors. We catch up with Dr. Muralidhar Joshi to figure out the efforts of ISSP.

Dr. Muralidhar Joshi has authored the first ‘Text Book of Pain Management’ in India. He was instrumental in starting various teaching programmes like online pain course and fellowship in pain management in the country for the first time. Currently he is the national active member of Apex Academic Body of ISSP. He is also the general secretary of Andhra Pradesh chapter of ISSP and organizing secretary for the national conference of ISSP in February 2009. At present he is the Director of Kamineni Pain Management Centre at Hyderabad.

Changing attitudes and entrenched practices is never quick and easy. ISSP works in the hope of greasing that path. How far have we progressed in terms of training in pain medicine?
For quite some time, we had short courses of 2 to 6 weeks duration, developed by ISSP and Palliative Care Society of India to train the professionals. This was never enough. An apex academic body was formed in 2006 by ISSP to look into standardizing pain education and training in India. Based on its recommendation an ISSP Task Force was formed in 2009. The remit of the Task Force was to formulate guidelines and monitor the training programmes. It was obvious, that to make pain education more acceptable, the curriculum should be introduced at Undergraduate and Post graduate level of medical education. We have been in discussion with Medical Council of India (MCI) and Ministry of Health in an attempt to take this agenda forward.

When ISSP sat down to formulate guidelines, there must have been limitations on what it could and could not do. Could you take us through the thought process?
That’s right. We were well aware that, with ISSP not being a statutory body, we have no legal control over public or private organizations which intend to start an academic programme in pain medicine. Moreover, to have legal or employment value, the course should be university and MCI affiliated.  ISSP cannot endorse or certify any such training programme; it could only provide its seal of approval or provide guidelines to conduct training programmes in universities.

There are other barriers too, like

  • Limited number of trained teaching faculty
  • Accreditation from MCI, NBE or Universities
  • Lack of motivation from institutions
  • Stipend or honorarium for students
  • Inadequate volume of patients and resistance from other specialties

Yet, we have a set of guidelines. Why?
Well, status quo was simply unacceptable. Many reasons we could count

  • To popularize the specialty. If more training centers are recognized, more junior/senior doctors would be trained to manage pain effectively.
  • Impart some uniformity and standard in training.
  • The guidelines, furthermore, can be utilized by concerned institutions/pain centers to obtain university or MCI approved long term training programmes of six months/one year duration.

But still, ISSP endorsed programmes will be of additional skill category, without legal or employment value. That would be the responsibility of MCI.

Sociology students could do well watching Jhalak Dikhlaja, Bigg Boss or worse Karan Johar. Doctors? They will need a bit of structured training surely!
Structured training is the way forward. For undergraduates, we have proposed 5 lectures in the anaesthesia module during 3rd or 4th year. The lectures would be on

  • Physiology and psychology of pain, history & examination
  • Acute pain, postoperative pain, post traumatic pain
  • Development of chronic pain with examples of chronic pain syndromes
  • Cancer pain
  • Neuropathic pain

For postgraduates we have proposed 12 lectures

  • Overview of Pain Management.
  • Physiology & Pathophysiology of pain
  • Clinical history & Physical exam
  • Radiology & Electrodiagnostics
  • Acute Postoperative pain
  • Chronic pain syndromes
  • Cancer pain
  • Neuropathic pain
  • Interventional Pain Management
  • Establishing a Pain Clinic
  • Adjuncts to Pain Management
  • Advanced Pain Therapy

It is the age of specialisation, after all. Everyone has used science to get better at what they do. Bacteria and Virus included. Anything for the junior doctors?
There are short-term training programmes of 2-6 weeks duration endorsed by ISSP. There are also courses proposed to be introduced next academic year.

  • Two weeks training programme (basic course).
  • Two weeks training programme (advanced).
  • Six weeks comprehensive training programme (basic & advanced).
  • Six months training programme (diploma).
  • One year training programme (fellowship/PDCC {post doctoral certificate course})

A quick update on recent developments.

  • Status at MCI & Health Ministry: At initial discussion stage.
  • Status at National Board Examinations: There is already a Diploma in Pain Management
  • Status at University level: NTR Health University of Andhra Pradesh and Banaras Hindu University have started regular courses at University level. Recently SGPGI of Lucknow has started PDCC in Pain Management
  • Status at individual institution level: Kamineni Hospital at Hyderabad has a one year fellowship in Pain Management.
  • Many institutions in the country conduct short term courses of 2 weeks to 6 months.

Thank you, that was comprehensive.
In medicine, seeking to reduce and alleviate human suffering, increase and enhance the capacity for freedom and happiness and, when necessary, to accept death with dignity and courage, still seem ideals not wholly unworthy of respect. Efforts at palliation need to confront the influences that caused the pain to be insufferable as assiduously as they confront the pain itself, if not more so. However, doctors trained in alleviating pain and suffering are only a handful. The reason – pain education and training in India till a few years ago was Nil. Nihil. Nada. Nichts. Rien. Even in developed nations, pain medicine is considered a Cinderella specialty due to neglect. Developing training programmes to match the needs of the population, however, should be like Cinderella’s glass slipper. Perfect. Specific. Ultra-refined. We are still a long way from that elusive fit.

Disclaimer: No affront to sociology students. Some young doctors in India, not all, learn their medicine as well as mannerisms, watching E.RScrubs and House. So, beware of pill-popping juniors who walk with a limp or a Malinga look alike who thought of flattering George Clooney.

Dr. Muralidhar Joshi

Post author

Director, Kamineni Pain Management Centre, Hyderabad, India

There are 5 Comments

  1. Posted by Dr.Dharamveer Reply

    sir
    Im an anaesthesiologist working in apollo hospital at present.I want to work with you and learn the art of pain medicine.please enlighten and guide me.

    • Dr Muralidhar Joshi
      Posted by Dr Muralidhar Joshi Reply

      Please wait till middle of november and then contact us, things will be more clear for the year 2015. We appreciate your interest in pain management.

  2. Posted by HABTEWOLD ASSEFU WOLDETSADIK Reply

    I am Anesthesiologist working in referral teaching hospital in Ethiopia, Addis Ababa. I am interested to join fellowship training on chronic pain management. Would you please give me more information on your training program especially for applicants out of India?
    With kind regards

  3. Dr Muralidhar Joshi
    Posted by Dr Muralidhar Joshi Reply

    Please wait till middle of november and then contact us, things will be more clear for the year 2015. We appreciate your interest in pain management.

  4. Posted by Smiral Desai Reply

    Hello sir. I am 3rd year resident in MD Anaesthesiology from gujarat and would like to join a fellowship course in chronic and cancer pain management. Would you please give me information about training course? Thank you.

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