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EDITORIAL
Year : 2018  |  Volume : 36  |  Issue : 4  |  Page : 453-457
 

IAMM recommended modification of MD microbiology curriculum to MD clinical microbiology as a speciality of medicine under consideration of MCI and Niti Ayog: Time has come to move on! Are we ready?


Department of Clinical Microbiology, Sir Ganga Ram Hospital, New Delhi, India

Date of Web Publication18-Mar-2019

Correspondence Address:
Dr. Chand Wattal
Department of Clinical Microbiology, Sir Ganga Ram Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmm.IJMM_19_69

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How to cite this article:
Wattal C. IAMM recommended modification of MD microbiology curriculum to MD clinical microbiology as a speciality of medicine under consideration of MCI and Niti Ayog: Time has come to move on! Are we ready?. Indian J Med Microbiol 2018;36:453-7

How to cite this URL:
Wattal C. IAMM recommended modification of MD microbiology curriculum to MD clinical microbiology as a speciality of medicine under consideration of MCI and Niti Ayog: Time has come to move on! Are we ready?. Indian J Med Microbiol [serial online] 2018 [cited 2019 Apr 19];36:453-7. Available from: http://www.ijmm.org/text.asp?2018/36/4/453/254410


Nelson Mandela said, quote 'Vision without action is just a dream; action without vision just waste of time and vision with action can change the world, unquote'. The speciality of Clinical Microbiology needs the vision with action.


 ~ Why This Change is Needed? Top


Infectious diseases (IDs) are a major component of current day medicine. Most of the developed countries have IDs division managed by ID physicians and clinical microbiologists. It is an irony that the country that needs it the most does not have it except a few institutes. IDs are being recognised more in modern medicine (cancer treatment, transplants, innovative surgeries and procedures, AIDS and multidrug-resistant tuberculosis). The emergence of susceptible population, advent of many new microbial species as pathogens, re-emergence of old infectious agents and antimicrobial drug resistance has made the situation more complicated. Resource-constrained and developing countries like India are trailing behind due to the lack of adequate clinical expertise associated with the training of the clinical microbiologists in various medical schools of our country. The knowledge of the diagnostics exists, but they fail to translate it into action.[1]

We have not changed in the past 40 years or so. Need to bring focus on to the contribution to the patient care as any other specialty of medicine do. This should not be a part-time job where you lock your workplaces after 2 pm till the next morning. Ours is a round the clock job remember, we are antemortem.

Ours was never a post-mortem science as pathology instead everything happens in real time.

Only if history had not failed us by combining this branch of medicine with pathology and in poorly medicine literate Indian masses including our bureaucrats the differentiation is unfortunately not perceived. Policy decisions of far-reaching consequences for diagnostic medical sciences are still handled with a single sentiment as 'PATHOLOGY Laboratories' which is misleading.

The work algorithm of clinical microbiology has changed a lot in the past few years with the arrival of automated devices, rapid and point of care (POC) tests. It has been observed that the clinical microbiology syllabus has not undergone significant patient care oriented change over the past 40 years or more. The curriculum that exists aims to provide training only in the bench work once the patient's sample is received in the laboratory. As a result, the patient is rendered to JUST A CLINICAL SAMPLE! This does not create a real-time situation in the minds of the medical microbiologists working on the bench.[1] In the absence of interaction with the treating unit and the patient the clinical correlation becomes impossible and remains limited to a few conscientious clinicians and medical microbiologists.

Although the revised curriculum does advise the inclusion of clinical rounds, case discussions, etc., no road map is laid down in it (ref: Delhi University MD Microbiology curriculum).[1],[2]

The examination style of the students appearing for MD in Microbiology desires a lot to be changed.[3] In wake of the above, it is important that we incorporate the clinical interactions more clearly in the curriculum and give a road map for the syllabus to be a clinical branch of medicine.[1] This is only possible if MCI implements it to ensure compliance.

The foremost reason for seeking change in the syllabus is that we need to pay back to the very society and the Exchequer who has spent in training us first for our MBBS and then for our M. D. Pitfalls of the current curriculum remains that with changing times information that was relevant earlier has become redundant now. This requires changing the emphasis on acquiring new skills and knowledge in place of old. The current training programme lacks continuum in clinical training, rendering a fully MBBS trained an individual with limited clinical skills at the end of the MD Microbiology training. Losing a big number of doctors to the common pool of medicos involved in delivering patient care in the background of a poor patient to doctor ratio in our country is unacceptable.

The whole course needs to be put on a clinical platform. AIIMS, an autonomous body, has taken upon itself to start DM in ID for which a candidate with MD medical Microbiology is recommended to be eligible. This change in the syllabus at MD Microbiology level will be a foundation course for one who wants to pursue ID DM subsequently.


 ~ Subject Specific Learning Objectives Top


The burden of ID in India requires an integrated approach as in the US or Europe and elsewhere in the world.[4],[5] This can be achieved by modification and advancement of the existing training module of the M. D. Microbiology curriculum for the benefit of the patients and preventive ID programmes.[6] The literature also supports that integrated team effort towards patient care has better treatment outcomes rather than different specialties doing it alone. Health-care acquired infections exist no matter how sophisticated a health-care facility might be and its control is essentially the responsibility of medical microbiologist. Various objectives of this speciality can be envisaged to make it a state-of-the-art course [Table 1].
Table 1: Objectives of MD clinical microbiology syllabus

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At the end of the training in M. D. Clinical Microbiology, the candidate should develop competence to handle the following:

  1. Discuss epidemiology, natural history, pathological abnormalities, clinical manifestations, diagnostic modalities, principles of management and prevention of a common variety of IDs affecting children and adults
  2. Make rational and relevant selection of laboratory tests with the selection of appropriate, relevant and representative specimens
  3. Perform the specified important tests in microbial immunology with a high order of precision and interpretation
  4. Develop hospital policies on antimicrobial use and hospital infection control
  5. To discuss epidemiology, detection and prevention of IDs in the community
  6. To detect and prevent nosocomial infections
  7. Discuss vaccines and immunisation programmes, emerging and re-emerging pathogens and development of multidrug-resistant organisms
  8. Have the adequate knowledge of other subspecialties
  9. Supervise and train technical staff of the laboratory and maintain QA
  10. Applied and integrated the teaching of the undergraduates in conjunction with other clinical specialties (Through Medical Education Units).


Syllabus course content as submitted to MCI

The course content needs to have the following essential components:

I. Basic principles in the pathogenesis of infectious diseases

  1. Major clinical syndromes
  2. IDs and their causative agents
  3. Immunisation
  4. Traveller's IDs
  5. Bioterrorism
  6. Clinical microbiologists and digital resource
  7. Zoonosis
  8. Microbiology as applied to public health and epidemiology.


II. Skill developments (practical)

  1. Clinical skills:


    1. History taking
    2. Physical examination and assessment of the patients with suspected IDs, Formulation of diagnostic algorithms, patient care plan. The patient may be in the outpatient department (OPD), emergency services, general or private wards, intensive care units and any other relevant specialties of the health-care facility.
    3. Clinicomicrobiological correlation with laboratory results.


  2. Laboratory skills


    1. Collection/transport of specimens
    2. Preparation, examination and interpretation of direct smears
    3. Plating of clinical specimens on media for isolation, purification, identification and quantification of pathogens
    4. Preparation of stains, namely Gram, Albert's, capsules, spores, ZN, Preparation of antibiotic discs; antimicrobial susceptibility testing. Kirby-Bauer, Stoke's method, Estimation of Minimal Inhibitory/etc……
    5. Disposal of contaminated materials including cultures Maintenance and preservation of bacterial cultures
    6. Various serological techniques used in clinical microbiology
    7. Typing methods and genetic relatedness
    8. Molecular techniques used in Microbiology: PCR, RFLP and Real-time PCR (working knowledge)
    9. CD4 and CD8 count estimation, FACS Count machine
    10. The automation system for identification and susceptibility testing for bacteria, fungal and mycobacterium pathogens (working knowledge)
    11. Investigation of an outbreak.


III. Teaching and learning methods

This training needs to be a whole time-in-service residency on the residency pattern with clinical responsibilities:

  1. Candidate need to take part in the activities of the department including bench work in the Clinical microbiology laboratory and bedside assessments and management of patients in, OPD, in-patient care units and management of emergencies in IDs
  2. Training is expected to be through lectures, interdepartmental seminars, clinical meetings, group discussions and bedside case discussions
  3. Clinical microbiology laboratory training need to be through lectures and hands-on experience in the laboratory
  4. A resident need to participate in all academic activities of the hospital
  5. Will be on call for ID consultations
  6. Will be an observer in the HICC of the hospital.


The post-graduate (PG) joining a clinical microbiology MD course needs to understand that the course thus made is going to be much more challenging than before and no longer will be a branch of medicine where you have no waits nights, calls or an OPD!

IV. Methods of teaching need to be broadly as below as followed by most of the medical specialties

Weekly Journal Clubs (Paper presentation/discussion), Seminar, Lecture/Group discussion: As per syllabus. Syndrome-based learning needs to be encouraged. Case presentation in the clinical department of posting: Before a faculty and discuss its management should be a routine feature. Residents are expected to work up one case monthly for case conference.

Radiology classes are held twice weekly in which the radiological features of various problems are discussed.

Clinico-microbiological Conference as a Combined Round/Grand Round for a complete discussion of a disease profile and its understanding need be part of the curriculum.

Emergency duties have to be the part of learning. This can be achieved by Casualty duty by rotation among the PGs with a faculty cover both broad and medical microbiology speciality.

Bedside clinical training for patient care management should happen daily for 1/2–1 h during ward round with faculty as bedside patient case discussions.

Clinical teaching

In OPD, ward rounds (in main specialties i.e., medicine/surgery/obstetrics and gynaecology/paediatrics), emergency and ICU.

Daily attendance in the department of clinical microbiology: As per posting schedule to carry bench to bedside, all positive findings need to be carried to the words and discussed with the treating units.

Thesis work is part of learning, and it lays the foundation for a research mind. Undergraduate teaching can be achieved through organising practical classes by PGs. All PGs should have attended two conferences/CMEs/Workshops in their tenure, and this need be inbuilt in the course.

Postings: Recommended schedule for 3-year training

First 4 months

Orientation programme including exposure to casualty/Emergency ward (full-time posting as recommended by MCI). Learn bedside history taking in ward, casualty and ICU. Assist in ward rounds and visits other wards with senior colleagues to attend call/consultation from other departments. Participate in the teaching sessions happening in wards during bedside clinical teaching. The present seminar/journal club and case conferences as mentioned above.

Start microbiology desk work after finishing daily rounds for hands-on experience with Clinical Microbiology and microbial immunology procedures. You are also to learn the hospital infection control practices.

To help in understanding HICC practices need to be an observer in Hospital Infection Control Committee.

Next 32 months

The resident is required to work both in the broad speciality where he/she is posted as well as in the department of clinical microbiology, participate in the patient care and academic and research activities as per the above details. Continue to be an observer in Hospital Infection Control Committee.

Clinical postings

Could be divided as below: Rotational postings in medical patient care units (14 months); surgical patient care units (6 months); high-risk areas (e.g., critical care units) (6 months); and hospital infection control and prevention activity (6 months). Thus, the total duration will be for = 32 months.

Simultaneous laboratory posting

After having finished morning rounds, the resident can start laboratory work as per their schedule below, absence due to emergency or evening postings should be accepted:

Total: 32 months – Bacteriology: 12 months; Anaerobic laboratory: 1 month; Serology: 3 months; Mycology: 3 months; Virology: 3 months; Parasitology: 3 months; Histopathology: 3 months; Molecular Microbiology: 2 months; Mycobacteriology: 2 months.

The programme incharge need to be flexible as many of the above departments may not be present in every institute (e.g., molecular, anaerobic and virology).

V. Infectious diseases beds

Bed dynamics can easily be reorganised out of the existing beds of the hospital. No additional beds are required. What is required is to only dedicate beds for clinical microbiology in various specialties as below:

A minimum of 20 beds (medicine, surgery, paediatrics and obstetrics and gynaecology) need to be mandatorily dedicated for infection-related clinical microbiology admissions in each basic speciality of medicine.

These beds need directly be under the supervision of the faculty of the respective speciality (physician/surgeon/gynaecology and obstetrics) to whom the beds belong to.

VI. Who will teach: Faculty under one roof

HOD, Clinical Microbiology department should conduct the rotations and the course and need to act as the course Director. The department has to own the responsibility of the investigative work of the patients admitted under the category of infections or fever occupying clinical microbiology beds within the respective speciality. To begin with clinical microbiology may not have the admission rights but this can be visited in due course of time as the specialty matures.

The whole faculty of the department of clinical microbiology should be on the roster prepared by the course Director for the clinical services, on a turn-key basis.

Adjunct faculty

HODs of Clinical departments (medicine, surgery, gynaecology/obstetrics and paediatrics) where the resident is posted should be the nodal person who will function in tandem with the clinical microbiology department to provide clinical services to the allocated 20 infection-related beds. The whole faculty of the concerned departments should be involved on a rotational basis.

Visiting faculty

Eminent national and international faculty can be invited for guest lectures both didactic or bedside training. However, this faculty should not be considered as part of the minimum strength required for running the course. This faculty will be over and above the minimum requirement of the faculty.

VII. How the pg can be assessed on this knowledge and skill?

Summative assessment

The PG examination shall be in three parts; Thesis, Theory and Practical.

Theory

There should be four theory papers: Paper I: General Microbiology and Microbial Immunology; Paper II: Bacteriology and Mycology (Syndrome and investigation based); Paper II”: Virology and Parasitology (Syndrome and investigation based); Paper– IV: Applied Microbiology and Recent advances.

It is recommended that the candidate should independently pass in the theory examination to be eligible to appear in the practical examination.

Practical

Clinical ID related one long case: History taking, physical examination, interpretation of clinical findings, radiology, differential diagnosis, microbiology investigations and perform the same in the clinical microbiology laboratory, interpret the results and suggest treatment and prognosis.

Microbiology laboratory based

Identify a pure microbial culture till species level and perform antibiotic sensitivity testing.

ID-related Short cases from various sections of the speciality with POC testing/rapid testing can be performed.

Spots clinical microbiology related with microscopic slides/cultures/tissue cultures from virology, mycology, entomology and parasitology would be explored.

Viva-voce Examination

The following components of medicine need to be evaluated:

  1. Basic microbiology and epidemiology
  2. Radiology: Clinical problems for interpretation
  3. Etiopathogenesis
  4. Recent advances
  5. Emerging and re-emerging infections
  6. Component of presentation of a thesis done by the student.


Since the above programme is conceived for the first time, subsequent learning should guide further modifications but not before the first batch has gone for final exams after completion of 3 years.

VIII. What has iamm done since 2015 in this direction

Submitted to MCI, a document explaining competency-based PG programme for award of MD in clinical microbiology dated 23rd july 2015.

A delegation of our office bearers gave a representation to the President MCI on 21st April 2015. Subsequently, on 21st April 2015, we had our meeting with Dr. V. P. Mishra, then Chairman, Academics, Medical Council of India and after having interacted with him the modified curriculum leading to MD Clinical Microbiology as a specialty of Medicine was submitted to him on 23rd July 2015.

The society in its annual general body meeting held on 28th November 2015, at Puducherry endorsed with majority the recommended modifications to the MD Clinical Microbiology curriculum. The consensus syllabus was made with the help of stalwarts in the specialty of Medical Microbiology across the country and around 7 months were spent in finalising this document in track changes over the internet. Reminders were sent to all the office bearers of MCI as well the overriding committee for MCI headed by Prof. Sareen, Director, ILBS, New Delhi, India. Moreover, lately, we were happy to give the representation with a copy of the syllabus containing above details to Prof. Vinod Paul President BoG MCI and member Niti Ayog at the recently concluded national congress at Bengaluru on 27th November 2018, who has promised us action. Finally, the full 45-page document can be accessed from our website www.iamm.com.



 
 ~ References Top

1.
Bhattacharya S. Laboratory microbiology to clinical microbiology: Are we ready for a transition? Indian J Med Microbiol 2009;27:97-9.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Rao RS, Lalitha MK, Narang P. Curriculum designing for post graduates in medical microbiology. Indian J Med Microbiol 1999;17:116-24.  Back to cited text no. 2
    
3.
Kanungo R. Microbiology curriculum for MBBS: Is there a need for change? Indian J Med Microbiol 2003;21:5.  Back to cited text no. 3
    
4.
The Royal College of Pathologist. Curriculum for Specialty Training in Medical Microbiology and Virology. The Royal College of Pathologist; January, 2007.  Back to cited text no. 4
    
5.
The Royal College of Pathologist. Specimen Job Description: Consultant Medical Microbiologist. The Royal College of Pathologist; April, 2005.  Back to cited text no. 5
    
6.
Bhattacharya S. ESBL – From petri dish to the patient. Indian J Med Microbiol 2006;24:20-4.  Back to cited text no. 6
[PUBMED]  [Full text]  



 
 
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