Medical Education

Undergraduate training in ENT Head

and Neck Surgery In Nepal : Is there
any uniformity?

R Guragain
R Bhatta
Ganesh Man Singh Memorial Academy
of ENT and Head and Neck Studies,
TU Teaching Hospital,
Kathmandu, Nepal
Correspondence to
Dr. Rishi Bhatta
Ganesh Man Singh Memorial
Academy of ENT and Head and Neck
Studies, TU Teaching Hospital,
Kathmandu, Nepal.
Email: rishi_31@yahoo.com

AIMS AND OBJECTIVES:

To compare the ENT-Head and Neck Surgery training program of MBBS students of different universities
and institutions of Nepal and India.

MATERIALS AND METHODS:

A descriptive cross-sectional study was conducted in the form of rolling audit in Ganesh Man Singh memorial
Academy of ENT Head and Neck Studies, Kathmandu, Nepal. The undergraduate (MBBS) curriculum of
Institute of Medicine (I.O.M), Tribhuwan University (T.U.)., Kathmandu University (K.U.)., BP Koirala Institute
of Health Sciences(BPKIHS), All India Institute of Medical Science(AIIMS) and other medical colleges
under Medical Council of India(MCI) were studied and compared.
RESULTS:
Practical exposure was more in TU training where as more time (almost 50%) were devoted in theory
lectures in KU.curruculum. Logbook maintenance and internal examinations were lacking in most universities.
ENT training was optional during internship in KU, BPKIHS and AIIMS.
CONCLUSIONS AND RECOMMENDATIONS:
As there was no uniformity in the undergraduate training in ENT Head and Neck Surgery in Nepal, the
concerned institutions like Nepal Medical Council and Society of Otolaryngologists of Nepal should take
an initiative to make the training uniform which will help to control the quality of ENT Head and Neck
Surgery practices in this country.
Keywords: MBBS curriculum, Tribhuwan University (T.U.), Kathmandu University (K.U.), BP Koirala
Institute of Health Science (BPKIHS), All India Institute of Medical Science (AIIMS), NMC (Nepal Medical
Council)

INTRODUCTION:
Quality control in medical education in Nepal is one of the hot
topic nowadays, mainly because of mushrooming up of medical
colleges in the private sector.This matter is also relevant because
of Nepalese students being graduating abroad and practicing
medicine in Nepal afterwards. During the last decade there has
been tremendous increase in the opening up of new medical
colleges and also the Nepalese students going abroad for training
in medicine.There are at present four universities in Nepal.
Tribhuvan university and Nepal Sanskrit Universities are the
older one while Kathmandu University and the Purbanchal
University are the newer ones. However, only two of them
Tribhuvan and Kathmandu universities affiliate for medical
training to six medical colleges each. Besides these, there are
three autonous institution in the country which provide medical
education BPKIHS in eastern Nepal and NAMS Bir Hospital (only
postgraduate training) and Patan University of Health Sciences
in the Kathmandu very. Every year increasig number of medical
graduates are registered in the Nepal Medical Council, who were
trained other than above mentioned universities or institutes.
This number is even expected to increase in years to come.
Looking at the diversity of training institutes, the quality of
training in ENT Head and Neck Surgery like in other specialities
is a matter of concern. This article compares the training among
different institutes of Nepal and also to that of India wihich is
supposed to be gold standard in this region.
M AT E R I A L S A N D M E T H O D S
A descriptive cross-sectional study was conducted in the form
of rolling audit in Ganesh Man Singh Memorial Academy of ENT
Head and Neck Studies. MBBS training in ENT Head and Neck
Surgery was studied in detail regarding theory and the practical
classes, duration, subdivision of the group, exposure to OPD,
OT, bedside teaching, audiology, speech therapy and lecture

Society of Otorhinolaryngologists of Nepal (SOL Nepal)

topics and examination system. New syllabus recommended by

ENT/HNS department of IOM was also studied.1 Similarly,the
syllabus of Kathmandu university (2006) 2 and BPKIHS,
Dharan ,Nepal (1996)3 in MBBS ENT training were studied.
Current schedules of undergraduate training at AIIMS (2005)4
and other medical colleges of India under MCI (1997) were
obtained from their web sites and was compared to the training
in Nepal.
The following aspects were compared :
1) Aims and Objectives of undergraduate program in ENT and
Head and Neck Surgery
2) Duration of Course
3) Knowledge
a. Theory classes(lectures)-topics covered
b. Seminars by students themselves
c. Tutorials and problem based learning
4) Skills
a. Ward Clinical Teaching( history taking/ clinical examination)
b. OT exposure(instruments/procedures)
c. Emergency management
5) Teachers: Students Ratio/ Bed :Students ratio
6) Evaluation
a. Logbook
b. Examination System
R E S U LT S :
The first objective of all institutions studied was to learn basic
principles and practice of ENT followed by curative and
management of patients and then Preventive aspects. AIIMS also
focused on performing minor surgical procedures. New syllabus
of IOM aims an appropriate and timely referral to experts.
Durations allocated for theory and practical classes are given
in table1 which shows less theory classes in T.U., and BPKIHS.
Regarding time for clinical teaching it is highest in T.U. with

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Guragain et al: Teaching Learning Activities

least in BPKIHS.Current syllabus of T.U. lacks theory lectures on

Head and Neck lesions grossly, but this will be fulfilled in
upcoming syllabus. Besides that, principles of Functional
Endoscopic Sinus Surgery (FESS) will be included. Head and Neck
malignancies are still not given importance in curriculum of K.U.
and BPKIHS. AIIMS has focused on principles of common surgeries
like myringoplasty, septoplasty, tympanoplasty in its curriculum.
Seminar by MBBS has only been mentioned in BPKIHS curriculum
and not even in curriculum of Indian medical colleges. This part
will be covered in upcoming syllabus of T.U. Problem based
learning (PBL) though is being implemented in basic science of
K.U. Medical School (KUMS); it has not been started in ENT/HNS.
Clinical teaching focuses on history taking and methods of
examination. Commonly used ENT instruments and procedures
are taught along with X rays, models and specimens. This part
is basically similar in different universities but in upcoming
syllabus of T.U. operative procedures, endoscopy and ENT
emergencies wii also covered. As per Nepal Medical Council
(NMC) guideline5 there should be 7 beds per student of a batch
and 25/700 beds should be for ENT. This is fulfilled by IOM and
BPKIHS only. Similarly 6 teachers for 100 students per batch
should be there which is fulfilled by IOM, BPKIHS , and some
medical colleges of K.U.Evaluation of students has been mentioned
to be done by log book in curriculum of T.U. and MCI. Interval
Examinations is being taken by K.U. and AIIMS but was left to
individual medical colleges of India by MCI. As per table 2

Examination system in T.U., K.U., and medical colleges under

MCI have maximum marks for final exams. AIIMS emphasized
more in formative or internal exams. In BPKIHS curriculum there
is no seperate ENT paper but it is a part of General Surgery and
allied science. It is not necessary to pass ENT section
seperatelywhere even though you fail individually in ENT but
has done good in other subjects of Surgery there is chance to
pass. Internship is elective in K.U., AIIMS, BPKIHS where student
can choose other posting instead of ENT. But in T.U. and other
medical colleges of India under MCI it is compulsory for 2 weeks.
In T.U. at least 2 night duties should be done in 2 weeks. The
procedures to be done in internship are given in table 3.

28

Society of Otorhinolaryngologists of Nepal (SOL Nepal)

DISCUSSION
Although the complexities of medical care are increasing, the
methods of teaching medicine have changed little.6 Even in
developed countries curriculum regarding ENT is not as per need
for medical graduate. ENT has been removed from the curriculum
of nine of the 29 medical schools in the United Kingdom, as it
was not deemed relevant to general medical practice. But in
a survey done by Sharma et al in 2006 showed , 90 per cent felt
their undergraduate ENT teaching was directly beneficial to
working in Accidents & Emergency department, 75 per cent felt
they had not received enough undergraduate ENT teaching.7
Nepal has seen a dramatic increase in the number of medical
schools/colleges in the last decade. It is important to explore
the current advances and practices in medical education to
meet the needs of the health services of the country.8 Teaching
learning activities in most of medical colleges of Nepal is by
traditional approach. Dhungel et al in their survey over medical
students found that only 5.0% use to surf the internet regularly
for their study matter and 79.0% students had never consulted
any medical journals.9 Though strong need to standardize the
entrance selection procedure of MBBS is being felt,10,11 but
curriculum standardization is immediate requirement. Regular
evaluation of curriculum and syllabus of ENT-HNS during MBBS
is must as it is fast growing field and a large proportion of
population is being affected by ENT diseases. Most of Nepal
Medical Council registered doctors are being trained in Nepal
itself, so improving the standard of syllabus, improves quality
of health care delivery system.Training Programme in ENT HNS
in almost all institution has prime aim of providing basic principles
and practice of ENT followed by curative and then preventive
aspect. But in AIIMS curriculum of performing surgical procedures
has also been targeted.Current syllabus of T.U. has less time
allocated for theory lectures almost half of what K.U, has. But
topics covered as almost same. Practical classes are given more
time in T.U. and least in K.U. Weeks allocated for ward posting
is almost half of Indian Institution.But overall time allocated is
almost same in different institution. In theory lectures T.U.
curriculum involves base of skull and orbit which is not so much
important during undergraduate training period but it lacks
Head and Neck malignancies in their curriculum, which is
nowadays rapidly growing up. Curriculum in AIIMS in addition
has focused on principles of common surgeries which are again
not much related to undergraduate as the surgeries like
myringoplasty, septoplasty, tympanoplasty need not to be dealt
at periphery and can be referred at appropriate centers.
Undergraduate training should help a doctor to differentiate

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Guragain et al: Teaching Learning Activities

emergency from non emergency cases, and timely referral and

appropriate management of common and immediate attention
requiring conditions. Seminars by students is being mentioned
in curriculum of BPKIHS only. PBL though being done in basics
sciences of KUMS curriculum is not been started in clinical
subjects as ENT-HNS.Time allocated for ward postings in T.U.
though seems to be highest but is not practically feasible and
according to medical college it differs slightly. NMC guidelines
of bed per student though may be fulfilled by college in totality
but in practice for ENT it is not being followed in some medical
colleges. Similar is the scenario of teacher per student. Log
book during posting is mentioned In IOM Curriculum and not in
other medical colleges and not even in that of India.
Internal examination being taken in AIIMS is not being incorporated
in T.U., BPKIHS. But K.U. curriculum has end semester exams
for evaluation of students. During examination AIIMS more focuses
in internal assessment, while BPKIHS takes exams under surgery
paper and separately passing in ENT/HNS is not required. In that
Perspective T.U., K.U. curriculum is better. Internship is optional
in K.U., AIIMS, and BPKIHS. It is not needed to do in ENT if one
has done internship in other specialty like Psychiatry. But ENT
disease burden in community is so much that a graduate must
have idea of managing the common problem under supervision
which can be done during internship. This part if only is changed
and is done as of other medical colleges of India and T.U. then
confidence of medical officer to manage ENT condition is quite
good.
C O N C L U S I O N A N D R E C O M M E N D AT I O N :
Time allocated for theory lectures in T.U. and ward posting in
K.U. is less compared to other universities and need of focusing
on head and neck lesion is must. Regular examinations and

Society of Otorhinolaryngologists of Nepal (SOL Nepal)

making internship a compulsory posting should be done. Timely

and frequent re-evaluation of curriculum to make it time
appropriate is recommended.
1. Bachelor Of Medicine and Bachelor of Surgery(MBBS)Curriculum
Maharajgunj campus, IOM, 1994
2. Curriculum for Bachelor Of Medicine and Bachelor of
Surgery(MBBS)part two, clinical sciences, Kathmandu
University, Dhulikhel, Kavre,2006
3. Curriculum for MBBS, BPK Institute of Health Science, Aug
2007
4. Syllabus MBBS at the AIIMS, All India Institute of Medical
Sciences, 2nd Ed, July 2005
5. Nepal Medical Council Guidelines, 1997. NMC, Kathmandu.
6. Nandi PL, Chan JN, Chan CP, et al, Undergraduate medical
education: comparison of problem-based learning and
conventional teaching HKMJ 2000;6:301-6
7. Sharma A, Machen K, Clarke B, et al. Is undergraduate
otorhinolaryngology teaching relevant to junior doctors
working in accident and emergency departments? J Laryngol
Otol. 2006;120(11):949-51.
8. Marahatta SB, Dixit H. Students' perception regarding medical
education in Nepal. Kathmandu Univ Med J (KUMJ).
2008;6(2):273-83.
9. Dhungel KU, Prajapati R, Pramanik T, et al. Study habits and
attitude of medical students of basic sciences. Nepal Med
Coll J. 2007;9(2):129-31
10. Niraula SR, Khanal SS. Critical analysis of performance of
medical students. Educ Health (Abingdon). 2006;19(1):5-13.
11. Sharma SC, Maharjan S. Entry knowledge and situational
feedback of MBBS students. Kathmandu Univ Med J (KUMJ).
2005;3(4):442-8.

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