Emergency medicine in India has advanced substantially from its nascent origins and continues to expand at an exponential pace.
The country’s healthcare community has recognized the need for quality emergency care as the number of citizens affected by motor vehicle accidents, communicable and non-communicable diseases, and natural disasters continues to grow.
The Society for Emergency Medicine in India (SEMI) was established in 1999, and EM was recognized as a specialty by the Medical Council of India by 2009. Decision makers acted quickly to recognize the importance of training quality emergency physicians and enhancing patient care across the country.
Around the world, emergency departments have served as the face of the hospital, but lower middle-income countries have been slow to adopt this model until recently. Previously, EDs in India would be staffed by junior medical doctors who were limited in their emergency care due to low resources, limited clinical training, and poor administration. Many hospitals believed there was no need for an around-the-clock service, but soon realized the importance of prompt and good quality emergency care.
India loses more than 3% of its gross domestic product due to traffic accidents.1 With the dramatic increase in traffic accidents across the country, healthcare providers have highlighted the damaging impact poor emergency care can have on the economy.
We were fortunate to interview Dr. Arun Nandi, associate professor of emergency medicine at the Icahn School of Medicine at Mount Sinai Hospital in New York City. Dr. Nandi serves as ACEP’s ambassador to India, Nepal, and Sri Lanka.
Discussing the differences between the Indian and U.S. populations, Dr. Nandi noted that patients presenting to the ED in the Indian subcontinent often present at the late stages of their illnesses. Few patients visit doctors for primary care. Patients, therefore, present late and with greater severity and pose a challenge for resource-limited doctors. Timely and standardized emergency care in India is essential to improve health outcomes and economic well-being. Emergency medical services across the country vary from state to state with no centralized system, further complicated by terrain, weather, and geopolitical conflict.
India’s EM infrastructure was limited in its early development partly because stakeholders believed illnesses could be better treated by specialists than emergency physicians. However, research showed the effectiveness of EM interventions that expedited care and improved outcomes of time-sensitive conditions like trauma, stroke, and myocardial infarction.
Medical infrastructure is a large determinant in the standard of care delivered and, while India has advanced significantly in the past two decades, there is much left to learn. To improve patient outcomes and the quality of emergency care, India needs to focus on three aspects: education, delivery of care, and research.
Regarding education, administrators must emphasize the development of standardized training for emergency physicians, with ample opportunities for employment and promotion, including simulation-based and experiential learning.
For proper delivery of care, EDs must be given adequate space within the hospital for triage, diagnosis, and transfer of care.
Lastly, research into health outcomes and quality improvement is needed to enhance patient care through continuous quality improvement, especially for common ED presentations such as stroke, MI, toxicologic emergencies, and polytrauma.
We also interviewed Dr. Sushant Chhabra, ACEP’s ambassador liaison from India, chief of emergency medicine at Manipal Hospital, New Delhi, and a regional leader of SEMI.
When asked about the EM training programs in India, Dr. Chhabra said they are carried out under different banners. The MD (postgraduate degree) and DNB (Diplomate of National Board) postgraduate programs host EM across a few hospitals in India, but the number of positions for trainees is insufficient.
Then, there are 3-year training programs like the Masters in Emergency Medicine (MEM), an international program affiliated with George Washington University. This is a structured program with equal weight for academics, clinical skills, and research. EM faculty from the United States, United Kingdom, Australia, Singapore, and India train residents to grow into qualified emergency physicians.
A similar program called CCT-EM (certificate of completion of training in emergency medicine) has been implemented by SEMI.
In addition to these major 3-year programs, there are minor 1- to 2-year diplomas and fellowships in EM awarded by local universities like Medvarsity Apollo.
Since Dr. Chhabra’s EM residency in 2011, there has been a significant expansion in training programs. This expansion came about as healthcare systems began to recognize the importance of EM in hospital operations and revenue. However, Dr. Chhabra believes extensive progress — which includes gaining governmental support to establish the emergency department as the “face” of the hospital across the Indian subcontinent — has yet to be made. The biggest challenge is a lack of EM-trained faculty. Hence, within some courses there is “self-learning,” or teaching by a specialist who isn’t an emergency physician. In his research paper, Dr. Chhabra conducted a survey of the perception of medical education among EM residents in India and concluded that programs must adopt a “student-centered educational atmosphere” that will ultimately lead to well-trained emergency physicians tending to the population of India.2
When discussing the impact of the COVID-19 pandemic, Dr. Chhabra described it as a double-edged sword that enabled emergency physicians to attend important medical conferences virtually, but also deprived them of the “hands-on” experience pivotal for their residencies. Furthermore, in India — just like in many other nations — the COVID-19 pandemic exposed weak points in the healthcare system, overwhelming the country’s doctors and hospitals. Limited access to primary care facilities caused patients with milder COVID cases to occupy beds at hospitals when many of them could have managed their symptoms in an outpatient setting. Challenges with organization, logistics, and disaster management complicated this public health emergency and showcased the scarcity of resources. Dr. Chhabra believes that by improving facets of the country’s fundamental healthcare infrastructure, from disaster management to primary care, patient outcomes will improve as a whole.
Our conversations with Drs. Nandi and Chhabra were enlightening and informative. We learned about the great advances in emergency care across the Indian subcontinent and potential ways that its delivery could be improved. Global health leaders should note the resourcefulness and adaptability of India’s emergency physicians in treating severe, end-stage diseases at their first presentations in the ED, similar to situations in many marginalized areas within the United States. However, further progress must be made in EM research, care delivery, and future-physician training to optimize patient health outcomes in India.
References
- Mohan D. Traffic Injuries and Fatalities in India. Transportation Research & Injury Prevention Programme, Indian Institute of Technology Delhi. 2004.
- Chhabra S, Misra A, Shah S, Kole T. Survey of student perception of medical education environment among emergency medicine residents of an academic medical center in Northern India. International Journal of Emergency Medicine. 2016;9(1):1-5.