GUIDELINES FOR COMPETENCY BASED POST

GRADUATE TRAINING PROGRAMME FOR MD IN

TROPICAL MEDICINE

Preamble

The purpose of PG education is to create specialists who would provide high quality
health care and advance the cause of science through research & training.

The Tropical Medicine programme is designed to provide the nation with specialist who
are trained to address unique needs of patients in tropical environments that may not be
emphasized in conventional/ traditional medicine training programs. MD (Tropical
Medicine) will provide the ideal opportunity to tune the objectives of the post graduate
level training in internal medicine to the health care needs of the nation.

The purpose of this document is to provide teachers and learners illustrative guidelines to
achieve defined outcomes through learning and assessment. This document was prepared
by various subject-content specialists. The Reconciliation Board of the Academic
Committee has attempted to render uniformity without compromise to purpose and
content of the document. Compromise in purity of syntax has been made in order to
preserve the purpose and content. This has necessitated retention of “domains of
learning” under the heading “competencies”.

SUBJECT SPECIFIC OBJECTIVES

The goal of the programme is to produce a physician who is well-informed of the health
care needs of tropical countries with special reference to the Indian subcontinent. It
would train and equip him/her with knowledge and skills necessary to address these
health care needs by efficiently utilising the available resources. The student should also
be able to identify priority areas of health care needs and apply the scientific method to
find feasible, relevant, and cost-effective solutions to meet these health care needs.

For a physician who wishes to engage in clinical practice, this programme will offer a
balanced training in all aspects of the health care needs of a whole family, not just
individuals in certain age-groups. In short, this programme would be an integrated,
comprehensive yet context-specific, utility-based, post graduate level training in modern
medicine.

SUBJECT SPECIFIC COMPETENCIES

By the end of the course, the student should have acquired knowledge (cognitive
domain), professionalism (affective domain) and skills (psychomotor domain) as
given below:

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A. Cognitive Domain
At the completion of training, a post graduate in Tropical Medicine must be able to:

1. Independently practice clinical tropical medicine, i.e. to approach and solve

clinical problems, diagnose, and appropriately treat various tropical diseases
2. Appropriately manage common medical (non-communicable diseases included),
maternal and childhood health problems prevalent in tropical settings
3. Offer advice on tropical diseases to specialists in other fields and liaise with them
in the care of patients
4. Identify areas of health care need and apply the scientific principles to
find/suggest solutions
5. Should be able to advise international travelers on prevention of locally prevalent
diseases
6. Teach tropical medicine to undergraduate and post graduate students

B. Affective Domain:

1. Should be able to function as a part of a team, develop an attitude of

cooperation with colleagues, and interact with the patient and the clinician or
other colleagues to provide the best possible diagnosis or opinion.
2. Always adopt ethical principles and maintain proper etiquette in dealings with
patients, relatives and other health personnel and to respect the rights of the
patient including the right to information and second opinion.
3. Develop communication skills to word reports and professional opinion as
well as to interact with patients, relatives, peers and paramedical staff, and for
effective teaching.

C. Psychomotor domain
At the end of the course, the student should acquire following clinical skills and be
able to:

 elicit the relevant clinical history from patients in a coherent and logical manner
and perform a complete physical examination of all organ systems.
 interpret the symptoms/physical signs in pathological terms and chalk out the
possible course of action such as relevant laboratory investigations and treatment.
 interpret the laboratory findings in the context of the patient’s illness.
 appropriately manage the disease condition including drug treatment and its side
effects.

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 At the completion of training, the student should be capable of independent clinical
practice in tropical medicine and in managing medical emergencies independently by
acquiring the following practical skills:

 Cardio-pulmonary resuscitation including advanced cardiac life support and

endotracheal intubation
 Diagnostic and therapeutic thoracocentesis, abdominal paracentesis
 Lumbar puncture
 Cell count on body fluids such as cerebrospinal, pleural, and peritoneal fluid
 Bone marrow aspiration, trephine bone biopsy
 Fine-needle aspiration of lymph node
 Short-term peritoneal dialysis
 Arterial puncture, central venous cannulation, peripheral venous cannulation
 Nasogastric tube placement
 Indwelling urinary catheter placement
 Interpretation of chest radiographs, electrocardiographs, arterial blood gas
analysis
 Funduscopy

The student should have acquired:

 Laboratory skills - sputum AFB staining, stool concentration and microscopy for
parasites, identification of haemoparasites, bacterial cultures, basic laboratory
techniques such as ELISA, PCR

 Computer skills

Syllabus
Course contents:
1. Environmental disorders
Heat stress and heat stroke, hypothermia, high-altitude illness, podoconiosis, adverse
health consequences of tobacco (smoked and smokeless), air-pollution, indoor air-
pollution, occupational lung diseases, health consequences of large-scale natural
disasters such as famines, floods, tsunami, earthquakes, land slides, forest fires, etc;
health impacts of global warming

2. Nutritional disorders
Assessment of nutritional status, malnutrition, protein-energy malnutrition, specific
nutrient deficiencies - iron, vitamin A, vitamin D, vitamin C, beri beri, pellagra,
micronutrient deficiencies, alcoholism, endemic hypothyroidism, nutritional anaemia.

3. Infectious diseases

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3a. Viral infections

Acute and chronic viral hepatitis, arboviral infections, dengue fever and dengue
haemorrhagic fever, chikungunya, varicella, measles, mumps, rubella, viral
haemorrhagic fevers, Epstein-Barr virus infection, rabies, viral gastroenteritis, viral
respiratory infections, cutaneous viral infections - molluscum contagiosum, viral
warts, hand-foot-mouth disease, viral infections of the central nervous system,
poliomyelitis, HIV/AIDS, HIV-related opportunistic conditions; National AIDS
Control Programme, NACO guidelines on management of HIV/AIDS

3b. Rickettsial infections

3c. Bacterial infections

Acute diarrhoeal illness, cholera, typhoid and paratyphoid, non-typhoidal Salmonella

infections, shigellosis, pneumococcal infections, impetigo, erysipelas, acute bacterial
meningitis, meningococcal infections, pulmonary and extrapulmonary tuberculosis,
non-tuberculous mycobacterial diseases, leprosy, anthrax, brucellosis, tetanus,
diphtheria, plague, melioidosis, gonorrhoea, syphilis and other sexually transmitted
infections, endemic treponematoses, leptospirosis, sepsis, infective endocarditis,
tropical pyomyositis, urinary tract infections, otitis media, cerebral abscess, trachoma.

3d. Fungal infections

Superficial fungal infections, candidiasis, mycetoma, systemic fungal infections

including histoplasmisis and penicilliosis, Pneumocysits jiroveci infection.

3e. Protozoan infections

Malaria, hyperreactive malarial splenomegaly, African trypanosomiasis, American
typanosomiasis, leishmaniasis, toxoplasmosis, amoebiasis, amoebic liver abscess,
giardiasis, pathogenic free-living amoeba, trichomoniasis.

3f. Helminthic infections

Soil-transmitted helminths, filariasis, onchocerciasis, hydatidosis, cysticercosis,

schistosomiasis, food-borne trematodes.

3g. Ectoparasites

Pediculosis, scabies, myiasis, arthropod dermatoses, insect stings, bites, allergies.

3h. Miscellaneous

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 Vaccinations - childhood and adults, advice to international travelers.

4. Tropics-specific organ-limited diseases

Acute rheumatic fever, rheumatic heart disease, endomycocardial fibrosis, tropical
pulmonary eosinophilia, parasitic pulmonary diseases, tropical pancreatitis, tropical
sprue, haemoglobinopathies, G6PD-deficiency.

5. Poisoning
General management of the poisoned patient, toxidromes, organophosphorus
poisoning, organocarbamate/chlorine poisoning, aluminium phosphide poisoning,
copper sulphate poisoning, heavy metal poisoning - lead, arsenic, thallium, and
mercury, inhalant substance abuse and corrosive ingestion, snake bite and snake
envenomation, animal bites, scorpion stings, yellow oleander poisoning, mushroom
poisoning, other plant poisons, lathyrism, aflatoxin, epidemic dropsy, fluorosis.

6. Internal medicine
Epilepsy, Guillain-Barre syndrome, Alzheimer’s dementia, Parkinson’s disease,
osteoarthritis, infectious arthritis, reactive arthritis, fibromyalgia, somatoform
disorders, depression, anxiety disorder, peptic ulcer disease, irritable bowel
syndrome, acute intestinal obstruction, bronchial asthma, chronic obstructive
pulmonary disease, bronchiectasis, lung abscess, pleural effusion, empyema,
congestive heart failure, pericardial effusion, acid-base and electrolyte disorders,
management of acute/chronic renal failure, skin manifestations of internal disease,
adverse drug reactions, principles of transfusion therapy and transfusion-related
complications, approach to fever of unknown origin, diagnostic evaluation of
anaemia, diabetes mellitus, hypertension, coronary artery disease, cerebrovascular
disease, low-cost management and prevention of non-communicable diseases, cancers
prevalent in tropical settings.

7. Medical emergencies
Severe dehydration, acute myocardial infarction, malignant hypertension, acute
stroke, status epilepticus, acute severe asthma, pneumothorax, hypoglycaemia,
diabeteic ketoacidosis, acute pancreatitis, approach to an unresponsive patient, heat
stroke, septic shock and severe sepsis, oxygen therapy.

8. Child health
Pattern of morbidity and mortality in children, management of common childhood
illnesses such as acute respiratory infections, pneumonia, gastroenteritis, dehydration,
tuberculosis in children, exapanded immunization programme, Vitamin A
prophylaxis, IDD control programme; common dietary sources, assessment of
nutritional status based on history and physical examination, protein energy

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 malnutrition - identification, classification; causes and management including
complications, planning diet for protein-energy malnutrition; breastfeeding; vitamin
deficiency disorders.

9. Maternal health
Antenatal care, immunisation against tetanus, abortion, septic abortion, hyperemesis
gravidarum, conduct of labour, complications of labour, postpartum haemorrhage,
injuries to the lower genital tract, foetal distress and foetal death, pregnancy induced
hypertension, eclampsia, complications of eclampsia; anaemia in pregnancy, other
medical disorders like heart disease/ diabetes mellitus and urinary tract infection, liver
diseases in pregnancy, care of newborn, common problems in the new born, Medical
Termination of Pregnancy, contraception.

10. Public health

Applied epidemiology of infectious diseases (tuberculosis, HIV/AIDS, malaria,
typhoid fever, dengue, hookworm infestation, filariasis, Japanese B encephalitis,
chikungunya, leptospirosis, leprosy), non-communicable diseases (obesity,
hypertension, cardiovascular disease), environmental diseases (arsenic, lathyrism,
aflatoxin), occupational diseases, poisoning, and nutritional disorders in developing
countries, “Disease Control Priorities in Developing Countries”, micro- and macro-
economics of health, social determinants of health, poverty and disparity in heath
care, concepts of environmental engineering, health policy making and cost-
effectiveness issues, national disease control programmes in India; preventive tropical
medicine.

11. Clinical epidemiology and research methodology

11a. Study designs

Observational vs. interventional studies, cross-sectional vs. longitudinal, case-control,

cohort studies, randomised controlled trials

11b. Methodology

Sample size estimation, sampling and measurement errors, sampling strategies, bias,
confounding, interaction, clinical trials - random allocation, blinding, allocation
concealment, parallel vs. cross-over design, factorial design.

11c. Basics of medical statistics

Types of data, descriptive statistics, confidence intervals, bivariate analysis -
categorical vs. continuous, categorical vs. categorical, continuous vs. continuous,
concepts of multivariable analysis, absolute risk reduction, numbers needed to
treat/harm, statistical vs. clinical significance, association vs. causation.

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11d. Introduction to systematic reviews and meta-analysis

What is a systematic review/meta-analysis? How to perform a systematic review?

Pros and cons of meta-analyses.

11e. Evidence-based medicine (EBM)

What is EBM? Formulating the question - PICO format, searching for evidence,
critical appraisal of evidence, and evidence synthesis.

TEACHING AND LEARNING METHODS

Postgraduate teaching programme

General principles
Acquisition of practical competencies being the keystone of PG medical education, PG
training should be skills oriented. Learning in PG program should be essentially self-
directed and primarily emanating from clinical and academic work. The formal sessions
are merely meant to supplement this core effort.

Teaching methodology
This should include regular bedside case presentations and demonstrations, didactic
lectures, seminars, journal clubs, clinical meetings, and combined conferences with allied
departments. The post graduate student should be given the responsibility of managing
and caring for patients in a gradual manner under supervision. Department should
encourage e-learning activities.

In addition to bedside teaching rounds, at least 5-hr of formal teaching per week is
necessary. Other requisites are:

• Additional sessions on resuscitation, basic sciences, biostatistics, research

methodology, teaching methodology, hospital waste management, health
economics, medical ethics and legal issues related to medical practice are
suggested.
• There should be a training program on Research methodology for existing faculty
to build capacity to guide research.
• The postgraduate students shall be required to participate in the teaching and
training programme of undergraduate students and interns.
• A postgraduate student of a postgraduate degree course in broad specialities/super
specialities would be required to present one poster presentation, to read one
paper at a national/state conference and to present one research paper which
should be published/accepted for publication/sent for publication during the

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 period of his postgraduate studies so as to make him eligible to appear at the
postgraduate degree examination.
• Log book: During the training period, the post graduate student should maintain a
Log Book indicating the duration of the postings/work done in Wards, OPDs and
Casualty. This should indicate the procedures assisted and performed, and the
teaching sessions attended. The Log book shall be checked and assessed
periodically by the faculty members imparting the training.
• Department should encourage e-learning activities.

Due to the multidisciplinary nature of the programme and the lack of established
Tropical Medicine departments in most medical colleges, it is imperative that an
Academic Committee of all involved departments be formed with one key faculty
from each of these departments identified and vested with the responsibility of
coordination. However, the overall administrative control should be with the
Department of Internal Medicine, in the absence of an established Department of
Tropical Medicine.

Rotations:
The total duration of training is 36 months. The first 6 months should be spent in
Internal Medicine learning general principles of internal medicine and clinical
medicine.
Rotations should include clinical training as given below:
 01 month in Paediatrics
 01 month in Obstetrics
 at least 01, preferably 02, active externships (active clinical duties, not mere
observership) of at least 01 month, preferably 02 months, each
 02 months in a primary care set-up (primary health centre)
 02 months in emergency medical services
 02 months in Cardiology
 02 months in Neurology
 01 month in Nephrology
 01 month in Endocrinology/diabetes care
 01 month in Gastroenterology
 03 months of laboratory work in general Microbiology, parasitology, and
virology laboratory; remaining time should be spent in Internal Medicine.

At least 30 hours of instruction in clinical epidemiology/research methodology is

required.

Thesis

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All MD (Tropical Medicine) post graduate students should carry out work on an assigned
topic under the direct guidance of a recognised post graduate teacher. A written protocol
of the proposed work should be submitted before the end of the first 6 months.
Subsequently, the post graduate student should carry out the proposed work for at least
one year (not inclusive of the period for submitting the protocol and writing-up the final
thesis).

During the training programme, patient safety is of paramount importance,

therefore skills are to be learnt initially on the models, later to be performed under
supervision followed by performing independently; for this purpose, provision of
skills laboratories in medical colleges is mandatory.

ASSESSMENT

FORMATIVE ASSESSMENT, ie, during the MD training

Formative assessment should be continual and should assess medical knowledge,
patient care, procedural & academic skills, interpersonal skills, professionalism, self
directed learning and ability to practice in the system.

General Principles
Internal Assessment should be frequent, cover all domains of learning and used to
provide feedback to improve learning; it should also cover professionalism and
communication skills. The Internal Assessment should be conducted in theory and
clinical examination.

Quarterly assessment during the MD training should be based on:

1. Journal based / recent advances learning

2. Patient based /Laboratory or Skill based learning
3. Self directed learning and teaching
4. Departmental and interdepartmental learning activity
5. External and Outreach Activities / CMEs

The student to be assessed periodically as per categories listed in postgraduate

student appraisal form (Annexure I).

SUMMATIVE ASSESSMENT, at the end of three years:

The summative examination would be carried out as per the Rules given in
POSTGRADUATE MEDICAL EDUCATION REGULATIONS, 2000.

The Post Graduate Examination shall be in three parts:

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1. Thesis:

Every post graduate student shall carry out work on an assigned research project under
the guidance of a recognised Post Graduate Teacher, the result of which shall be written
up and submitted in the form of a Thesis. Work for writing the Thesis is aimed at
contributing to the development of a spirit of enquiry, besides exposing the post graduate
student to the techniques of research, critical analysis, acquaintance with the latest
advances in medical science and the manner of identifying and consulting available
literature.

Thesis shall be submitted at least six months before the Theory and Clinical / Practical
examination. The thesis shall be examined by a minimum of three examiners; one
internal and two external examiners, who shall not be the examiners for Theory and
Clinical examination. A post graduate student shall be allowed to appear for the Theory
and Practical/Clinical examination only after the acceptance of the Thesis by the
examiners.

2. Theory Examination:
The examinations shall be organised on the basis of ‘Grading’or ‘Marking system’ to
evaluate and to certify post graduate student's level of knowledge, skill and
competence at the end of the training. Obtaining a minimum of 50% marks in
‘Theory’ as well as ‘Practical’ separately shall be mandatory for passing examination
as a whole. The examination for M.D./ MS shall be held at the end of 3rd academic
year. An academic term shall mean six month's training period.

It should have 4 theory papers:

Paper I: General tropical medicine and basic sciences;
Paper II: Clinical tropical medicine including internal medicine and medical
emergencies;
Paper III: Clinical tropical medicine including maternal and child health, public
health;
Paper IV: Recent advances in tropical medicine, research methodology, and clinical
epidemiology.
The final qualifying examination should include an assessment of clinical skills in the
form of case presentations and discussions.

3. Practical/Clinical and Oral/viva voce Examination:

The case-based discussions should involve at least 2 long cases in clinical tropical
medical problems, and 1 short case each in maternal and child health. Other rules laid
down by the MCI regarding M.D. examinations shall apply here as well.

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 Oral/viva voce Examination shall be thorough and shall aim at assessing the
knowledge and competence of the post graduate student on the subject, investigative
procedures, therapeutic technique and other aspects of the specialty which form a part
of the examination.

Recommended Reading:
Books (latest edition)

1. Cook GC, Zumla A, editors. Manson’s Tropical Diseases. Published by WB

Saunders.
2. Guerrant RL, Walker DH, Weller PF, editors. Tropical Infectious Diseases:
Principles, Pathogens & Practice. Published by Churchill Livingstone.
3. Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL,
Loscalzo J, editors. Harrison’s Principles of Internal Medicine. Published by
McGraw-Hill.
4. Boon NA, Colledge NR, Walker BR, Hunter J, editors. Davidson's Principles and
Practice of Medicine. Published by Churchill Livingstone.
5. Strachan M, Sharma SK, Hunter JA, editors. Davidson’s Clinical Cases.
Published by Churchill Livingstone.
6. Eddleston E, Davidson R, Brent A, Wilkinson R. Oxford Handbook of Tropical
Medicine. Published by Oxford University Press.
7. Peters W, Pasvol G. Atlas of Tropical Medicine and Parasitology. Published by
Mosby.
8. Park K, editor. Park’s Textbook of Preventive and Social Medicine. Published by
Banarasidas Bhanot Publishers.
9. Detels R, McEwen J, Beaglehole R, Tanaka H. Oxford Textbook of Public Health.
Published by Oxford University Press.
10. Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJL, editors. Global
Burden of Disease and Risk Factors. 1st edition. Published by World Bank
Publications.
11. Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M, Evans DB, Jha P,
Mills A, Musgrove P, editors. Disease Control Priorities in Developing
Countries. Published by World Bank Publications.
12. Schulz K, Grimes DA, editors. The Lancet Handbook of Essential Concepts in
Clinical Research. Published by Elsevier.
13. Bonita R, Beaglehole R, Kjellstrom T. Basic Epidemiology. Published by the
World Health Organization.
14. Rothman KJ, Greenland S, Lash TL, editors. Modern Epidemiology. Published by
Lippincott Williams & Wilkins.
15. Katz M, editor. Study Design and Statistical Analysis: A Practical Guide for
Clinicians. Published by Cambridge University Press.

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 16. Altman DG, editor. Practical Statistics for Medical Research. Published by
Chapman & Hall/CRC.
17. Greenhalgh T, editor. How to Read a Paper: The Basics of Evidence-based
Medicine. Published by BMJ Books
18. Guyatt G, Rennie D, Meade M, Cook D, editors. Users' Guides to the Medical
Literature: Essentials of Evidence-Based Clinical Practice. Published by
McGraw-Hill Professional.

Journals
03-05 international Journals and 02 national (all indexed) journals

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 Annexure I
Postgraduate Students Appraisal Form
Pre / Para /Clinical Disciplines
Name of the Department/Unit :
Name of the PG Student :
Period of Training : FROM…………………TO……………
Sr. PARTICULARS Not Satisfactory More Than Remarks
No. Satisfactory Satisfactory
1 2 3 4 5 6 7 8 9
1. Journal based / recent
advances learning
2. Patient based
/Laboratory or Skill
based learning
3. Self directed learning
and teaching
4. Departmental and
interdepartmental
learning activity
5. External and Outreach
Activities / CMEs
6. Thesis / Research work
7. Log Book Maintenance

Publications Yes/ No

Remarks*______________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________
*REMARKS: Any significant positive or negative attributes of a postgraduate student to be mentioned.
For score less than 4 in any category, remediation must be suggested. Individual feedback to
postgraduate student is strongly recommended.

SIGNATURE OF ASSESSEE SIGNATURE OF CONSULTANT SIGNATURE OF HOD

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