The National Medical Commission (NMC) has released the Guidelines For Competency-Based Postgraduate Training Programme For MCh In Plastic and Reconstructive Surgery.

1. PREAMBLE

Plastic and Reconstructive Surgery is a unique specialty
that defies definition, has no organ
system of its own, is based on principles rather than specific
procedures. It pertains to restoring
form and functions and, in many situations, enhancing it. The scope ranges from the top of the Calvarium to the bottom
of the sole. It has also been defined as a ‘Problem solving specialty’- solving
problems related to many other specialties. The range of Plastic and Reconstructive Surgery
has expanded by leaps and bounds in the past few decades.

Thus, a structured program for a comprehensive training
in the wide range of Plastic and Reconstructive
surgery is the need of the hour as it would lay down the gold standard for training
across all the platforms in the country.
Moreover, it will also help in standardizing the training of future plastic surgeons. This comprehensive
document has been prepared keeping
this need in mind. The core idea all through has been to prepare a curriculum
that is inclusive of theoretical knowledge, practical aspects,
and the desired operative capabilities of the trainee. The document will help the teachers micromanage the nitty gritty
of the daily training and teaching assignments. At the end of the 3-year
training, the candidate would be
equipped with vast knowledge, skills, the right aptitude to function as an independent, knowledgeable consultant, teacher and researcher.

SUBJECT SPECIFIC LEARNING
OBJECTIVES

(Complete details in annexure
II available with Expert Group members)

The aim of course is to produce plastic surgeons capable
of setting standards and demonstrate
commensurate expertise in the field. The training should aim to facilitate the candidate’s acquisition of a judicious
mix of the three domains of learning that will
be practiced ethically: -

• Cognitive (knowledge) domain,
• Affective (communication) domain,
  and
• Psychomotor (practice)
  domain.

i.
COGNITIVE DOMAIN
(KNOWLEDGE DOMAIN)

• Understand the basic sciences
  (embryology, anatomy, physiology, biochemistry, pharmaco-therapeutics etc.) and principles of plastic surgical
  care as applicable to practice in plastic surgery.
• Be conversant with the embryology,
  aetiology, pathophysiology, diagnosis and management of common (elective
  or emergency) conditions requiring plastic surgical
  intervention.
• Be
  conversant with principles guiding care with reference to plastic surgery,
  aesthetic medicine and surgery
  and burn management.
• Group
  approach: Recognize the role of multidisciplinary and
  interdisciplinary approach in the management of various conditions requiring plastic surgery so as to obtain
  relevant specialist consultation, where appropriate.
• Research Methodology: Basic knowledge of research methodology and bio- statistics; familiarity and participation in clinical and experimental research
  studies; involvement in scientific presentation and publication.

Recognize the importance of family,
society and socio-cultural environment in the
treatment and rehabilitation of the individual
needing plastic surgery care.

ii.
AFFECTIVE DOMAIN

The trainee should imbibe the following:

• Group /Team approach: function
  as a part of a team, co-operate with colleagues, and interact
  with the patient
  to provide the optimal medical
  care.
• Ethical
  practice: Abide by ethical principles in medical practice,
  maintain proper etiquette
  in dealings with patients, caretakers and other health
  personnel including due attention to the patient’s right to
  information, consent and second
  opinion. Maintain professional integrity while dealing with patients, colleagues, seniors, pharmaceutical companies and equipment manufacturers.
• Teaching
  and Communication: Preparation
  of oral presentation, medical documents,
  professional opinion in interaction with patients, caretakers, peers and paramedical staff – both for clinical
  care and medical teaching. Effective communication with the patient/caretakers regarding the nature and extent
  of

disease, treatment options available and realistic
outcome following optimal management is essential.

• Provide counselling to the patient and caretakers for the smooth dispensation of medical care.
• During the course of three years, the post graduate student is expected to attend instructive courses that facilitate proficiency relevant to this domain,
  for example, communication skills, biomedical ethics,
  patient counselling, teaching,
  etc.

iii.
PSYCHOMOTOR SKILLS

• Evaluate a patient thoroughly (history, clinical examination), order relevant investigations and interpret them to
  reach a diagnosis and plan of management.

• Plan and carry out routine investigations/ procedures (bedside, laboratory, radiology) independently.

• Provide Basic and Advanced Life
  Support services in emergency according to ATLS guidelines.

• Acquire Skills to provide critical
  care of individuals requiring airway support,
  ventilation, central vascular
  access etc. during the
  course of treatment.

• Prepare a patient for an
  elective/emergency surgery and provide specific post- operative care.

• Acquire skills in routine
  ward procedures (wound dressings and peripheral vascular
  access).

• Acquire proficiency in prescribed
  minor and major operative procedures, and provide these,
  initially under supervision and later independently.

• Acquire proficiency in managing
  emergency and elective referrals and provide
  adequate support under supervision and later independently.

• Monitor the post-operative patient
  in the routine post-op ward / high dependency
  unit / and in the intensive
  care setting.

• Provide specific and relevant advice
  to the patient and family at discharge time for
  proper domiciliary care, reporting to hospital in an emergency and routine follow up.

• Acquire proficiency in teaching
  undergraduate students,
  nursing and other health care personnel.

SUBJECT SPECIFIC COMPETENCIES

(Complete details in annexure II available with Expert Group members)

At the end of the course, the student should
be able to acquire the following competencies under the three domains, knowledge/skills/ expertise::

1.
Cognitive domain (Knowledge domain)

A.
THEORETICAL KNOWLEDGE:

Should be able to describe
& discuss and synthesize knowledge
of different conditions
needing plastic surgical care and
their diagnosis and management.

B.
CLINICAL/PRACTICAL SKILLS:

Should be able to diagnose,
investigate, perform surgery, manage and follow-up patients
with conditions needing
plastic surgical care using modern therapeutic methods.

C.
TEACHING SKILLS:

Should be able to teach relevant aspects of conditions
needing plastic surgical care to resident doctors,
junior colleagues, nursing
and para-medical staff.

D.
RESEARCH METHODOLOGY:

Should be able to identify and investigate a research
problem in conditions needing plastic
surgical care using appropriate
methodology.

E.
GROUP APPROACH:

Should participate in multi-disciplinary meetings with
radiologists, paediatricians, pathologists,
orthopedic surgeons, rehabilitation specialists, oncologists and experts from allied clinical
disciplines.

2.
Affective domain
(Attitudes including Communication and Professionalism)

The M.Ch. candidate, at the end of training
should demonstrate the ability to:

• communicate in a professional manner the treatment plan with patients,
  their family and care givers,
• function as
  a part of a team in collaboration with other geriatric
  mental health care team members
  including those from related clinical
  disciplines, psychiatric nursing/occupational therapy
  staff and nutrition
  unit.
• Adopt ethical principles and maintain proper etiquette in
  dealing with patients, relatives and other
  health personnel and to respect the rights of the patient including the right
  to information and second opinion.
• Develop communication skills to word reports
  and professional opinion
  and to interact with patients, relatives, peers and paramedical staff, and for effective teaching.
• Organize team activities in the
  department and community on Plastic Surgery-related conditions including prevention and public awareness.
• Plan and implement
  group activities with health staff
  in the hospital and community.

Leadership skills

Professionalism

• Accept personal responsibility for care of patients with mental health
  problems, consistent with good work ethics and empathy.
• Demonstrate appropriate truthfulness and honesty with colleagues.
• Recognize personal beliefs, prejudices, and limitations, which should not come in the way of providing
  service.
• Respect patient confidentiality at all times
  in verbal and written communication.

Attitude

• Respect patients' religious, moral, and ethical beliefs and biases, even if
  they differ from the
  student’s own beliefs.
• Present all available options
  accurately to the patient and relatives.
• Be
  aware of the advantages and potential hazards
  of referring patients and families to community or to national
  resources.
• Recognize the limitations of their own skills
  and seeks consultation when necessary.
• Understand and develop sensitivity to end-of-life care and issues regarding provision
  of care.
• Acquire an effective system for identifying and addressing ethical,
  cultural, and spiritual
  issues associated with health care delivery to geriatric mental health patients.
• Acquire knowledge or applies an understanding of psychological, social,
  and economic factors which are pertinent to the
  delivery of health care to geriatric mental health patients.
• Effectively engages the patient
  and/or family in communications which are non- judgmental and non-coercive.

Interpersonal and Communication Skills
Human Relationships

3.
Psychomotor domain

The list of procedures which a trainee needs to perform
independently, perform under supervision,
assist, and observe are given below. In addition, trainees are encouraged to improve skills by doing procedures on
cadavers, surgical simulators and the surgical
skills laboratory.

Sl. No

Competencies in Psychomotor Domain.

At the end
of the course, the trainee should be able to:

A. Perform
Independently

1.

GENERAL PRINCIPLES

• Create a consent document appropriate to the clinical care sought by a patient
• Perform steps of WHO safety
  protocol: surgical patient safety checklist
• Obtain standard views
  of photographs for different conditions and create a photograph logbook
• Select and use appropriate dressing materials for wounds
• Demonstrate wound debridement
• Demonstrate application of Negative pressure wound therapy
• Demonstrate the use of external tissue expansion on
  simulation models
• Demonstrate the harvest
  of split skin
  grafts in patients
• Harvest and use a full
  thickness skin graft
• Demonstrate use of the skin
  graft Mesher
• Identify cutaneous vascular perforators using a vascular

doppler

• Demonstrate with appropriate planning, local skin
  flaps, pedicled skin
  flaps, muscle flaps,
  osseous flaps, free
  flaps, perforator flaps
• Demonstrate delay procedures
• Demonstrate secondary flap
  modification (eg; flap
  debulking)
• Demonstrate harvest of tendon, bone,
  cartilage for grafts
• Demonstrate the administration of local anaesthetics, Tumescent anaesthesia, nerve
  blocks in patients
• Demonstrate Endotracheal intubation on a patient or Simulator

MICROVASCULAR SURGERY, BRACHIAL PLEXUS, PERIPHERAL NERVE SURGERY

• Set up the microscope in the operation theatre or
  Laboratory.
• Clean and store
  the Micro instruments after use.
• Use magnifying loupes
  and operating microscope during surgery.
• Make a pattern of the reconstructive plan with its various components for a given
  defect.
• Examine, decide the management, implement, operate and rehabilitate cases of brachial plexus injuries.
• Diagnose, investigate, exploration and repair of peripheral nerves under magnification.

BURNS

• Perform escharotomy, escharectomy and fasciotomy on the
  limbs and trunk
• Place central venous
  lines in the Subclavian, Internal Jugular and Femoral
  veins in Paediatric and adult patients
• Should manage acute
  burn patients in intensive care unit including respiratory and critical burn patients.
• Set-up Central Venous
  pressure measuring systems
• Perform burn wound
  dressings
• Harvest, apply, manage
  split skin grafts used to resurface burn
  wounds
• Procure and apply
  allograft skin on wounds
• Perform a burn
  wound biopsy
• Perform dressings for hand burns
• Perform a Z-plasty to lengthen a post burn
  contracture band Release and resurface post
  burn contractures of various joints

• Make appropriate splints to immobilize hand burns
  in the functional position.
• Prescribe appropriates splint, pressure garments and
  exercises for acute
  burns and post burn deformities.

CRANIOFACIAL, CLEFT
AND PEDIATRIC PLASTIC
SURGERY

• Place a Nasopharyngeal Airway to maintain
  the upper airway
• Demonstrate the various incisions and the anatomy
  to approach the Craniofacial skeleton
• Demonstrate the
  markings for a Unilateral and Bilateral Cleft lip repair
• Apply arch bars
  and Intermaxillary fixation for fractures of the maxilla and mandible.

HEAD AND NECK

• Obtain biopsies from benign
  and malignant lesions of the head and
  neck
• Incision biopsy
• Excision biopsy
• Core biopsy
• Perform excision biopsy
  of Benign lesions of the Head
  and neck
• Make patterns and plans for partial auricular defects
• Demonstrate the carving
  and shaping of a cartilage framework to
  reconstruct microtia.

BREAST

• Demonstrate the pre-operative
  markings of any one technique of reduction mammoplasty
• Perform subcutaneous excision of Gynecomastia.

HAND AND
UPPER EXTREMITY

• Administer the following blocks:
• Axillary
• Wrist,
• Digital
• Demonstrate the various local and cross finger
  flaps used in the management of Fingertip injuries
• Perform Flexor tendon
  repair

• Demonstrate Extensor tendon
  repair
• Set up the Controlled dynamic mobilization following Flexor tendon repair
• Set up the Controlled dynamic mobilization following Extensor tendon repair

• Perform amputations of the:

1. Thumb
2. Digits
3. Below elbow and Above elbow

Drain apical space
infections, Paronychia

Perform drainage and irrigation in a case
of Tenosynovitis.

TRUNK, GENITALIA, LOWER EXTREMITY

• Demonstrate the debridement of a pressure sore.
• Evaluate cases of genital abnormalities.
• Assess and
  manage congenital and acquired defects in the trunk.

AESTHETIC SURGERY

• Illustrate the design
  of a small Aesthetic surgery
  clinic
• Mark the important facial Anthropometric points
  on a given patient
• Measure the important distances and angles
  used for facial
  deformity analysis
• Write a consent
  format for common
  aesthetic surgical procedures
• Record photographs of the face, nose, ears,
  peri-orbital region, malar
  region, breasts, trunk,
  arms, thighs, and calves in
  standard views for documentation
• Administer regional and local anaesthesia to patients undergoing Aesthetic surgery
• Measure the vertical height of the skull, forehead, midface, and lower
  face
• Measure the Intercanthal distance, Palpebral fissure
  length, Inter-alar distance, Commissure length
• Measure the width
  of the skull,
  forehead, face at the zygoma
  and mandibular angle
• Measure the nasofrontal & nasolabial angles
• Calculate the Cephalic index
• Draw RSTLs on the Face and other
  areas

• Demonstrate the pinch
  test to identify RSTLs
• Plan incisions on the face and other
  parts based on the RSTLs
• Perform a Z-plasty and scar revision using the
  Z-plasty principle
• Prepare tumescent fluid
  to be used
  to infiltrate the abdomen, thighs and arms
• Perform ear
  lobe repair for partial and complete tears.

B. Perform under supervision

GENERAL PRINCIPLES

• Demonstrate placement of suitable tissue
  expanders in clinical cases.

MICROVASCULAR SURGERY, BRACHIAL PLEXUS, PERIPHERAL NERVE SURGERY

• Demonstrate dissection of recipient and donor vessel
  for microvascular anastomosis
• Demonstrate the steps
  of a microvascular anastomosis and choose the appropriate instruments
• Demonstrate tests to assess arterial and venous patency after microvascular transfer
• Demonstrate perforator-based
  flap elevation in a cadaver:
• Perform Neurorrhaphy
• Harvest a Sural/
  Superficial peroneal/ forearm cutaneous nerve graft
• Demonstrate the anatomy of common
  sites for Compression of the Ulnar, Median, Radial, Sciatic, common
  Peroneal and Posterior Tibial nerves.

BURNS

• Plan and participate in a mock drill to manage mass casualties from a major burn
  accident
• Participate in the
  early excision and
  resurfacing of burn
  wounds
• Perform various limb
  and digit amputations in deep electric burns
• Plan and perform flexion, extension, first web
  contracture release, syndactyly release and resurfacing in chronic hand

burns

• Perform release,
  resurfacing of a post burn
  neck contracture and
  make a post-operative splint for immobilization
• Perform contracture release and resurfacing of post burn
  contractures over various
  joints
• Resurface Facial
  burns according to the Aesthetic units of the face.

CRANIOFACIAL, CLEFT
AND PEDIATRIC PLASTIC
SURGERY

• Dissect the parotid gland and the Facial
  Nerve branches in the face
• Demonstrate the Bicoronal and subciliary incisions used to expose the skull and orbit
• Take a tongue
  stitch to prevent
  Glossoptosis
• Perform nasal bone reduction and make an external nasal
  splint for a patient
• Demonstrate the anatomy of the TMJ

•
Mark incision for cleft palate
repair and dissect.

AESTHETIC SURGERY

• Create a digital archiving system for
  storing patient data
• Perform liposuction and prepare a sample for micro fat
  grafting in a patient.

C. AS: Assist,
OB: Observe, CAD: Cadaver, LAB: Laboratory,
SIM: Surgical Simulator

GENERAL PRINCIPLES

• Perform submental intubation in a patient
  or cadaver
• Perform tracheostomy in a patient
  or cadaver
• Demonstrate the use of power
  tools
• Demonstrate perforator-based
  flap elevation in a cadaver:

1. TDAP and latissimus dorsi
2. Scapular and Parascapular
3. DIEP
4. SGAP and IGAP
5. Gracilis
6. Fibula and peroneal perforator flap
7. Posterior tibial perforator flap.

MICROVASCULAR SURGERY, BRACHIAL PLEXUS, PERIPHERAL NERVE SURGERY

• Demonstrate the anatomy
  of the digit
• Demonstrate the macro anatomy
  of the upper
  limb at the arm, forearm and hand
• Demonstrate the anatomy
  of the lower
  limb at the level of the thigh, leg, and foot
• Demonstrate the neurovascular anatomy of the scalp
• Demonstrate use
  of anastomotic coupler devices in the
  Laboratory
• Demonstrate the topographic anatomy of the Ulnar, Median,
  Radial nerves in the
  mid arm, upper, mid and lower forearm
• Demonstrate the anatomy
  of the Brachial Plexus
• Demonstrate the Spinal
  accessory to Suprascapular, Triceps branch to
  axillary, Ulnar fascicle to Biceps nerve, Median fascicle to Brachialis nerve, and
  Intercostal to Musculocutaneous nerve
• Demonstrate the anatomy of the Fallopian tubes
• Demonstrate the anatomy of the Vas Deferens
• Perform superificialization of the Brachial artery prior to performing
  an AV fistula.

BURNS

• Place naso-gastric and naso-jejunal feeding tubes
• Participate in the respiratory and nursing care
  of a patient with MODS, on the ventilator
• Participate in the post-operative monitoring and care of a patient with burns after
  General anaesthesia
• Demonstrate Subclavian and
  Femoral artery ligation an electrical burn.
• Participate in primary
  excision and tangential excision of burns.
• Harvest split thickness skin graft.

CRANIOFACIAL, CLEFT
AND PEDIATRIC PLASTIC
SURGERY

• Dissect the various
  fat compartments of the
  face
• Harvest cancellous bone
  from the Iliac
  bone for alveolar bone grafting

• Perform frontal craniotomy, orbito-frontal advancement, and
  occipital advancement
• Draw the Facial midline in the 3 Coronal planes
  from the Cephalometric tracing, to depict the
  asymmetry, as described by Grayson
• Assist and perform the
  key steps of surgery for unilateral cleft
  lip, anterior palate
• Assist and perform
  the key steps of surgery for bilateral cleft lip, anterior palate
• Assist and perform
  the key steps
  of cleft palate
  surgery
• Assist in the bone grafting for alveolar clefts
• Demonstrate the
  Abbe flap for philtral reconstruction
• Demonstrate the open septo-rhinoplasty to correct nasal deformities of the cleft nose
• Demonstrate the
  LeForte 1 advancement of the maxilla
• Demonstrate the Bilateral Sagittal Split of the Mandible
• Demonstrate arch bar
  and Ivy loop
  application in a patient or
  typhodont
• Perform intermaxillary fixation in patients
  with fractures of
  the mandible
• Perform open reduction and Miniplate fixation
  in fractures of the Frontal
  bones, Orbit, Zygoma, Maxilla,
  and Mandible
• Perform intercanthal wiring
  in a patient
• Demonstrate the vascularized auricular cartilage transfer to the Glenoid
  fossa
• Excise a bony block and perform Costochondral reconstruction of the mandible for Temporomandibular ankylosis
• Plan alloplastic reconstruction of Temporomandibular joint.
• Set-up an external and internal distractor on a Stereolithographic model
  of a skull in a child with
  Brachycephaly
• Perform a Box osteotomy and Facial Bipartition on a model
  of a patient with Hypertelorism
• Set-up an external and internal distractor on a Stereolithographic model of a
  mandible in a child.
• Demonstrate a maxillary swing procedure on a model.

HEAD AND NECK

• Demonstrate tongue reconstruction with the following flaps:

1. Pectoralis major myocutaneous
2. Anterolateral thigh

iii. Radial forearm microvascular flaps

• Demonstrate the Glabella, Paramedian forehead and
  Nasolabial flaps for nasal reconstruction
• Demonstrate the Radial
  forearm microvascular flap
  for total nasal
  reconstruction
• Demonstrate the following flaps for lip reconstruction:

1. Abbe
2. Estlander
3. Fan
4. McGregor
5. Kerapandzic

Demonstrate the
lateral canthotomy and Temporal flap
for upper and lower
eyelid repair

Demonstrate the Glabella and Lateral supra-brow flap for reconstruction of the Medial and Lateral canthus

Demonstrate the harvest
of the nasal
chrondromucosal graft

Demonstrate the lid switch procedure to reconstruct the upper eyelid

Demonstrate the elevation of the Temporalis fascia flap

Demonstrate the use of the Pectoralis
major myocutaneous flap for pharyngeal and oesophageal reconstruction

Demonstrate the Radial
forearm free flap for
oesophageal reconstruction

Demonstrate the anterior rhinotomy approach to the anterior cranial fossa

Demonstrate the LeForte
I and the maxillary swing
approaches to the skull base

Demonstrate the mandibular swing and condylotomy to approach the skull base and
infra-temporal fossa

Demonstrate the sublingual, submandibular, retropharyngeal, buccopharyngeal and prevertebral spaces
of the neck.

BREAST

• Display the anatomy
  of the breast
  and draining lymph
  nodes
• Demonstrate the steps
  of a Simple mastectomy and axillary node
  clearance
• Demonstrate the
  flaps that can be used for Oncoplastic reconstructions:

1. Thoracodorsal Artery Perforator
2. Lateral Intercostal artery
   Perforator
3. Anterior Intercostal artery
   Perforator and Superior epigastric artery Perforator based
   flaps

• Demonstrate, in the Breast
  glandular flaps that can be used
  in the redistribution of
  glandular tissue
• Demonstrate the Pectoral fascial flap and the lower
  pole dermal apron
  flap
• Demonstrate the Latissimus dorsi muscle transfer to replace the missing Pectoralis major in Poland's syndrome
• Demonstrate any one technique of mastopexy
• Demonstrate augmentation mammoplasty using implants.

HAND AND
UPPER EXTREMITY

• Demonstrate the anatomy
  of the Flexor
  and Extensor compartments of the Upper
  limb
• Demonstrate the Vascular anatomy of the Upper
  limb
• Demonstrate the anatomy of the hand
• Demonstrate the Nerve
  supply to the upper
  limb
• Demonstrate various local and regional flaps that can be used
  to resurface the thumb
• Demonstrate the anatomy of the Nail
  bed
• Manage fractures of the Hand
  with:

1. K-wiring
2. Open reduction and internal fixation
3. External fixation

Demonstrate the Groin
and Abdominal flaps
for Hand resurfacing

1. Thumb
2. Digits
3. Below elbow and
4. Above elbow

Perform the Great
and second toe dissections in preparation for
a toe to the thumb
transfer in a cadaver

Perform Pollicization of the Index
finger

Demonstrate the Flexor
muscle slide

Demonstrate the following tendon transfers

1. Biceps to Triceps
2. Deltoid to Triceps
3. Brachioradialis
   to Flexor Pollicis Longus
4. Split FPL to EPL
5. FPL tenodesis
6. FDS Lasso procedure
7. House intrinsic balancing procedure
8. EDC and EPL tenodesis
9. ECRL to FDP

x. Pronator teres to FPL.

TRUNK, GENITALIA, LOWER EXTREMITY

• Demonstrate the anatomy of the chest
  wall, abdominal wall
  and back
• Demonstrate the anatomy
  of the:

1. Latissimus dorsi
2. Trapezius
3. Omentum and
4. Gluteal flaps

Demonstrate reconstruction of the Chest
wall using:

1. Pectoralis Major
2. Latissimus Dorsi
3. Serratus Anterior
4. Rectus Abdominis
5. Omentum

Demonstrate the anatomy of the anterior abdominal wall and
the component separation techniques

Demonstrate the anatomy
and vascularity of the Penis,
scrotum, and perineum

Dissect and prepare a Radial forearm flap for phallic reconstruction

Demonstrate vaginal reconstruction using:

1. Pudendal artery-based flaps
2. Gracilis myocutaneous
3. Rectus abdominis and
4. Colon

Demonstrate the surgical steps involved in
excision of the penis and testis along
with creation of flaps for the neo vagina and
vulva in a male to female gender
reassignment surgery

Demonstrate the surgical steps in
obliteration of the vagina, phalloplasty and scrotoplasty in a patient
for female to male gender reassignment

Demonstrate the commonly used flaps in the
treatment of pressure sores:

Superior and inferior Gluteal flap

Gluteal rotation flap

Posterior thigh flap

Tensor Fascia Lata flap

Vastus lateralis flap

Hamstring flap

Demonstrate the anatomy
of the perineum

\

• Demonstrate the anatomy
  of the lower
  limb at the level of the thigh, leg, and foot.
• Demonstrate the following Flap anatomy i). Anterolateral thigh
• Anteromedial thigh
• Superior and Inferior
  Gluteal Artery iv). Gracilis

v). Posterior
leg Fasciocutaneous vi). Fibula
and fibula perforator vii). Gastrocnemius

• Soleus
• Reverse sural artery
  x). Dorsalis pedis
• Medial plantar artery
• Perforator and propellor flaps.

AESTHETIC SURGERY

• Assist in the cleaning, packing and sterilization of commonly used surgical instruments
• Dissect the superficial muscles, the Facial
  nerve and the blood vessels of the face
• Demonstrate the Superficial Muscular Aponeurotic System
  (SMAS)
• Identify the retaining ligaments of the face
• Identify the Supra-orbital, Infra-orbital and Mental
  nerves
• Demonstrate/ observe a Glycolic acid
  face peel
• Demonstrate the forehead lift and expose
  the Supra-orbital neurovascular bundle
• Demonstrate the anatomy
  of the Upper
  and Lower eyelid
• Dissect to demonstrate the subcutaneous and Sub-SMAS
  lifts
• Demonstrate the harvest of rib, iliac
  crest and cranial
  bone grafts in a cadaver or patient
• Plan a
  simple W-plasty scar revision on a patient
• Design a small
  Geometric Broken Line
  scar revision
• Display the Open
  approach to the nose and septum
• Demonstrate the Open
  reduction rhinoplasty
• Demonstrate Costochondral graft
  for nasal augmentation
• Demonstrate high and low septal
  preservation rhinoplasty
• Demonstrate the various
  procedures to modify the nasal tip
• Demonstrate the use of septal
  and costal cartilage as spreader and septal extension grafts
• Demonstrate the anatomy
  of the nasal septum

• Demonstrate the muscular and neurovascular anatomy of the Rectus abdominis, External oblique
  Internal oblique, Transversus abdominis and Peritoneum
• Demonstrate the perforator anatomy of the anterior abdominal wall
• Demonstrate any one
  technique of creating a neo-umbilicus
• Demonstrate the posterior and anterior component separation procedure for repair of the anterior abdominal wall
• Harvest a strip
  of skin and hair from the Occipital region and prepare Follicular units for Transplant
• Perform follicular unit
  extraction and hair restoration
• Perform hair restoration procedures over scalp
  and face
• Demonstrate the anatomy of the Buccal
  fat pad
• Use different types
  of LASERs for aesthetic procedures
• Should use LASER
  for the management of scars, pigmented lesions, hair removal, vascular lesion etc.
• Use threads, Botox
  and Fillers for aesthetic
  surgery.

SYLLABUS

COURSE CONTENT:

The M.Ch.
Plastic and Reconstructive Surgery course will include
Aesthetic, Hand Surgery and Burn
Care in its syllabus.

1. General Plastic
   Surgery
2. Microvascular surgery,
   Brachial plexus and Peripheral nerve
   surgery
3. Burns and postburn deformity
4. Craniofacial, Cleft and Paediatric Plastic Surgery
5. Head and Neck Surgery
6. Breast
7. Hand and Upper Extremity
8. Trunk and Lower Extremity

9. Aesthetic Surgery
and medicine

1. Reconstructive Surgery
   of External Genitalia and intersex disorders
2. Sex reassignment
3. Peripheral vascular
   surgery
4. Maxillofacial surgery,
   trauma and reconstruction

1. General Plastic Surgery
1. History and development of plastic surgery
   in India and across the world
2. The scope of plastic surgery

A.
General Principles

1.3 Evidence Based Medicine and research in plastic surgery

1. Medico legal issues in plastic surgery
   practice

1.5 Liability issues
in plastic surgery,
legal & insurance
perspective

1. Documentation, Record
   keeping and consent.

1.7 Patient safety
issues in plastic
surgery

1. Psychological aspects
   of plastic surgery
2. Ethics in plastic surgery
3. Photography in plastic
   surgery.
4. Information technology relevant to plastic
   surgery.

B.
Basic principles and techniques

2.1 Wound: Definition, classification and implications

2. Wound healing-normal and abnormal.
3. Wound management - Mechanical and pharmacological dressing
   techniques. Negative pressure
   wound therapy & other techniques.
4. Scar biology
   and management

2.5 Keloid, hypertrophic scars- prevention and management

2. Unstable scar and scar contracture.

2.7 Anatomy and functions of skin

2.8 Viscoelastic Properties of Skin

2.9 Infective conditions of skin

2. Benign and malignant skin and soft tissue tumours
3. Radiation and Radiation Injuries
4. Principles of tissue reconstruction
5. Skin grafts
6. Blood supply to skin, cutaneous circulation and vascular basis of flaps.
7. Flaps: Classification, variations and applications
8. Flap pathophysiology and pharmacology
9. Grafts – fat, fascia,
   tendon, nerve, cartilage, bone, composite tissue
10. Principles of Cancer Management
11. Lymphedema: Pathophysiology and management
12. Principles of microvascular surgery and technique
13. Nosocomial infections
14. Principles of genetics and general approach
    to the management of congenital malformations.
15. Vascular anomalies: Pathophysiology and management
16. Foetal surgery
17. Local anaesthesia, nerve blocks, regional
    anaesthesia
18. Principles of anaesthesia for infants, adults,
    hypothermia, hypotensive anaesthesia.
19. Pain management
20. Plastic Surgical
    instrumentation: General principles.

C.
Technology applications

3.1 Technological innovations

3.2 Laser and energy device
applications

3. Tissue expansion- principles and application

3.4 Distraction Histogenesis

3.5 Endoscopy in Plastic Surgery

3.6 Robotics

3. Simulations

3.8. 3.D printing
technology & applications

3. Suture materials, Implants and Biomaterials in plastic surgery
4. Transplantation biology, techniques and applications
5. Regenerative
   medicine, cell therapy & stem cells
6. Tissue Engineering applications in plastic
   surgery
7. Telemedicine in plastic
   surgery
8. Information and Digital
   Technology for Plastic
   surgeon
9. Teaching tools
   and methods in plastic
   surgery

3.16. Training modules
for plastic surgery
trainees.

2. Microvascular surgery, Brachial
   plexus and Peripheral nerve surgery

A.
Microvascular surgery

1. Instrumentation in Microsurgery

2. Basic Principles of free-flap surgery

3. Fundamental principles

3.1 Fundamental Principles of microvascular surgery

3. Pre-operative planning for microsurgery
4. Factors affecting outcome
   of microvascular flap surgery

3.4.
Anatomy of angiosomes and perforators

4. Replantation and revascularization

5. Recent advances
in microsurgery

6. Terminologies in Microsurgery.

B.
Peripheral Nerve surgery

1. Types of Nerve injury

2. Diagnosis and management of peripheral nerve lesions/injuries
3. Compression neuropathies- upper and lower limb

4. Topographic anatomy
of various peripheral nerves.

C.
Brachial plexus Surgery

1. Anatomy of the Brachial
Plexus

2. Mechanism of Brachial Plexus
Injury

3. Examination, Investigations and Diagnosis of Brachial Plexus
Injury

4. Management of neonatal brachial
   plexus injury
5. Management of adult Brachial
   Plexus injury

6. Management of Chronic Brachial
Plexus injury.

D.
Microlymphatic surgery

1. Lymphedema pathophysiology

2. Assessment of lymphedema

3. Medical Management of Lymphedema

4. Surgical management of Lymphedema
5. Microlymphatic surgery.

E.
Composite Tissue
Allotransplantation

1. Principles and regulations of Composite Tissue Allotransplant

2. Recent developments in Hand transplant

3. Face transplant.

F.
Video microsurgery

1. Robotic microsurgery
2. Arteriovenous Fistula

H.
Tubal recanalization and Vaso-vasostomy

3.
Burns

1
History of acute burns injuries
& management

• Multidisciplinary
  burn team
• Prevention of burns
• Burn management
  in disasters and humanitarian crisis
• Pathophysiology of acute burns

6
Systemic Inflammatory Response
Syndrome (SIRS)

• Early burn care
• Fluid management in
  acute burns
• Inhalation burns
• Management of the burn wound
• Skin and
  skin substitutes
• Nutrition in Burns

13
Burn wound infection and treatment

• Sepsis in burns
• Multiorgan Dysfunction Syndrome
  (MODS)
• Anaesthesia for a burned patient
• Biomarkers in Burn care
• Electrical burns
• Chemical burns
• Facial burns
• Hand burns
• Feet burns
• Paediatric burns
• Geriatric burns
• Burns in pregnancy
• Management of Pain in burns
• Psychiatric and psychological considerations in burns
• Burn rehabilitation
• Post burns scars
• Post burns contractures
• Post burn facial
  deformities
• Skin bank
• Role of allografts in burns
• Skin substitutes

34. Organizing a burn unit.

4.
Craniofacial Cleft and Paediatric Plastic
Surgery

1
General

1. Embryology and anatomy
   of craniofacial complex.
2. Growth and development changes
   in face, anatomy
   of facial skeleton.
3. Structure and development of teeth and Dentofacial anomalies.

1.4 Harvesting of bone
grafts (including cranial
bone).

2
Craniofacial anomalies

2. Principles of craniofacial surgery.
3. Craniofacial clefts.
   Tessier’s clefts classification.
4. Craniosynostosis - syndromic
   and non-syndromic
5. Hypertelorism.
6. Craniofacial microsomia.
7. Craniofacial distraction.
8. Hemifacial atrophy.
9. Treacher-Collins Syndrome.
10. Pierre Robin sequence.
11. Other craniofacial syndromes, e.g.- Binders
    syndrome etc.

2.11 Distraction osteogenesis

2. Distractors and craniofacial fixation
   devices.
3. Embryology of head and neck.
4. Embryogenesis of cleft
   lip and palate.
5. History and evolution of techniques in Cleft surgery.
6. Classification of Clefts
7. Unilateral Cleft lip
8. Bilateral Cleft lip
9. Cleft Palate
10. Alveolar Clefts
11. Secondary deformity
    correction in clefts
12. Management of palatal
    fistula
13. Flaps in clefts- Abbe flap, Tongue flap, buccal flaps, free flaps etc.
14. Secondary cleft nose correction
15. Orthodontics in Cleft lip and Palate.
16. Midface skeletal evaluation and corrections and Orthognathic surgery

3
Cleft Lip and Palate

3.15 Distraction in Clefts.

3. Velopharyngeal incompetence.
4. Speech therapy in cleft lip and palate.
5. Middle ear management in Cleft palate

3.19. Antenatal diagnosis
and management.

4
Maxillofacial Trauma

4. Dentofacial anatomy, occlusions, various terminologies.
5. ATLS protocols.
6. Management of Airway and acute care.
7. Evaluation of injuries,
   imaging, principles of treatment.
8. General principles of facial soft tissue injury repair.
9. Management of soft tissue injuries of specific regions
   of the face.
10. Facial nerve injuries
    and management.
11. Restoration of anatomical subunits
    of face.
12. Incisions to access the craniofacial skeleton.
13. Access osteotomies to the skull base.
14. Skeletal Fractures
    –Principles and management
15. Fracture Mandible and condyle fractures.
16. Midface fractures: maxilla, nasal bone,
    NOE complex
17. Naso-Orbito-Ethmoid injuries.
18. Nasal bone
    fractures.
19. Frontal bone
    fractures.
20. Zygomatic complex fractures.
21. Management of Panfacial
    injuries.
22. Management of dento-alveolar injuries.
23. Fracture reduction and different modalities of skeletal
    stabilization; AO principles.
24. Primary and secondary bone grafting of the facial
    skeleton.
25. Avulsion injuries of face.
26. Gunshot injuries
    of face.
27. Paediatric Facial fractures.

4.25. Management of facial fractures in elderly and edentulous jaw.

5
Maxillofacial Disorders

5. Temporomandibular
   joint: Ankylosis, Hypermobility, dislocation.
6. Temporomandibular joint
   pain, dysfunctions.
7. T. M Joint Reconstruction.
8. Obstructive sleep apnoea –
   Evaluation, planning and management.
9. Principles of osteointegration and Implantology.
10. Craniofacial and Maxillofacial Prosthetics.
11. Craniofacial Implants and retained prosthesis.
12. Radiological imaging

5. Head and Neck
Surgery A Head and Neck Tumors

• Benign and Malignant
  tumors of Head and Neck.
• Tumors of oral cavity, oropharynx and Mandible.
• Jaw tumours, lesions
  and cyst.
• Principles of Reconstruction

4.1 Principles of reconstruction of Cancer of upper Aerodigestive system

4.2 Reconstruction of the Mandible
and Maxilla

• Tumors of skin

6. Benign skin tumors of the Head and neck

6.2 Malignant skin tumors
of the Head and Neck

• Paediatric head and neck tumours.

B
Head and Neck reconstruction by region

• Reconstruction of Scalp and Calvarium
• Reconstruction of the Nose
• Reconstruction of the Eyelids and Orbit
• Reconstruction of external
  ear
• Reconstruction of the Lip and commissure
• Cheek reconstruction
• Tongue reconstruction
• Reconstruction of pharynx
  and oesophagus

C
Principles Skull Base Surgery

• Vascular malformations of head and neck E Infections
  of the Head & Neck
• Infection of the Cervical spaces
• Ludwig's angina
• Post Hansen's deformities of the face
• Cancrum oris/ Mucor mycosis

6.
Breast

• Diagnosis of Breast Cancer

2
Oncoplastic Surgery

3
Management of Carcinoma Breast

• Nipple and Areola
  Reconstruction
• Congenital Anomalies of The Breast

6
Tuberous Breast

• Poland's Syndrome

8
Fat Grafting in The Breast

• Reduction Mammoplasty 10 Mastopexy
• Augmentation Mammoplasty and Breast Implants
• Anaplastic Large Cell Lymphoma
  and Breast Implants
  (ALCL) 13 Gynaecomastia.

7.
Hand and Upper Extremity

1
Regional anatomy
and principles

1.1 Functional anatomy
of hand

1. Biomechanics of the Hand

1.3 Regional anaesthesia in upper limb surgeries

1. Examination of hand and upper limb

1.5 Diagnostic
imaging of hand and upper
extremity

2
Traumatic disorders
of hand

2.1 Fingertip and nail injuries

2. Anatomy of the skeleton
   of the hand and fractures of the hand and wrist
3. Flexor tendon injuries of the Upper Limb

2.4 Extensor tendon
of the Upper Limb

2.5 Mutilating injuries
of the Upper extremity

2.6 Amputation and Prothesis

2.7 Thumb reconstruction

2. Acute nerve injuries and repair

2.9 Compartment syndrome
of the Upper limb

2. Paediatric upper extremity trauma and reconstruction.

3
Non-traumatic disorders of upper extremities

3.1 Infections of hand

3.2 Dupytrens disease

3. Rheumatoid arthritis of the Hand

3.4 Compression neuropathies of upper extremity

3. Hand ischemia
   and Volkmann’s ischemic
   contracture
4. Complex Regional
   Pain Syndrome

3.7 Tumors of the upper limb.

4.
Congenital disorders of hand and upper extremities

4.1 Embryology, classification and principles.

4.2 Common congenital hand anomalies.

4. Vascular anomalies of upper extremity.

5
Miscellaneous

5.1 Comprehensive management of burned hand.

5. Occupational hand disorders

5.3 Management of the stiff
hand

5.4 Management of the Spastic
hand

5. Management of upper extremity in tetraplegia.

5.6 Hand therapy.

8.
Trunk and Lower Extremity

1
Lower Extremity

1.1 Comprehensive Lower
Extremity Anatomy

1. Management of Lower Extremity Trauma

1.3 Lower Extremity Sarcoma Reconstruction

1. Reconstructive Surgery:
   Lower Extremity Coverage/Composite reconstruction

1.5 Diagnosis and Treatment of Painful Neuroma
and of nerve

compression in the lower extremity

1.6 Lower Extremity
Composite Reconstruction

1. Foot Reconstruction.

2
Trunk Reconstruction

2.1 Comprehensive Trunk
Anatomy

2.2 Reconstruction of chest

2. Reconstruction of the soft Tissues
   of the back
3. Abdominal Wall reconstruction.

3
Reconstruction of Genitalia

3.1 Reconstruction of Male Genitalia

3. Reconstruction of acquired vaginal
   defects

3.3 Gender identity
disorders and disorders of sex development.

4
Pressure Sores

• Perineal Reconstruction

9.
Aesthetic Surgery

1. Aesthetic surgery practice

1.1. Setting up an aesthetic
surgery practice

1. Preoperative analysis and surgical Planning
   in aesthetic surgery
2. Psychological assessment &
   specialist referrals

1.4. Obtaining informed
consent and patient
counselling

1.5. Clinical photography, documentation and record keeping

1. Dealing with complications and unsatisfied patients

1.7. Communication and team
building

1. Ethics and medico-legal aspects of aesthetic
   surgery
2. Anaesthesia for aesthetic surgery:
   general and regional
   nerve blocks
3. Care and maintenance of instruments sterilization and infection control
   practices.

2.
Age related changes & rejuvenation

A. Facial ageing

2. Anatomy of the face relevant
   to aesthetic surgery
   and injectables (soft tissues and skeletal)

2.2. Ageing of the face- skin, soft tissues and skeleton.

B. Facial rejuvenation

2. Non-surgical skin care and rejuvenation topicals
   and cosmeceuticals

2.4. Cutaneous resurfacing - chemical peel, surgical dermabrasion

2. Regenerative medicine: platelet rich plasma,
   mesenchymal stem cells and
   their aesthetic applications

2.6. Laser: physics,
tissue interactions and various clinical
applications

2. Other
   energy based devices: radio-frequency and ultrasound: their application in skin tightening and
   body contouring.
3. Forehead lift:
   endoscopic and surgical

2.9. Brow lift

2. Blepharoplasty: upper and lower

2.11. Oriental blepharoplasty

2.12. Secondary blepharoplasty

2.13. Thread lifts:
science, indications, technique
complications

2. Various facelift techniques: minimal access cranial
   suspension (macs)
   subcutaneous lift, Smas-platysma plication, extended Smas, subperiosteal lift
3. Secondary deformities from facelift surgery.

3.
Aesthetic skeletal
surgery

3. Facial skeleton: male and female.
   Age related changes in the facial skeleton

3.2. Facial skeletal
augmentation: bone graft and
implants

3. Facial masculinisation and feminisation surgeries

3.4. Anthropometry, cephalometry, orthognathic surgery.

4.
Soft tissue fillers

4.1. Chemical composition and application of soft tissue fillers

4. Temporary, semi-permanent, permanent fillers
   vascular and other
   complications of fillers.

5.
Botulinum toxin

5.1. Botulinum toxin:
science, indications, techniques, complications.

6.
Incisions and scars

6. Resting skin tension lines
   and their relation
   to incision placement and scar revision.

6.2. Non-surgical management of incisions and scars

6.3. Surgical management of scars of the face and other
regions.

7.
Rhinoplasty

7.1. Nasal anatomy,
physiology and assessments

7. Rhinoplasty: aesthetic and functional, open and closed,
   reduction and augmentation

7.3. Structural and preservation rhinoplasty

7.4. Tip-plasty

7. The deviated/
   crooked nose and cleft rhinoplasty
8. The septum in rhinoplasty

7.7. Secondary rhinoplasty.

8.
Lip

8.1. Augmentation

8.2. Reduction

9.
Fat grafting

9. Structural fat grafting:
   principles, extraction, preparation & injection techniques. Micro, milli & nano fat grafting. indications and complications.
10. Autologous fat grafting: biology,
    volumetric & non-volumetric effects of fat grafts
11. Platelet rich plasma, platelet
    rich fibrin, nano-
    fat grafting.

10.
Liposuction

1. Principles and composition of various wetting
   solutions & safety
   issues
2. preoperative planning,
   postoperative care
3. Lipo-structuring- concept,
   applications, 7 techniques- power assisted
   liposuction (PAL), ultrasound assisted liposuction (UAL), laser assisted
   liposuction, cryo-lipolysis

10.4. High definition lipostructuring

10.5. Face liposuction and lipolysis

1. Axillary contouring and axillary breast
   management
2. Gynaecomastia correction
3. Recent techniques- Vaser, radio
   frequency, j plasma skin tightening
4. Large volume
   liposuction.

11.
Body contouring surgeries

1. Obesity & massive weight
   loss (MWL) and post bariatric
   surgery weight loss
2. Management of high BMI patients

11.3. Body and limb contouring procedures: brachioplasty,
belt lipectomy, lower body lift,
upper body lift,
thigh plasty, buttock
lift: assessment, indications, techniques & complications.

12.
Abdominoplasty

12.1 anatomy and blood
supply

2. Standard abdominoplasty & variants
3. High tension lateral abdominoplasty, mini abdominoplasty, extended lipo-abdominoplasty

12.4. Neo-umbilicoplasty

12.5. Correction of divaricated recti, ventral hernia,
mesh repair.

13.
Implants and augmentation

13.1. Implant biology

13.2. Buttock augmentation, calf augmentation.

14.
Aesthetic genital
surgery: male & female

14.1. Anatomy & embryology

4. Analysis and planning, anatomical and functional corrections
5. Penile, scrotal,
   vaginal, vulval, mons pubis surgical
   procedures.

15.
Hair restoration

5. Scalp anatomy
   and pathology biology
   of the hair follicle from the surgical perspective

15.2 Patterns of hair loss

15.3 Tools for evaluation of hair quality-
TrichoScan, densitometry etc.

5. Management protocols for alopecia. Medical restoration
6. Various techniques of restoration including strip
   harvest (FUT), (FUE)

15.6 Body hair transplant (non-scalp donor harvest)

15.7 Surgical correction of baldness

15.8 Eyebrow, moustache, beard hair transplantation.

16.
Other aesthetic procedures

16.1. Aesthetic jewellery
piercing

6. Cheek dimple
   creation

16.3. Buccal fat pad removal

6. Ear lobe: repair, augmentation, reduction.

TEACHING AND LEARNING METHODS

GENERAL PRINCIPLES:

The syllabus has been designed to ensure
competency-based training of the student during the 3 years. This will cover the Cognitive, Psychomotor and Affective domains.

The training will essentially be self-directed and
revolve around practical skills acquired from
graded patient care responsibilities and formal academic sessions.
Trainees are expected to be fully
conversant with the use of computers (documentation, editing and presentation
software (word, power point, excel etc.)) and be
able to use databases like the Medline,
PubMed etc.

PATIENT CARE RESPONSIBILITIES:

The student will be posted
in the OPD, Wards, Operation theatres
and the Emergency
medicine where he will participate in patient care responsibilities

1. History taking,
2. Clinical Examination,
3. Documentation : Clinical
   notes, Clinical photographs,
4. Progress notes,
5. Order and interpret relevant investigations,
6. Treatment planning,
7. Make a
   pattern of the treatment plan where indicated,
8. Counsel the patient or relatives regarding the procedure to be undertaken,
9. Take informed consent,
10. Assist or perform
    the surgical treatment,
11. Coordinate care and
    rehabilitation with other ancillary departments.

FORMAL ACADEMIC
SESSIONS:

Below is a suggested Academic
schedule that could be
followed:

Sr. No.

Description

Frequency

1

Subject seminars

Once a week

2

Journal club

Once in two weeks

3

Didactic lectures by faculty

Once a month

4

Bedside teaching

As and when
feasible

5

Clinical rounds

Once a week

6

Structured interactive group
discussions (Including buzz sessions, debates,

problem-based learning
etc)

Once a week

7

Case Presentation and Treatment Planning

Once a week

8

File Audit/Statistic Meet/Mortality and

Morbidity Audit

Once month

9

Cadaver dissections

As and when
possible/

Once a week

10

Skills Laboratory

• Microvascular laboratory
• Craniofacial
  techniques/ fracture fixation iii). Simulator based

Daily/ Weekly/ Once a month (as per requirement)

11

Grand Round/Interdepartmental Meet

Once a month

The following
things have to be considered in the formal teaching program

1. PG
   students shall be required to participate in the teaching and training
   programme of Undergraduate students and interns.
2. The department should
   encourage e-learning activities.

EXTERNAL POSTINGS:

As it is not possible for all departments to expose the
student to all aspects of Plastic and reconstructive surgery, it is recommended (if permissible) that the student be permitted external
postings to departments of excellence in various subspecialties for a
period of 2 weeks to a month at a
time, a total of three months being permitted during a period of 3 years. This
is provided that the student has shown the required
progress and worked to the satisfaction of the

faculty members and head of the department, availability
of permissible leave of absence as per the concerned University
Rules & Regulations.

The sub-speciality where posting may be done would include:

1. Burns
2. Hand surgery
3. Microvascular surgery
4. Aesthetic surgery
5. Cleft and craniofacial surgery
6. Others as deemed useful by the HOD and student

i.
Orthopaedics

ii.
Anaesthesia

iii.
Oncosurgery

iv.
Radiodiagnosis

PAPER PRESENTATION AND PUBLICATION (Compulsory)

A postgraduate student
would be required
to present one poster, 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 period
of his postgraduate studies so as to make him eligible to appear at the
postgraduate degree examination.

RESEARCH METHODOLOGY/ THESIS: (Optional)

It is desirable for the trainee to take up a thesis during their
posting and complete
it before their
training ends.

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

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 practical/clinical examination.

FORMATIVE ASSESSMENT

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.

INTERNAL ASSESSMENT

The student to be assessed periodically as per categories listed in postgraduate student appraisal form (Annexure I).

QUARTERLY ASSESSMENT

1.
Patient based:

1. Documentation of case records
2. Progress notes

iii.
Clinical photographs

2. Laboratory or Skill
   based learning:
1. Cadaver dissection
2. Microvascular laboratory
3. Learning on simulation models

3.
Self-directed learning and teaching:

1. Seminar: departmental
2. Journal based / recent advances
   learning

iii.
Case presentation and treatment planning.

The department could also conduct an annual assessment
on the lines of the final Summative assessment.

SUMMATIVE ASSESSMENT: Assessment at the end of training.

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 two parts:

The examinations shall be organised based on ‘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.

1. Log book of work done during the training period including rotation postings, departmental presentations, and internal
   assessment reports should
   be submitted.

2. At least
   two presentations at national
   level conference. At least one research paper
   should be published/ accepted in an indexed journal. (It is suggested that the local or University Review committee assess
   the work sent for publication).

There will be four theory papers
based on broad distribution, as below:

Paper I: General principles and basic sciences relevant to plastic and
reconstructive surgery.

Paper II: Clinical part I- Burns, Cleft and Craniofacial, Micro neurovascular and Brachial plexus, Hand and upper extremity
surgery

Paper III: Clinical part II- Aesthetic surgery,
Head and neck, Breast, Trunk,
Genitalia, Lower limb surgery

Paper IV: Recent Advances in Plastic and Reconstructive Surgery

1. Clinical Examination

1. Long
   case: Should assess the students’ ability to diagnose a
   complex condition, order and interpret
   relevant investigations and plan the reconstruction of a composite defect.
2. Short
   cases: 2 or 3: Each case would assess one or more aspects of one of
   areas of reconstruction.
3. Ward
   rounds: 4 cases: Assess the students’ ability to counsel a patient or
   relatives about a procedure, possible
   complications, expected results
   and post-operative management. It could also assess his
   ability to anticipate complications, prevent them and manage them should they occur.

2.
Viva voce

1. Surgical planning
2. Operative procedures
3. Instruments
4. Radiology: X-rays, CT scan,
5. Osteology (Skull, Mandible,
   Hand, Fibula)
6. Photographs based
   viva.

LOG BOOK:

The student will maintain
a comprehensive log of:

1. Cases operated- observed, assisted, performed
   independently,
2. Seminars presented/ attended,
3. Faculty lectures attended,
4. Journal presentations
   made and attended,
5. Conferences/webinars attended, and presentations made.

WORK RECORD: PHOTO ALBUM:

The student will maintain photographic documentation of the important
cases operated or assisted including
relevant post-operative follow up. 

Recommended reading:

Books (latest
edition)

1. Neligan, Peter C. Textbook of Plastic surgery.
   Elsevier.

2.
Karoon Agrawal. Text book
of Plastic, Reconstructive and Aesthetic surgery
(6 volumes): Thieme

3. Kevin C. Chung, Grabb & Smith’s:
Plastic Surgery. Lippincott, Williams and Wilkins,
New York.

4.
Mathes, Stephen J.
Plastic Surgery (Vol. 1-8). London. W.B. Saunders.

5.
Mimis Cohen. Mastery of Plastic & Reconstructive Surgery
(Vol.1-3). Little, Brown & Co.

6. Alan D. McGregor, Ian A. McGregor.
Fundamental Techniques of Plastic Surgery.
Elsevier.

7. Berish Strauch,
Luis Vasconez, Charles
K. Herman, Bernard
T. Lee. Grabb’s
Encyclopaedia of flaps (2 Vol) .

8.
Fu-Chan Wei, Samir Mardini. Flaps and Reconstructive Surgery. Elsevier.

9. Scott W. Wolfe, William
C. Pederson, Scott H. Kozin,
Mark S. Cohen. Green’s Operative Hand Surgery (2 Vol.).

10. David N. Herndon,
Total Burn Care. Elsevier.

11. Sujatha Sarabhai. Principles & Practice
of Burn care. JP
Brothers.

12. Rajiv Sood, Bruce M. Achauer. Burn surgery- Reconstruction and Rehabilitation. Saunders Elsevier.

13. Raymond Fonseca.
Oral and Maxillofacial Surgery. Elsevier.

14. Robert Acland, S. Raja Sabapathy. Acland‘s
Practice manual for Microvascular Surgery. The Indian Society
for Surgery of The
Hand.

15. Prabha Yadav, Vinay Shankhdhar, Dushyant Jaiswal. Mastering Cancer Reconstructive Surgery with Free Flaps. JP Brothers.

Journals

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

Student
appraisal form for M.Ch. in Plastic and Reconstructive Surgery

Element

Less than Satisfactory

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than satisfactory

Comments

1

2

3

4

5

6

7

8

9

1

Scholastic
Aptitude and Learning

1.1

Knowledge appropriate

for level of training

1.2

Participation and contribution
to learning activity e.g.,
Journal Club, Seminars, CME

etc)

1.3

Conduct of research and other
scholarly activity

assigned (e.g
Posters, publications etc)

1.4

Documentation of acquisition of competence

(eg Log
book)

1.5

Performance in
work

based assessments

1.6

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2

Care of the patient

2.1

Ability to provide patient care appropriate to level

of training

2.2

Ability to work with
other members of the health

care team

2.3

Ability to communicate appropriately and empathetically with

patients
families and care givers

2.4

Ability to do procedures appropriate for the level

of training and assigned role

2.5

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appropriate for level of
training

2.6

Participation and contribution
to health care quality improvement

3

Professional attributes

3.1

Responsibility
and

accountability

3.2

Contribution
to growth of learning of the team

3.3

Conduct that is ethical

appropriate and respectful at all times

4

Scholarship

4.1

Teaching and mentoring skills
appropriate to level

of training

4.2

Ability to formulate research questions, initiate conduct and

complete
research projects

4.3

Ability to review and use the published literature appropriately in care of

the patient lab or workspace

4.4

Ability to provide consultations to other specialties as may be

required

5

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6

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Date

PAHO Director Dr Jarbas Barbosa made the call as the novel coronavirus pandemic, linked to millions of deaths and infections worldwide, entered its third year.

Over the past three years the Americas had more than 190.3 million COVID-19 cases and over 2.9 million deaths, accounting for 25 and 43 per cent of the global total, respectively.

"The pandemic underscored that no country or organisation in the world was fully prepared for the impact of this pandemic," Dr Barbosa told a news conference, adding this includes the Americas which is a region "marked by inequities".

The PAHO director said currently, incidence rates are 20-30 times lower than a year ago and so "while we are not totally out of the woods, we are in a much better place".

He highlighted the key role PAHO played in helping countries, including building and strengthening the COVID-19 Genomic Surveillance Regional Network which is key to tracking the evolution of the virus, as well as monitoring for other pathogens with pandemic potential, including avian flu.

Over the past three years the network has facilitated the uploading of more than 580,000 sequences from Latin America and the Caribbean into global databases.

Dr Barbosa also spoke of the role PAHO played in acquiring COVID-19 vaccines and "mobilising more than 160 million doses through COVAX, and helping the countries of Latin America and the Caribbean roll out more than 1.3 billion vaccine doses in less than two years".

But he acknowledged that, despite these achievements, "COVID-19 is still with us and the virus has yet to settle into a predictable pattern".

"Throughout the last month we have seen more than 1.5 million new cases and 17,000 deaths. We cannot be complacent," he warned, adding that while testing rates have dropped it is crucial that countries maintain and continue to strengthen surveillance as the SARS-CoV-2 virus "can evolve and adapt quickly".

Reaching the 30 per cent of people who have yet to receive their primary series of the COVID-19 vaccine is also key to "preparing ourselves for any new wave of infection or new variant of concern".

He said while the region has experienced a variety of setbacks throughout the pandemic that have "revealed or exacerbated weaknesses in our health systems" — including in the detection and treatment of diseases such as tuberculosis and HIV, in the testing and treatment of noncommunicable diseases, and in declining rates for routine vaccination — we now have a unique opportunity to "place health at the centre of the Sustainable Development Agenda.

"We must focus on recovering losses and on rebuilding resilient health systems that work for everyone, as well as being better prepared for future health threats," the PAHO director said, noting "as I begin my tenure, a primary focus is to help countries of the Americas move past the COVID-19 pandemic".

"PAHO stands ready to support our countries in the Americas to learn from and apply the lessons we have learned from the COVID-19 pandemic," he said.

The Host

Julie Rovner
KHN

@jrovner

Read Julie's stories.

Julie Rovner is chief Washington correspondent and host of KHN’s weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

President Joe Biden’s fiscal 2024 budget proposal includes new policies and funding boosts for many of the Democratic Party’s important constituencies, including advocates for people with disabilities and reproductive rights. It also proposes ways to shore up Medicare’s dwindling Hospital Insurance Trust Fund without cutting benefits, basically daring Republicans to match him on the politically potent issue.

Meanwhile, five women in Texas who were denied abortions when their pregnancies threatened their lives or the viability of the fetuses they were carrying are suing the state. They charge that the language of Texas’ abortion ban makes it impossible for doctors to provide needed care without fear of enormous fines or prison sentences.

This week’s panelists are Julie Rovner of KHN, Shefali Luthra of The 19th, Victoria Knight of Axios, and Margot Sanger-Katz of The New York Times.

Panelists

Victoria Knight
Axios

@victoriaregisk

Read Victoria's stories

Shefali Luthra
The 19th

@Shefalil

Read Shefali's stories

Margot Sanger-Katz
The New York Times

@sangerkatz

Read Margot's stories

Among the takeaways from this week’s episode:

• Biden’s budget manages to toe the line between preserving Medicare and keeping the Medicare trust fund solvent while advancing progressive policies. Republicans have yet to propose a budget, but it seems likely any GOP plan would lean heavily on cuts to Medicaid and subsidies provided under the Affordable Care Act. Democrats will fight both of those.
• Even though the president’s budget includes something of a Democratic “wish list” of social policy priorities, the proposals are less sweeping than those made last year. Rather, many — such as extending to private insurance the $35 monthly Medicare cost cap for insulin — build on achievements already realized. That puts new focus on things the president has accomplished.
• Walgreens, the nation’s second-largest pharmacy chain, is caught up in the abortion wars. In January, the chain said it would apply for certification from the FDA to sell the abortion pill mifepristone in states where abortion is legal. However, last week, under threats from Republican attorneys general in states where abortion is still legal, the chain wavered on whether it would seek to sell the pill there or not, which caused a backlash from both abortion rights proponents and opponents.
• The five women suing Texas after being denied abortions amid dangerous pregnancy complications are not asking for the state’s ban to be lifted. Rather, they’re seeking clarification about who qualifies for exceptions to the ban, so doctors and hospitals can provide needed care without fear of prosecution.
• Although anti-abortion groups have for decades insisted that those who have abortions should not be prosecuted, bills introduced in several state legislatures would do exactly that. In South Carolina, those who have abortions could even be subject to the death penalty. So far none of these bills have passed, but the wave of measures could herald a major policy change.

Also this week, Rovner interviews Harris Meyer, who reported and wrote the two latest KHN-NPR “Bill of the Month” features. Both were about families facing unexpected bills after childbirth. If you have an outrageous or exorbitant medical bill you want to share with us, you can do that here.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: KHN’s “Girls in Texas Could Get Birth Control at Federal Clinics, Until a Christian Father Objected,” by Sarah Varney

Shefali Luthra: The 19th’s “Language for Treating Childhood Obesity Carries Its Own Health Risks to Kids, Experts Say,” by Jennifer Gerson

Victoria Knight: KHN’s “After People on Medicaid Die, Some States Aggressively Seek Repayment From Their Estates,” by Tony Leys

Margot Sanger-Katz: ProPublica’s “How Obamacare Enabled a Multibillion-Dollar Christian Health Care Cash Grab,” by J. David McSwane and Ryan Gabrielson

Also mentioned in this week’s podcast:

• The New York Times’ “The Programs You’d Have to Cut to Balance the Budget,” by Alicia Parlapiano, Margot Sanger-Katz, and Josh Katz

Click to open the transcript

Transcript: Biden Budget Touches All the Bases

KHN’s “What the Health?”Episode Title: Biden Budget Touches All the BasesEpisode Number: 288Published: March 10, 2023

[Editor’s note: This transcript, generated using transcription software, has been lightly edited for style and clarity.]

Julie Rovner: Hello and welcome back to KHN’s “What the Health?” I’m Julie Rovner, chief Washington correspondent at Kaiser Health News. And I’m joined by some of the best and smartest health reporters in Washington. We are taping this week on Friday, March 10, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go. Today we are joined via video conference by Shefali Luthra of The 19th.

Shefali Luthra: Hello.

Rovner: Victoria Knight of Axios News.

Victoria Knight: Hi. Good morning.

Rovner: And Margot Sanger Katz of The New York Times.

Margot Sanger Katz: Hello, everybody.

Rovner: Later in this episode we’ll have my “Bill of the Month” interview with Harris Meyer. It’s a twofer this time: two successive bills from two different families related to having a baby. But first, this week’s news. We are taping on Friday this week because President [Joe] Biden released his budget Thursday afternoon, and it felt weird to have a news podcast without talking about the budget. And yes, like most presidential budgets since the 1980s, this one is, quote-unquote, “dead on arrival” on Capitol Hill. But one thing the president’s budget does is provide a pretty-detailed look at the administration’s priorities and policy initiatives. Which health program stuck out to you as getting a publicity, if not an actual funding, boost in this document? Victoria, you were looking at the budget.

Knight: Yeah. My colleagues at Axios and I spent several hours yesterday morning going through the budget. I think it was really interesting because I think he was trying to toe the line between “we want to save Medicare, make sure it stays solvent,” but also “we want to push some more progressive ideas as well.” So there’s kind of both things in there. Some obvious things: He wants to permanently extend the enhanced tax credits for the ACA [Affordable Care Act] — so, make permanent those subsidies. Those expire, currently, at the end of 2025. He also wanted to do something called Medicaid-like coverage for eligible people in states that haven’t expanded Medicaid. And then he also wants to expand the number of drugs to be negotiated under the IRA [Inflation Reduction Act] and also move up the timeline a little bit. So, just an example: It’s supposed to be 10 drugs to be negotiated in 2026. And now he wants to do 20. Something also really interesting: [He] wants to do like a Netflix-like subscription service for hepatitis C to basically eradicate hepatitis C within the U.S.

Rovner: I thought that was maybe the most interesting thing in this budget because it’s something that we just hadn’t heard of before.

Knight: Yeah.

Rovner: That, basically, I mean, these hepatitis C drugs were really expensive when they first came out and there was concern that Medicaid programs, in particular, were going to have trouble paying for them because many of the people who have hepatitis C are intravenous drug users, and they’re more likely to get hepatitis C — or people in prison. Lots of people on Medicaid who have hepatitis C. And this would basically be a way to pay in advance for the drugs. Is that essentially what they would do?

Knight: Yeah. And I think it’s also interesting that it at least has one Republican senator — Bill Cassidy is super into this idea. He did something similar in Louisiana. I’m not sure there’s other Republicans that are on board for that, but I thought that was really interesting. You know, of course, he was talking about extending the $35 insulin cap to the commercial market. There’s some other stuff about behavioral health, pandemic preparedness. One other thing Shefali will appreciate also, he proposed increasing Title X family planning funding by almost 80% from 2023 levels, which I think — Shefali, maybe you know — [is] one of the highest increases they’ve ever proposed, in a while at least.

Luthra: Yeah, the family planning clinics, interest groups, etc., were very, very happy about this proposal, even if they know it will not become reality. I think their sense was this was a commitment that would be really transformative for them, especially now, when they are so tightly funded.

Rovner: I did notice that for a president who has not technically said that he’s running again, some of these targeted increases were for some of the very important interest groups who have been kind of, I won’t say whining, but complaining. You know, Title X had not gotten big increases since Biden became president. There’s an initiative for more money for home- and community-based care in Medicaid, which is something, again, there’s an active constituency for in the Democratic Party; the “Cancer Moonshot,” you know, which has obviously been something near and dear to President Biden’s heart; also more money … also, the [American] Cancer Society sent out a lot of emails yesterday saying, yay, thanks for proposing this big budget increase. So there does certainly seem to be a lot of touching of the important constituencies, perhaps in anticipation of reelection campaign?

[Three panelists chime in at once.]

Luthra: Julie, you forgot …

Sanger-Katz: I would say …

Knight: And I think he did … Go, Margot!

Rovner: One at a time! [laughing all around] Margot, you go first.

Sanger-Katz: I would say so. And I would also just point out that the Medicare policies in the bill were previewed by the White House a couple of days before the budget release, and they were, like, the main thing. This is what they were leading with. The president had an op-ed in The New York Times describing his Medicare policies, and they put out a fact sheet with a lot of the Medicare policies. And I think it really reflects this notion that improving the solvency of Medicare and also committing to not really cutting the core services of Medicare, that this is a very key political message that the president cares about, that the president wants to run on, and that he thinks is a very useful contrast with what some Republicans have proposed in the past and what he imagines they might want to propose as House Republicans get ready to release their own budget, which faces some difficult constraints because Speaker [Kevin] McCarthy has promised certain members that the budget that they will pass will be a balanced budget. And that’s quite hard to do without touching the big health care programs.

Rovner: Yeah. Republicans have not promised not to touch Medicaid, which now the president has been very careful to say, “It’s not just Medicare and Social Security. I’m not going to let you cut Medicare, the Affordable Care Act either.” All right, Victoria, you wanted to say something?

Knight: I think — it was also interesting that, I do think, the president did want to push forward some of the more progressive policies that … the progressive base care about, such as doing more negotiating of drugs; something Sen. Bernie Sanders (I-Vt.) has talked a lot about is the community health centers program; expanding Medicaid, home- and community-based services; … and the insulin price cap — things that I think the progressive base cares about as well. So I feel like, as you’re saying, that interest groups, but also the different bases and also the groups that care about reproductive health care, they want him to do something after Roe v. Wade. So it definitely was, like, this huge list of trying to cater to everyone.

Rovner: It’s kind of a Democratic wish list.

Sanger-Katz: At the same time, though, I think he did leave out some of the things that were part of the Build Back Better package. In the previous budgets, the president had gone even bigger on things that the progressive base wanted. And you can see a lot of things in this budget where he’s ticking those boxes, as you say. And I think a lot of policies that he has proposed in the past that he wasn’t able to get through the last Congress — but not all. It does seem like this budget is a little more focused on being able to reduce the deficit a little bit less on this very expansive notion of a robust federal government that is spending money to improve people’s lives in quite as many ways as the message that he has been proposing in his previous budgets. You can see, again, I think this is a pivot towards campaign mode, towards his assessment of the current political moment, growing concerns about the deficit and about inflation.

Rovner: But also, as you mentioned, Margot, they put out the Medicare part of this in advance, mainly because I feel like the Medicare part of the budget is not so much a part of, you know, the statement of the budget as it is a negotiating position for this whole fight we’re going to have over the debt ceiling in a couple of months, where the Republicans are going to want to demand cuts to programs basically in exchange for not letting the U.S. default on its debts. And what the president has managed to do here is say, “We’re going to lower the price of prescription drugs more, we’re going to tax the rich more. And those two things are going to a) reduce the deficit some and b) shore up the Medicare trust fund. So you can’t accuse me of not dealing with the impending problem of Medicare.” How much of a box does that actually put Republicans in when we start to get to these negotiations?

Sanger-Katz: I don’t know how much of a box it really puts them in for a couple of reasons. One is that some of what he’s proposing is really kind of an accounting gimmick. He’s taking money that is already flowing into the federal budget, that is already part of the dollars and cents of our deficit, and he’s just redirecting them from the general fund into the Medicare trust fund. So it is true that these proposals would extend the solvency of the Medicare Hospital Insurance Trust Fund, which is projected to run into some financial trouble in the coming decade. But it is not true that, like, all of the things that he’s proposing are actually new money. Some of it just comes out of other parts of the budget. It doesn’t change the deficit.

Rovner: So I will point out that that is a time honored way of extending the solvency of trusts.

Sanger-Katz: Oh, sure. I’m not saying that Biden is alone in doing that. But I just think there’s kind of three things he’s doing in this proposal. One of them is not deficit reduction. It’s just kind of moving money around. One is this drug price reduction proposal where he’s trying to get more savings by going more aggressively after more drugs. I think that is a place where he can put Republicans in a box a little bit. They’ve come out in opposition to the drug price negotiation provisions that were part of the Inflation Reduction Act that they passed last year. But those policies are super popular. The public really supports them. They feel like the pharmaceutical companies make too much money. They think that Medicare should be able to negotiate. So I think that’s a very politically shrewd decision that I think does demand potentially a response from Republicans as a possibility for deficit reduction. But then the third thing that he did is he really just raised taxes. You know, these are taxes on the rich; as Biden has been promising all along, he’s not going to raise taxes for people earning under $400,000 a year. So they’ve increased these payroll taxes, they’ve increased some investment taxes. There was kind of a loophole, a category of businesses that were not subject to that tax in the past. And, you know, I think those are basically nonstarters with Republicans. And when Republicans talk about deficit reduction, they often are very, very focused on cutting spending that the federal government does. They are much less interested in increasing taxes. And I do think that the fact that Biden led with this proposal, that he’s so comfortable talking about raising taxes as a core part of his platform, is a sign that the politics of tax cuts have changed a little bit, that that is … if you’re just taxing the rich, it seems like the public will accept that. Democrats seem actually excited about that in certain cases. But I still think tax increases are a hard political row to hoe. I think that it is not something that probably appeals to many Republican politicians. And I also think it’s probably not something that appeals to many Republican voters, either. So I don’t know that it really puts Republicans in a box in a meaningful way because they don’t feel any tension where their supporters will want them to do this thing.

Rovner: Obviously, this is a big fight yet to come. Victoria, you wanted to say something.

Knight: Yeah. I just want to add one thing. We did have, like, the first indicator: The House Freedom Caucus had a press conference this morning, and they didn’t give a lot of details, but they did say they want to restore Clinton-era work requirements for welfare programs. So they didn’t specify Medicaid, but it seems pretty likely that’s probably what they’re talking about. My colleagues and I did talk to some Republicans last week that were indicating they did want work requirements for Medicaid. So I think that seems like the very first. There’s going to be three different groups within the House Republican caucus that are going to release budgets: the Budget Committee, the House Freedom Caucus, the Republican Study Committee. So I think we are going to start seeing the outlines of what they want to do very soon. But that was kind of the first one coming out this morning, so …

Rovner: Yes, underscoring the fact that the Republicans don’t agree on what they want to do …

Knight: No.

Rovner: … which is why we haven’t seen their budget yet.

Knight: Exactly.

Rovner: Although I will point out President Biden’s budget was a month late, too.

Sanger-Katz: Can I just say one thing about the Republican budget? Because I actually spent a lot of time looking at various budget proposals and trying to examine this goal that the Republicans have of balancing the budget. Just like: How hard is it to balance the budget? And it turns out that it’s extremely hard. It’s sort of hard in a normal year. But in this post-covid era, when spending has been so elevated for so long, balancing the budget within a decade is just really, really, really hard. If you do it without raising taxes, which Republicans say they don’t want to raise taxes; if you do it without cutting defense spending, which Republicans say they don’t want to cut defense spending; if you do it without cutting Medicare or Social Security, which recently McCarthy has said he does not want to do — you end up just … this is just the basic math … having to cut everything else by 70%. That’s 7-0%. That is not the kind of cut that you can achieve even by imposing a work requirement on Medicaid, a work requirement on food stamps, and other kinds of policies that Republicans have proposed in the past. That is like deeply, deeply reducing the role of the federal government, you know, cutting Medicaid in more than half. Larry Levitt [KFF’s executive vice president for health policy] pointed out earlier this week reducing Medicaid spending by 70% probably means 50 million fewer people would have Medicaid coverage. And that’s just Medicaid. You’re talking about basically everything that the government does — environmental protection, law enforcement, military pensions, just about any program that you can think about in the government that’s not Medicare, Social Security, or direct defense spending. Seventy percent cut is quite hard to do. And so I am very curious to see what these budgets look like. I can tell you, having looked at some of the previous Republican proposals, that those all relied on some reductions to Medicare and Social Security because those programs represent such a large percentage of federal spending that if you don’t cut those at all, there’s just not a lot of dollars left. And in my reporting on this question, it does seem like one thing that the Republican Budget Committee is very likely to do is to use very aggressive assumptions about the economic growth that their policies will unleash. And so the idea is that if the economy grows by so much, then tax revenue, what increase all by itself, because people will be earning more money, and so that will enable them to balance the budget in 10 years without having to actually reduce the deficit by as much as independent scorekeepers like the Congressional Budget Office think would be necessary.

Rovner: Although I would point out that every time we’ve had one of these big tax cuts that Republicans say it’s going to grow the economy enough to pay for it, it has not grown the economy enough to pay for it.

Sanger-Katz: Indeed! You know, cutting everything that the government does by 70% probably actually would have a negative impact on the economy. People would be losing money. They would be losing their government jobs. These would be very large economic impacts that probably most economists do not think would lead to economic growth.

Rovner: Yeah, well, we will see. I will put, Margot, the nice story you did with your colleagues demonstrating all of this in chart form in the show notes. OK. Let us turn to abortion. We will start with Walgreens, poor Walgreens, caught in the maw of the abortion wars. In January, the FDA said that brick-and-mortar pharmacies for the first time could start dispensing the abortion pill, mifepristone, whose distribution had been tightly regulated since it was first approved more than 20 years ago. Almost immediately, both CVS and Walgreens, the country’s largest and second-largest pharmacy chains, announced they would apply for FDA certification to distribute the pills in states where abortion is still legal. Then, last month, 20 Republican state attorneys general, including at least four in states where abortion is still legal, warned CVS and Walgreens that if they send the pills by mail, they could be in violation of the 1873 Comstock Act, which we have talked about here before, which prohibited the mailing of items considered, air quotes, “obscene,” which at the time included information about birth control. Cut to last week when Walgreens appeared to cave to the pressure and the threat of legal action, saying it would not sell the pill in states where it’s illegal, not actually naming those states. Then, after a huge backlash, it tried to walk back its position a little, mostly leaving lots of questions. Shefali, what is your take on what Walgreens is and isn’t going to do now vis-a-vis mifepristone? They’ve kind of said both things.

Luthra: I think there’s a lot of layers here, but I want to go back to January for a moment, when we got that news from Walgreens and CVS so quickly that they would participate in providing mifepristone. Frankly, a lot of these folks that I spoke to were very surprised that [the pharmacies] reacted so quickly because carrying mifepristone in stock opens you up to really intense harassment, boycotts, protests from the anti-abortion movement. And we did see right away many of the premier anti-abortion movements calling for boycotts of Walgreens and CVS, for protests, etc. They have been organizing protests outside pharmacies right now. And there has been pressure from the beginning from governors like [Florida] Gov. Ron DeSantis instructing pharmacies not to stock the press down. The fact that Walgreens ultimately has caved in these states with hostile governments wasn’t surprising. If anything, it was surprising that it took quite so long. I am incredibly curious to see what happens with CVS and Rite Aid, the other two pharmacies that are now getting caught in the crosshairs, facing really intense pressure from lawmakers and politicians who support abortion access and also those who don’t. We saw in New York this week, the governor and the attorney general called on pharmacies to continue carrying mifepristone. Frankly, I’m skeptical that that really matters because there is no reason not to carry mifepristone in New York, a state where the government is very friendly to abortion.

Rovner: And we should point out, because this is my biggest frustration: Nobody’s actually doing it yet because nobody’s gotten certified yet.

Luthra: Correct.

Rovner: They’re not — all these headlines that said, “Walgreens is going to stop doing this.” It’s like, no, they’re going to not start doing this. Sorry.

Luthra: And we have no idea when they will get certified how long it would take. We have no idea, frankly, if mifepristone will still be able to be distributed in the country at that point, because we are still waiting on the ruling from this judge in Texas. We simply have so many open questions. And at this point, this really is more of an avenue for people to make statements about how they feel about abortion access, than it is actually affecting people’s ability to get care. The other statement grandstanding that I have been really struck by is what we’ve seen from the California governor, Gavin Newsom, who really does love to talk a lot about his pro-abortion rights bona fides, even if those statements don’t translate much into actual impact or policy. And what we saw this week was his promise that California wouldn’t do business with Walgreens if they wouldn’t stock mifepristone.

Rovner: And this is not just an idle threat in California, right? There’s a huge contract that he now says he’s not going to renew.

Luthra: So there is a contract. But friend of the podcast and former KHNer Sydney Lumpkin found the contract that Newsom was referring to. You would think it would be a significant amount of money, given how much attention it has gotten. It is a $54 million contract over five years. When you look at the overall market cap of Walgreens, a $30 billion company, it’s not clear exactly how meaningful that actually is compared to the pressure they are facing from lawsuits and the very powerful anti-abortion movement.

Rovner: So, and what … I mean, you referred to this, but what are we thinking that CVS and Rite Aid are going to do — having seen Walgreens literally put through the wringer here on this issue?

Luthra: I think that’s a really good question. I — I mean, coming into this week — had assumed that they would follow the path of Walgreens and do the exact same thing, right? Stock mifepristone, provide it with a doctor’s prescription in states where they are protected and face no legal risks, but perhaps not do so in those states where a) mifepristone is banned, as they have said they would not do. And also in states where, like Kansas, for instance, abortion is legal, but you have a very anti-abortion attorney general. It is quite interesting that they have not said either way what they will do beyond just, well we won’t do it in states where it’s illegal.

Rovner: Yeah, if I was advising CVS at this point, I would tell them to not say a word to anybody until some of this shakes out.

Luthra: Exactly.

Rovner: All right. Well, let us move on to Texas, where there is always abortion news. As Shefali mentioned, we have not had the decision yet on that abortion pill case out of Amarillo, but both sides are still going at it on other issues. Remember all those stories we’ve been chronicling about women with wanted pregnancies gone wrong who couldn’t get medical care until they were literally at death’s door or they went to another state? Well, five of them are suing the state of Texas, saying they should have been allowed to terminate their pregnancies under existing exceptions to the abortion bans, except that doctors and hospitals have been unwilling to risk giant fines and even jail time. The five women — some of whom are still pregnant, some of whom are not — want the state, whose officials continue to claim that these women were eligible for abortions in Texas if their lives were truly at risk, they want the state to clarify those exceptions even more. Is there any chance this happens? They’re not asking for the bans to be lifted. I mean, this is a kind of a unique lawsuit that we’ve not seen before because we’ve not seen that many women in this situation before.

Luthra: I think this is a pretty smart approach. I wouldn’t be surprised if it has better odds of success than, as you mentioned, a request to fully overturn Texas’ abortion bans because the exceptions are really unclear. Doctors do not feel safe talking about abortion, even in cases where it is likely that it would be very beneficial for the pregnant person, for a fetus that has really minimal chance of survival upon birth. One thing that Nancy Northup, the head of CRR [the Center for Reproductive Rights], said to me when I asked her is, depending on how this case goes, it is not at all unlikely that we see similar lawsuits filed in other states with abortion bans with similarly vague “life of the parent” exceptions that are, in reality, impossible to enforce. I think this is going to be the beginning of a very robust series of legal challenges to state abortion bans. And we’ll see better success for abortion rights lawyers in some states than in others — really depending on the makeup of these different states’ supreme courts.

Rovner: Yeah, I mean, it’s funny because over the years I’ve heard obviously lots of warning about this possibility, both from the Center for Reproductive Rights, which, as you say, is pushing this case, and other groups. But nobody could sue because nobody had standing, because it hadn’t happened. It was all theoretical. Well, now it’s happened and we have people to whom it is not theoretical, who are able to go to court and say, hey, this happened to us and it violated our rights and you need to do something about it.

Luthra: And I do want to add just one thing. I mean, it’s — I think we can’t understate just what these people have been through, the women who are suing Texas. I was just really struck by one woman who flew from Texas to Colorado for an abortion that she couldn’t get in state, paid extra for a seat by the airplane in case she went into labor on the flight, and said that she still has PTSD to this day from having to travel while afraid that she might go into labor and could die from it. Like, what these people are going through right now is just … it’s really difficult for us to imagine. And I think we’re just going to hear so many more stories that are really troubling about people whose lives have been so deeply put at risk, and they’re unable to get the care their doctors want to provide.

Rovner: Right. And I say for the 11th time, these are not women who got pregnant by accident and don’t wish to be pregnant. Many of these are women who’ve been through infertility treatment and were desperately anxious to be pregnant, were thrilled when they got pregnant, but whose pregnancy took a bad turn either for the fetus or, in some cases, one of the fetuses of twins, or in some cases the pregnant person themselves. Well, meanwhile, the Texas Republican legislature has been busy proposing even more abortion restrictions. Last week, we talked about a bill that would ban websites that include information about how to get abortion pills and punish internet providers who don’t block those sites. This week, we have a bill giving state officials the upper hand in prosecuting abortion cases in parts of the state where local Democratic prosecutors have suggested they don’t plan to zealously pursue such cases. Another bill would create a special prosecutor whose job would be, among other things, to pursue violations of the state’s abortion bans. Why is Texas such a hotbed of this?

Luthra: It’s always Texas. Texas is the biggest state in the country to have banned abortion, right? Most of the people who are traveling out of state — well, maybe not most, but the plurality — are Texans, because just so many people live there. And if we think about it, Roe v. Wade, as a case, it came from Texas. SB 8, the first law that allowed a state to circumvent Roe and ban abortions [at] anything after six weeks, that was a Texas law. This is a place where lawmakers really believe that they can be a fertile testing ground for the future of abortion restrictions. Between them and Missouri, I think, that is where we will see the bulk of innovative new ways to further restrict access.

Rovner: Well, speaking of big states that are banning or thinking about banning abortion, you wrote about Florida this week, which already has a ban on abortions after 15 weeks [and is] now considering a ban after six weeks. Florida is kind of a pivotal state in all this, right?

Luthra: Florida, third-biggest state in the country. And if we look at the map of the U.S. South and particularly the Southeast, Florida is just critical. Between Florida and North Carolina, that is where people across the region are going for abortions. And Florida has more than 60 clinics compared to, you know, around a dozen in North Carolina. If abortion there is banned after six weeks, there will be thousands of people who are displaced. They will probably have to go to North Carolina, while abortion is legal there, to Virginia and then to Illinois. And that is just really too far for so many people to travel. There just aren’t realistic options once you take Florida off the map.

Rovner: Well, finally, a bill has been introduced in the South Carolina legislature that could potentially subject patients who get abortions to the death penalty. Now, I am old enough to remember last year, when anti-abortion groups insisted they didn’t want to punish women who had abortions, just those who provide or facilitate them. I guess that’s not the case anymore.

Luthra: And I think we need to see where this bill goes. It is not the only state, either, where we are seeing legislation proposed that would treat abortion as murder or as homicide. There was a bill in Louisiana just last summer that failed on that front. But we have seen bills introduced in Tennessee, in Georgia, in so many others that I cannot remember now. But it’s a long list. I think what’s interesting is, so far, none of these bills have actually moved forward. And it’s still obviously early in the session. But what I’m curious about is, is this chipping away at the resistance toward these kinds of really strict abortion bans? And is this the first step in a multiyear effort to redirect who is punished for getting an abortion to switch from the doctors, the health care providers, to the pregnant people themselves, which has always been sort of this Rubicon the movement has been afraid to cross.

Rovner: Yeah, I remember in 2016 Chris Matthews was interviewing then-candidate Donald Trump and sort of got Donald Trump to say, you know, yes, the woman should be punished. And the anti-abortion movement came at him, like, no, no, no, that’s not what we say. That’s not what we want. And now it’s, you know, seven, eight years later and that’s not necessarily what people are saying. So, we will see how that goes. OK. That’s the news for this week. Now, we will play my “Bill of the Month” interview with Harris Meyer and then we’ll come back and do her extra credits.

We are pleased to welcome to the podcast Harris Meyer, who reported and wrote the last two KHN-NPR “Bill of the Month” stories, which are kind of related. Harris, welcome to “What the Health?”

Harris Meyer: Thanks very much, Julie.

Rovner: So, both of these bills have to do with something very common and very treacherous to your financial health: having a baby. Let’s start with baby No. 1, a now-3-year-old named Joey Trumble. Where is she from? Why was she in the hospital for 36 days?

Meyer: Joey was born prematurely in December 2019. Her mother, Brenna Kearney, is a writer in Chicago, and she was diagnosed with preeclampsia, and her doctors ordered her hospitalized at Northwestern. And then she developed a worse form of preeclampsia called HELLP syndrome. But anyway, the baby was born healthy but premature. And the baby, Joey, was treated at Northwestern Prentice, but without the knowledge of the parents the doctors who were treating her came over from next door from Lurie Children’s, and her hospital, Northwestern, was in network for her health plan. But Lurie Children’s doctors were out of network. They did not know that. So after her baby was sent home — it had about a month, 36 days, of hospitalization — the family got a bill of about $12,000, which was unexpected.

Rovner: That’s right. And we should point out that the baby was covered, right, under the mother’s health insurance.

Meyer: Correct.

Rovner: And yet they still got a bill for $12,000.

Meyer: That’s right. The hospitalization was covered. And, to their surprise, the doctors, the neonatologist from Lurie who treated the baby, were not covered in network. And so Brenna spent the next year contesting these charges. And they were never told that the doctors were out of the network. But she had found out that there was a 2011 Illinois law, which was in effect, which prohibited this kind of out-of-network billing for neonatology services.

Rovner: That’s right. And we should point out that this was before the federal No Surprises Act took effect, because this was late 2019.

Meyer: Correct.

Rovner: But there was a state law that should have applied.

Meyer: There was a state law. Illinois was a pioneer in this. So she cited that law to Blue Cross Blue Shield Illinois and to Lurie Children’s, and they said they knew nothing about it. So the bill was sent to collections about a year later, and she was able to get Blue Cross, finally, and, a year after the birth, to cover the Lurie doctor charges fully. However, in December, three years after she gave birth, she finds out she’s being billed again, after she thought the whole ordeal was over — many years after. And she finds out that Blue Cross of Illinois had taken the money back and now Lurie was coming after her and her husband again for the out-of-network charges. And that’s when she came to Kaiser Health News, and I made calls to Lurie, to Blue Cross of Illinois, and to Northwestern. And after my calls, Lurie agreed to drop the charges. But now a state senator, the Illinois Department of Insurance, and the Illinois attorney general are looking into this to see if there was a long pattern of violations by Lurie of this 2011 state law. And Brenna actually has been contacted now by three other women who experienced similar out-of-network bills from Lurie. So we’ll see what happens with that.

Rovner: So sort of a happy ending to that one. Let’s move to baby No. 2, or, more accurately, his mother. Who is she and what happened to her?

Meyer: OK. This was last June. Danielle Laskey is a school nurse, an RN, in Seattle. She was on vacation with the family. And at 26 weeks pregnant she felt that her water broke. Her doctors in Seattle ordered her to come back and said, you’d better come in. And her doctors were at Swedish Maternal & Fetal Specialty Center in Seattle, which was in network for her Blue Shield health plan. And when she got there, they said, yes, your water broke. You were at risk for the same complication from your first pregnancy three years ago. We want you to go to Swedish Medical Center across the street immediately, and we want you to stay there until you give birth, and we’ll monitor you. So she was in the hospital for seven weeks until she gave birth in August of last year.

Rovner: Oh, so just for context, Swedish is one of the big hospitals in Seattle, right?

Meyer: Yes, absolutely. And it’s one of the specialty facilities for this particular uncommon complication, which is called placenta accreta. Anyway, she was there for seven weeks. And again, she and her husband were not told that the hospital was out of network. But it turns out that Swedish, even though her doctors were — her Swedish doctors were in network for her health plan, it turns out that Swedish Medical Center was out of network, and she found out. Then the baby was born. The baby was in the hospital, the baby boy, for about a month. And then, meanwhile, after the baby was born, she experienced symptoms again, and she was rehospitalized for a day to have this placenta condition treated. Both those hospitalizations — you know, she and her husband, who’s a psychiatrist, thought they were emergencies. The doctors regarded them as emergencies. But yet afterward, the Regence Blue Shield and Swedish decided they were not emergencies. And so, guess what? The family was hit with over $100,000 in out-of-network bills for the two Swedish hospitalizations.

Rovner: And this was after the federal law took effect, right? This was last year.

Meyer: The federal law and a Washington state law were both in effect at that point, which say that you cannot apply out-of-network charges in an emergency situation. So, at first, Blue Shield said that it was not an emergency and it didn’t come under the law. And Swedish Medical Center was going to take the family to collections. The family appealed to Regence Blue Shield. Regence in January granted the appeal for the first hospitalization, erasing $100,000 or so of the charges. But the second hospitalization, $15,000 bill, was still in effect. And then they contacted Kaiser Health News. I contacted Regence Blue Shield and Swedish, and then the charges were dropped for the second hospitalization.

Rovner: Amazing how that happens.

Meyer: Yeah, well, it’s not a solution. So the twist on this one is that Regence Blue Shield said we decided it was an emergency and that it wasn’t proper that the doctors were in network but the hospital wasn’t, so we’re going to consider this an in network and erase the charges. But they said Regence Blue Shield had a contract with Swedish, which made Swedish a quote-unquote “participating provider”; therefore, the federal and state laws do not apply to that situation, and the hospital was allowed to charge the out-of-network charge. We’re going to erase it for this case, but the law does not apply to that situation.

Rovner: I confess, if I’m in a hospital and they say they’re a participating provider, I’m going to assume that means they’re in network. And in this case, it doesn’t, right?

Meyer: Right. It’s a very strange twist that my experts had never encountered before. I took the issue to the federal agency CMS, which administers the No Surprises Act, and they said that they’re going to look into this and HHS, Treasury Department, and Department of Labor are all going to have to look into this to see if this could be fixed through an agency guidance or whether this would require a congressional action to fix this apparent loophole in the law.

Rovner: Creativity. So what’s the takeaway here for both women and particularly for pregnant women who know at some point they’re likely to be in the hospital? You can’t ask every single person who touches you whether they’re in your network. And isn’t that what state and the federal law are supposed to guard against? These are the exact things that we assumed would be taken care of. Right?

Meyer: Right. Well, first of all, the family, the patient, and their loved ones need to ask the hospital and the insurer to tell them their rights under the No Surprises Act and make sure that both the insurer and the provider are following the letter of those federal and state laws. Second, if they do get, God forbid, a out-of-network bill, they need to immediately appeal that to the insurance company, and there’s a two-level appeal process. The second level, they get an independent review. And then, at the same time, they need to file a report or a complaint with the state attorney general’s office, the state department of insurance, and maybe even contact state legislators. There also are private agencies or private companies with nurses and lawyers, etc., that will help families, for a fee, address issues like this. Hopefully it shouldn’t require that, but sometimes it may. And of course, then there’s Kaiser Health News. You can file your “Bill of the Month” complaint through the portal, which we can’t deal with hundreds of thousands of cases, obviously.

Rovner: But we can help at least a few. And Harris Meyer, you helped two. So thank you very much. And thank you for joining us.

Meyer: Thank you, Julie.

Rovner: OK, we’re back. And now it’s time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at khn.org and in our show notes on your phone or other mobile device. Victoria, why don’t you go first this week? You got one of my favorites.

Knight: My extra credit is called “They Could Lose the House — to Medicaid,” by Tony Leys, and it is published on NPR but is a KHN story. It’s about a family in Iowa who found out, after the mother in the family died, that they could lose their house because she was getting services through Medicaid. She had dementia, and so she needed really intensive at-home family care. Then after she died, they got a letter from the Iowa Department of Human Services — just a month after she died, so not long after — saying that the state was trying to recoup the money that they had spent on her care. So it was almost over $200,000 that they were asking for. And what was really upsetting is this family home was going to be the inheritance for the daughter. And so now they’re kind of like, what are we going to do? Thankfully, they don’t have to do anything with the house until something happens to the father. So it’s not gone immediately. But this is basically something that some states do. It’s called estate recovery programs. And if people use Medicaid in those states, the states have the ability to come back later … whether it’s, like, a house or they can ask for funds that these families used for Medicaid. So it’s really illuminating. I had no idea this was something that happened, and it varies by state to state. But in Iowa, this is something that they kind of pursue very aggressively.

Rovner: I remember when Congress made this a possibility, I think it was back in 1995. It’s been around, the possibility of states recouping Medicaid money for a long time. But as you point out, not all states do it. And it’s usually a surprise when states do do it. People still really don’t know about it. Shefali.

Luthra: So my story is from my 19th colleague, Jennifer Gerson. The headline is “Language for Treating Childhood Obesity Carries Its Own Health Risks to Kids, Experts Say.” And what Jen did, which I think is really smart and important, is she looked at the new clinical guidelines we got from the American Academy of Pediatrics. And those were meant to improve how we evaluate and treat obesity in children. And what she gets into is that there are a lot of children’s health experts, especially mental health experts, who are deeply concerned about what the impacts of these new guidelines could be, how they might exacerbate weight stigma, and how the long-term ramifications of some of the treatment guidelines could actually have worse outcomes for young people as a result, by building on weight stigma, which could lead to different kinds of unhealthy behaviors, could lead to mental health harms that could have much longer term repercussions, possibly more, in fact, dangerous than the actual problems that these guidelines are trying to treat. And one thing that Jen notes I think is really important is that the implications of weight stigma, in particular, are especially harmful for young girls who, as we know, are already facing so many mental health crises in general right now. I thought this was a really important look at a potentially really troubling unintended consequence, and I’m really glad Jen wrote about it.

Rovner: Yeah, I had no idea. It was a very counterintuitive but really interesting piece. Margot, what do you have this week?

Sanger-Katz: I wanted to suggest an article in ProPublica called “How Obamacare Enabled a Multibillion-Dollar Christian Health Care Cash Grab,” by J. David McSwane and Ryan Gabrielson which is just this wonderful historic dive into how the Affordable Care Act ended up allowing something called Christian health ministries to provide an alternative to health insurance. As we all know, the Affordable Care Act basically said, if you’re going to offer health insurance, it has to meet certain minimum guidelines in terms of what it covers and how it works. And these Christian health sharing ministries are just this huge, huge exception where basically it’s just, you know, groups of religiously affiliated people can get together and just pay for each other’s health care or not, depending on what they want to do. There has been a lot of reporting over the years about the degree to which these plans are kind of scammy or poorly run or are not paying for needed health care for their members who think that they are an alternative to insurance. And so this piece is just fun because it looked at the lobbying that generated this strange policy.

Rovner: Yeah. You know, I remember when they got the Christian sharing ministries exception into the ACA and not really knowing where it came from. Well, this story explains exactly where it came from. So it is quite an eye-popping read. Mine is from my KHN colleague Sarah Varney, and it’s called “Girls in Texas Could Get Birth Control at Federal Clinics, Until a Christian Father Objected. Now, for decades, underage girls have been able to get contraception from federally funded Title X family planning clinics without parental permission. An effort by the Reagan administration in the early 1980s, dubbed the “Squeal Rule,” which would have required that parents be notified after the fact, was struck down in federal court and the Reagan administration did not appeal it. And no, I was not there to cover that at that time. I did look it up. A couple of months ago, Judge Matthew Kacsmaryk — yes, that Judge Kacsmaryk, who will any day now rule on whether the FDA approval of the abortion pill should be revoked — ruled in favor of a father in Texas, not a father whose daughters did or said they wanted to obtain contraception from a Title X clinic. But the father complained that the very possibility that his daughters could get birth control without his consent rendered that portion of the law — which has been in effect since Title X, was signed by Richard Nixon in 1970 — unconstitutional. And of course, the judge agreed with him. So for now, the ruling only applies in Texas. But lest you think they’re not coming for your birth control, think again.

OK. That is our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review — that helps other people find us, too. Special thanks, as always, to our ever-patient producer, Francis Ying. Also, as always, you can email us your comments or questions. We’re at whatthehealth — all one word — @kff.org. Or you can tweet me. I’m @jrovner. Shefali?

Luthra: I’m @shefalil

Rovner: Victoria.

Knight: @victoriaregisk

Rovner: Margot.

Sanger-Katz: @sangerkatz

Rovner: We will be back in your feed next week. Until then, be healthy.

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Kraus, MD, discussed the 2026 home dialysis training guidelines being developed by the Facility Guidelines Institute.The guidelines for 2022 were recently published and, according to Kraus, about half of the United States follow these guidelines for home dialysis training.“As they open the proposals for 2026, it’s a good time to think about, ‘Is that something that interests you? Can you fill in their proposal [and] send in your thoughts about how home dialysis training might change?”

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An executive order issued in July 2021 forced the Food and Drug Administration and the U.S. Patent and Trademark Office to join forces to finding ways to reduce the number of poor-quality patents that are granted. And the Senate’s Judiciary Committee reported out five bipartisan bills addressing competitive abuses that delay generic competition or otherwise lead to higher prescription drug prices.

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Nephrology nurse manager at Mandeville Regional Hospital Marika Davis-Miller told the Jamaica Observer that the renal unit in celebration of World Kidney Day ramped up its sensitisation efforts.

"We want… to educate the public especially those who are vulnerable [including] people with diabetes, high blood pressure, lupus [and] any other disease conditions that would predispose them to have kidney failure," she said at a health fair in the Cecil Charlton Park.

She said the leading cause for kidney failure worldwide is uncontrolled diabetes and uncontrolled hypertension.

"We have five stages. Stages one [to] four, they [people] are not getting dialysis. The fifth stage is end-stage renal failure, which makes them [people] want dialysis. From stage one to four, we assist people in the clinic to kind of slow the process for them wanting dialysis, because there are a lot of people who require dialysis…" she said.

When asked about the number of patients on the renal unit's waiting lists, Davis-Miller said there is a burden on the system.

"Regarding the waiting list, I really don't like to talk about that because somebody has to die in order for somebody [else] to get dialysis and there are over 100 persons on the waiting list at Mandeville… We really need people to help themselves," she said.

She said the renal unit accommodates up to 36 patients daily to receive treatment from 12 dialysis machines.

"Monday, Tuesdays, Thursdays and Fridays, we would accommodate those patients, but on a Wednesday we only have one shift which would be for 12 patients. Reason being, we have to do our thorough cleaning of the units."

She is encouraging people to regularly exercise and eat healthy to reduce the risks of being diagnosed with renal failure

"For people who do not exercise, eat fatty foods, eating late and don't drink [enough] water to flush the kidneys. Those are things that would predispose you to have not only kidney failure, but diabetes and high blood pressure which would lead to kidney failure, if uncontrolled," she said.

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