Guidelines for

Competency Based Training Programme

DNB- GENERAL SURGERY

NATIONAL BOARD OF EXAMINATIONS

Medical Enclave, Ansari Nagar, New Delhi-110029, INDIA

Email: mail@natboard.edu.in Phone: 011 45593000

CONTENTS

INTRODUCTION

OBJECTIVES OF THE PROGRAMME
1. Programme goal
2. Programme objective

ELIGIBILITY CRITERIA FOR ADMISSION

TEACHING AND TRAINING ACTIVITIES

SYLLABUS

COMPETENCIES

THESIS & THESIS PROTOCOL

LOG BOOK

NBE LEAVE GUIDELINES

EXAMINATION –

FORMATIVE ASSESSMENT
FINAL THEORY & PRACTICAL

RECOMMENDED TEXT BOOKS AND JOURNALS

INTRODUCTION

Preamble

After qualifying in the final examination of the NBE, the candidate should be able to function as a specialist in General Surgery. This requires a thorough knowledge of the fundamentals. He/She should be reasonably acquainted with the recent advances and be able to perform essential elective and emergency operative procedures independently. He/She should be able to make decisions regarding patient management and adopt favorable attitudes. During this period, the candidate will also acquire skills of experience in research methodology by writing a dissertation / thesis.

PROGRAMME GOAL

The goal of DNB course in Surgery is to produce a competent surgeon who:

Has acquired the competence pertaining to surgery that is required to be practised in the community and at all levels of health care system
Has acquired the skills to manage the patients of trauma and all life saving surgeries effectively.
Has acquired skill in effectively communicating with patient and his attendants.
Has the desired surgical skills to independently operate on elective and emergency cases
Is aware of the latest developments in the field of surgery
Is oriented to principles of research methodology
Has acquired skills in educating medical and paramedical professionals

PROGRAMME OBJECTIVES

Objectives

The aim of the courses is to develop human recourses and personnel in the field of surgery who shall:

Provide the health care to the patients needing surgical care with principles and ethics.
Teach and train future undergraduates and postgraduates medical students and junior doctors in General Surgery in Hospitals and other Institutions.
Carry out and guide research to improve the practice of the art and science of surgery
Have management capabilities to manage personnel and budgets to make health care more cost-effective
Organize health teams to provide care during natural or man-made calamities.

Develop further in the areas of their interest and/or specialize to practice existing or new specialties allied to surgery through further training programs as required

At the end of the course, the Diplomate of National Board in Surgery shall be able to:

Practice the art and science of surgery in his/her field of practice and seek and provide consultation as required. He/She will be able to provide comprehensive and good quality surgical care in general surgery including pre-operative and postoperative care
Conduct research and communicate the findings, result and conclusion to his fraternity
Acquire necessary skills of teaching and training his junior colleagues and medical students and Para-medical personnel
Keep abreast with the latest developments by self learning and/or participating in continuing medical education programs
Organize and manage administrative responsibilities in the routine day to day work as well as new situations including natural and/or man-made accidents/ calamities
Manage situations calling for emergency interventions in the sphere of surgical specialties and also routine problems in their areas within the ambit of the general surgeon
Exhibit awareness of the importance of surgical audit and the need for considering cost affectivity in patient management
Be aware of one’s professional and infrastructural limitations and be able to refer to appropriate centers at the optimum time, when required
Exhibit awareness of the need for accurate documentation in medical records including medico-legal cases.
Adopt ethical procedures in the field of doctor-patient relationship

Exhibit proper attitude in dealing with patients and relatives and be able to communicate with them effectively
To develop the skill of innovation and improvisation in times of need.

ELIGIBILITY CRITERIA FOR ADMISSIONS TO THE PROGRAMME

(A)DNB General Surgery Course:

Any medical graduate with MBBS qualification , who has qualified the Entrance Examination conducted by NBE and fulfill the eligibility criteria for admission to DNB Broad Specialty courses at various NBE accredited Medical Colleges/ institutions/Hospitals in India is eligible to participate in the Centralized counseling for allocation of DNB General Surgery seats purely on merit cum choice basis.

Admission to 3 years post MBBS DNB General Surgery course is only through Entrance Examination conducted by NBE and Centralized Merit Based Counseling conducted by National Board of Examination as per prescribed guidelines.

Duration of Course : 3 Years

TEACHING AND TRAINING ACTIVITIES

The fundamental components of the teaching programme should include:

Case presentations & discussion- once a week
Seminar – Once a week
Journal club- Once a week
Grand round presentation (by rotation departments and subspecialties)- once a week
Faculty lecture teaching- once a month
Clinical Audit-Once a Month
A poster and have one oral presentation at least once during their training period in a recognized conference.

The rounds should include bedside sessions, file rounds & documentation of case history and examination, progress notes, round discussions, investigations and management plan) interesting and difficult case unit discussions.

The training program would focus on knowledge, skills and attitudes (behavior), all essential components of education. It is being divided into theoretical, clinical and practical in all aspects of the delivery of the rehabilitative care, including methodology of research and teaching.

Theoretical: The theoretical knowledge would be imparted to the candidates through discussions, journal clubs, symposia and seminars. The students are exposed to recent advances through discussions in journal clubs. These are considered necessary in view of an inadequate exposure to the subject in the undergraduate curriculum.

Symposia: Trainees would be required to present a minimum of 20 topics based on the curriculum in a period of three years to the combined class of teachers and students. A free discussion would be encouraged in these symposia. The topics of the symposia would be given to the trainees with the dates for presentation.

Clinical: The trainee would be attached to a faculty member to be able to pick up methods of history taking, examination, prescription writing and management in rehabilitation practice.

Bedside: The trainee would work up cases, learn management of cases by discussion with faculty of the department.

Journal Clubs: This would be a weekly academic exercise. A list of suggested Journals is given towards the end of this document. The candidate would summarize and discuss the scientific article critically. A faculty member will suggest the article and moderate the discussion, with participation by other faculty members and resident doctors. The contributions made by the article in furtherance of the scientific knowledge and limitations, if any, will be highlighted.

Research: The student would carry out the research project and write a thesis/ dissertation in accordance with NBE guidelines. He/ she would also be given exposure to partake in the research projects going on in the departments to learn their planning, methodology and execution so as to learn various aspects of research.

SYLLABUS

The following pages comprise schedules of knowledge and operative skills, which provide a syllabus for training in general surgery and its sub-specialties. The knowledge required includes the basic science relevant to each topic. There is no intention to limit knowledge and operative experience. Trainees, as part of their general surgical training, must acquire competence in the scheduled operations but will also have experience of other procedures from the sub- specialty departments.

Knowledge: The Postgraduates are required to acquire sound knowledge of the below listed topics. The list includes topics found in most standard surgical textbooks. The candidates should also be familiar with recent advances and current controversies.

Applied Basic Sciences include applied anatomy, physiology, biochemistry, microbiology, pharmacology and pathology.

General Surgical Topics include the following:

History of Surgery
Molecular and Cell Biology
Mediators of Inflammatory Response
Regenerative Medicine
Fluids and Electrolyte balance/ Acid – Base metabolism
Wound Healing and Wound Management
Pathophysiology and Management of Shock
Principles of Operative Surgery: Asepsis, Sterilization and Antiseptics
Surgical Infections and Antibiotics
Nutrition and Metabolism
Principles of Burn Management
Principles of Oncology
Principles of Laparoscopy, Endoscopy and Robotics
Hemostasis, Blood Transfusion
Trauma: Assessment of polytrauma, triage, basic and advanced trauma
Basic Principles of Anesthesia
Informed Consent and Medico legal Issues

Pediatric Surgery
Organ Transplantation
Molecular Biology and Genetics
Hernias: Types of hernias, repair techniques
Breast Diseases: Benign breast disorders, investigations, screening, genetics, Breast Cancer
Thyroid Disorders: Solitary nodule, investigations, multinodular goiter, Graves disease malignancies
GIT Diseases
Urogenital disease
Cardio thoracic disease
Hepatobilary disease
Surgery in CNS disorder
Diabetes and Renal failure in Surgery
HIV AIDS in Surgery (Universal Safety precautions)

3.Imaging modalities in Surgery

X-ray and Angiography
MRI, Ultrasound, CT, PET, Etc.
Image guided interventional procedures

PRE-OPERATIVE MANAGEMENT

Pre-operative Management

Assessment of fitness for anesthesia and surgery.
Tests of respiratory, cardiac and renal function.
Management of associated medical conditions, e.g.: diabetes; respiratory disease, cardiovascular disease; malnutrition; anemia; steroid, anticoagulant, Immunosuppressant and other drug therapy.
Nutritional Management

Infection

Pathophysiology of the body’s response to infection.
The sources of surgical infection - prevention and control.
Surgically important micro-organisms.
Principles of asepsis and antisepsis.
Surgical sepsis and its prevention.
Aseptic techniques.
Skin preparation.
Antibiotic prophylaxis.
Sterilisation.
HIV

Investigative and Operative Procedures

Excision of cysts and benign tumours of skin and subcutaneous tissue.
Principles of techniques of biopsy.
Suture and ligature materials.
Drainage of superficial abscesses.
Basic principles of bowel anastomosis.

Anesthesia

Principles of anesthesia.
Pre-medication and sedation.
Local and regional anesthesia.
Care and monitoring of the anaesthetized patient.

Theatre Problems

Surgical technique and technology.
Diathermy - principles and precautions.
Lasers - principles and precautions.
Explosion hazards relating to general anesthesia and endoscopic Surgery.
Tourniquets - uses and precautions.
Prevention of nerve and other injuries in the anaesthetized patient.
Surgery in hepatitis and HIV carriers (special precautions).
Disorders of coagulation and haemostasis (prophylaxis of thromboembolic disease).

PRE-OPERATIVE MANAGEMENT

Skin and Wounds

Pathophysiology of wound healing.
Classification of surgical wounds.
Principles of wound healing.
Incisions and their closure.
Suture and ligature materials.
Scars and contracture.
Wound dehiscence.
Dressings.

Fluid Balance

Assessment and maintenance of fluid and electrolyte balance.

Techniques of venous access.
Nutritional support - indications, techniques, total parenteral nutrition.

Blood

Disorders of coagulation and haemostasis.
Blood transfusion - indications, hazards, complications, plasma substitutes.
Haemolytic disorders of surgical importance.
Haemorrhagic disorders; disorders of coagulation.

Post-operative Complications

Post-operative complications - prevention, monitoring, recognition, management.
Ventilatory support - indications.

Post-operative Sequelae

Pain control
Immune response to trauma, infections and tissue transplantation.
Pathophysiology of the body’s response to trauma.
Surgery in the immuno-compromised patient.

TRAUMA

Initial Assessment and Resuscitation after Trauma

Clinical assessment of the injured patient.
Maintenance of airway and ventilation.
Hemorrhage and shock. BLS, ATLS

Chest, Abdomen and Pelvis

Cardio respiratory physiology as applied to trauma.
Penetrating chest injuries and pneumothorax.
Rib fractures and flail chest.
Abdominal and pelvic injuries.

Central Nervous System Trauma

Central nervous system: anatomy and physiology relevant to clinical examination of the central nervous system; understanding of its functional

disorders particularly those caused by cranial or spinal trauma; and interpretation of special investigations.

Intracranial hemorrhage.
Head injuries, general principles of management.
Surgical aspects of meningitis.
Spinal cord injury and compression.
Paraplegia and quadriplegia - principles of management.

Special Problems

Pre-hospital care.
Triage.
Trauma scoring systems.
Traumatic wounds - principles of management.
Gunshot and blast wounds.
Skin loss - grafts and flaps.
Burns.
Facial and orbital injuries.

Principles of Limb Injury

Peripheral nervous system - anatomy and physiology.
Fractures - pathophysiology of fracture healing.
Non-union delayed union, complications.
Principles of bone grafting.
Traumatic edema, compartment and crush syndromes, fat embolism.
Brachial plexus injury.

INTENSIVE CARE

Cardiovascular

The surgical anatomy and applied physiology of the heart relevant to clinical cases.
Physiology and pharmacological control of cardiac output, blood flow, blood pressure, and coronary circulation.
Cardiac arrest, resuscitation.
Monitoring of cardiac function in the critically ill patient, central venous pressure, pulmonary wedge pressure, tamponade, cardiac O/P measurements.
The interpretation of special investigations.
The management of hemorrhage and shock.
Pulmonary edema.
Cardiopulmonary bypass - general principles, cardiac support.

Respiratory

The surgical anatomy of the airways, chest wall, diaphragm and thoracic viscera.
The mechanics and control of respiration.
The interpretation of special investigations; lung function tests, arterial blood gases, radiology.
The understanding of disorders of respiratory function caused by trauma, acute surgical illness and surgical intervention.
Respiratory failure.
Complications of thoracic operations.
Adult respiratory distress syndrome.
Endotracheal intubation, laryngotomy, tracheostomy.
Artificial ventilation.

Multisystem Failure

Multisystem failure.
Renal failure - diagnosis of renal failure, complications of renal failure.
GI tract and hepatic failure.
Nutrition.

Problems in Intensive Care

Sepsis, predisposing factors, organisms causing septicemia.
Complications of thoracic operations.
Localized sepsis, pneumonia, lung abscess, bronchiectasis, empyema, mediastinitis.

Principles of ICU

Indications for admission.
Organization and staffing.
Scoring.
Costs.

NEOPLASIA: TECHNIQUES AND OUTCOME OF SURGERY

Principles of Oncology

Epidemiology of common neoplasms and tumour-like conditions; role of cancer registries.
Clinico-pathological staging of cancer.

Pathology, clinical features, diagnosis and principles of management of common cancers in each of the surgical specialties.
Principles of cancer treatment by surgery, radiotherapy, chemotherapy, immunotherapy and hormone therapy.
The principles of carcinogenesis and the pathogenesis of cancer relevant to the clinical features, special investigations, staging and the principles of treatment of the common cancers.
Principles of molecular biology of cancer, carcinogenesis; genetic factors; mechanisms of metastasis.
Tumor Biology and Tumor Markers

Cancer Screening and Treatment

The surgical anatomy and applied physiology of the breast relevant to clinical examinations, the interpretation of special investigations, the understanding of disordered function and the principles of the surgical treatment of common disorders of the breast.

The breast: acute infections; benign breast disorders; nipple discharge; mastalgia, Carcinoma of breast; mammography; investigation and treatment.
Screening program

Techniques of Management

Terminal care of cancer patients; pain relief.
Rehabilitation.
Psychological effects of surgery and bereavement.

Ethics and the Law

Medical/legal ethics and medico-legal aspects of surgery.
Communication with patients, relatives and colleagues.

Outcome of Surgery

The evaluation of surgery and general topics.
Decision-making in surgery.
Clinical audit.
Statistics and computing in surgery.
Principles of research and design and analysis of clinical trials.
Critical evaluation of innovations - technical and pharmaceutical.
Health service management and economic aspects of surgical care.

LOCOMOTOR SYSTEM

Musculo-skeletal anatomy and physiology relevant to clinical examination of the locomotor system and to the understanding of disordered locomotor function, with emphasis on the effects of acute musculoskeletal trauma.

Effects of Trauma and Lower Limb

Effects of acute musculo-skeletal trauma.
Common fractures and joint injuries.
Degenerative and rheumatoid arthritis (including principles of joint replacement).
Common disorders of the lower limb.
Amputations and prosthesis.

Infections and Upper Limb

Common soft tissue injuries and disorders.
Infections of bones and joints (including implants and prostheses).
Pain in the neck, shoulder and arm.
Common disorders of the hand, including hand injuries and infections.

Bone Disease and Spine

Common disorders of infancy and childhood.
Low back pain and sciatica.
Metabolic bone disease (osteoporosis, osteomalacia).
Surgical aspects of paralytic disorders and nerve injuries.

VASCULAR

The surgical anatomy and applied physiology of blood vessels relevant to clinical examination, the interpretation of special investigations and the understanding of the role of surgery in the management of cardiovascular disease

Arterial Diseases

Chronic obliterative arterial disease.
Amputations.
Aneurysms.
Carotid disease.
Special techniques used in the investigation of vascular disease.

Limb ischaemia: acute and chronic; clinical features; gangrene; amputations for vascular disease.
Principles of reconstructive arterial surgery.
Atherosclerosis
Principles of Angioplasty/stenting
Thrombolysis
Reno-vascular disease
Raynaud’s/vasospastic disorders
Lymphoedema
Cerebrovascular disease
Vasculitis
Mesenteric ischaemia
Graft prosthetics
Graft surveillance
Autonomic dysfunction
Reperfusion injury
Ischaemic limb Arterial trauma
Hyper/hypo coagulable state
Arteriography
Continuous wave doppler
Duplex ultrasound

Venous Diseases

Vascular trauma and peripheral veins.
Varicose veins.
Venous hypertension, post-phlebitic leg, venous ulceration.
Disorders of the veins in the lower limb.
Deep venous thrombosis and its complications.
Chronic ulceration of the leg.
Thrombosis and embolism.

Lymphatics and Spleen

Thromboembolic disease.
Spleen; role of splenectomy; hypersplenism.
Lymph nodes; lymphoedema.
Surgical aspects of auto-immune disease.
The anatomy and physiology of the haemopoeitic and lymphoreticular systems.
Surgical aspects of disordered haemopoiesis.

HEAD, NECK and ENDOCRINE

The surgical anatomy and applied physiology of the head and neck relevant to clinical examination, the interpretation of special investigations, the understanding of disorders of function, and the treatment of disease and injury involving the head and neck.

The Head

Laryngeal disease; maintenance of airway; tracheostomy.
Acute and chronic inflammatory disorders of the ear, nose, sinuses and throat.
Intracranial complications.
Foreign bodies in ear, nose and throat.
Epistaxis.
Salivary gland disease.
The eye - trauma, common infections.

Neck and Endocrine Glands

The surgical anatomy and applied physiology of the endocrine glands relevant to clinical examination, the interpretation of special investigations, the understanding of disordered function and the principles of the surgical treatment of common disorders of the endocrine glands.

Common neck swellings.
Thyroid: role of surgery in diseases of the thyroid; complications of thyroidectomy; and the solitary thyroid nodule.
Parathyroid; hyperparathyroidism; hypercalcaemia.
Secondary hypertension.
Pituitary Gland
Adrenal cortex
Adrenal medulla
Gut as endocrine organ
Endocrine pancreas and the management of:-
Thyrotoxicosis
Adrenal insufficiency
Hyper/hypo thyroidism
Carcinoid syndrome
Counselling and screening in familial disease
Anaesthetic and pharma-cological problems
Radio-immuno assays
Imaging techniques
Histo/cyto pathology

Skin in Surgical Disorders

Skin and Subcutaneous Tissue / soft tissue

Paediatric Surgical Disorders

Neonatal physiology: the special problems of anaesthesia and surgery in the newborn; and the principles of neonatal fluid and electrolyte balance.
Correctable congenital abnormalities.
Common paediatric surgical disorders: cleft lip and palate; pyloric stenosis; intussusception; hernia; maldescent of testis; torsion; and diseases of the foreskin.
RIF pain
Testicular pain
Paediatric trauma
Burns
Intussusception
Pyloric stenosis
Hirschprung’s disease
Ano-rectal anomalies
Tracheo-oesophageal fistula
Spina bifida
Congenital small bowel obstruction
Intestinal malrotation
Associated anomalies
Paediatric oncology
Management of less complex abdominal trauma
Hydrocephalus

ABDOMEN

The surgical anatomy of the abdomen and its viscera and the applied physiology of the alimentary system relevant to clinical examination, the interpretation of common special investigations, the understanding of disorders of function, and the treatment of abdominal disease and injury.

Abdominal Wall

Anatomy of the groin, groin and other ventral hernias, acute and elective; clinical features of hernias; complications of hernias.
Anterior abdominal wall, anatomy, incisions, laparoscopic access.

Acute Abdominal Conditions

Peritonitis; intra-abdominal abscesses.
Common acute abdominal emergencies.
Intestinal obstruction; paralytic ileus.
Intestinal fistulae.
Investigation of abdominal pain.
Investigation of abdominal masses.
Gynaecological causes of acute abdominal pain.
Pelvic inflammatory disease.
Assessment of the acute abdomen
Appendicitis and right iliac fossa pain
Peritonitis
Acute intestinal obstruction
Intestinal pseudo-obstruction
Biliary tract emergencies
Acute pancreatitis
Strangulated hernia
Intestinal ischaemia
Swallowed foreign bodies
Gastrointestinal bleeding
Toxic megacolon
Superficial sepsis and abscesses
Acute ano-rectal sepsis
Ruptured aortic aneurysm
Acute presentations of urological disease
Acute presentations of gynaecological disease
Sub-total colectomy
Diagnostic laparoscopy
Gastrectomy for bleeding
Endoscopy for upper GI obstruction
Laparotomy for perforated colon
Suture of bleeding peptic ulcer
Emergency cholecystectomy
Exploration of scrotum for torsion
Emergency hernia repair
Laparotomy for abdominal
Reduction of paraphimosis
Laparotomy for small bowel injury
Diagnostic peritoneal lavage
Intestinal obstruction
Splenic repair
Hartmann’s operation
Operation for ruptured liver

Pancreatic debridement
Median sternotomy

Reconstructive Surgery

Myocutaneous flaps
Tissue expanders
Breast reduction

Colorectal

Therapeutic Endoscopy, colonoscopy
Anterior resection of rectum
AP resection of rectum
Ileorectal anastomosis
Panproctocolectomy
Closure of Hartmann’s
Prolapse surgery
Incontinence surgery
Sphincter repair
Recto-vaginal fistula
Ileo-anal and colonic pouch
Colo-anal anastomosis
Operation for intestinal fistula
Complex fistula-in-ano
Posterior approach to rectum
Block dissection of groin
Operative cholangiography
Laparoscopic suturing and knotting
Nephrectomy
Pyelo and ureterolithotomy
Pyeloplasty
Open prostatectomy

Laparotomy for acute abdomen

Splenectomy
Oesophageal dilatation
Operations for upper GI bleeding
Exploration of common bile duct
Biliary bypass
Formation of Roux-en-Y loop
Oesophagectomy/total gastrectomy
Pancreatectomy

Liver resection
Oesophagectomy
Total and subtotal gastrectomy
Heller’s myotomy
Long oesophageal myotomy
Pharyngeal pouch
Repair of biliary stricture
Whipple’s procedure
Pancreatectomy (distal and total)
Drainage of infected pancreatitis
Drainage of pancreatic pseudo-cyst
Liver injuries
Hydatid disease
Porto-systemic shunt
Vascular suture/anastomosis
Control of venous bleeding
Balloon thrombo-embolectomy
Fasciotomy
Artenal injuries
Vascular access for dialysis

Abdominal injury

Assessment of the multiply injured patient
Triage (major accidents)
Battle triage and Field hospitals
Initial management of head injuries.
Closed abdominal injuries, especially splenic, hepatic and pancreatic injuries
Closed chest injuries
Stab and gunshot wounds
Arterial injuries
Injuries of the urinary tract
Initial management of head injuries and interpretation of CT scans
Initial management of severe burns

SMALL BOWEL AND COLORECTAL DISORDERS

Neoplasms of large bowel
Inflammatory bowel disease (inc.medical management)
Diverticular disease
Irritable bowel syndrome

Haemorrhoids
Anal fissure
Rectal prolapse
Acute appendicitis/RIF pain
Intestinal obstruction
Intestinal pseudo-obstruction
Intestinal ischaemia
Peritonitis
Large bowel and rectal injuries
Anal tumours
Pelvic autonomic nerves
Screening for colorectal cancer
Genetics of colorectal cancer
Place of radiotherapy and chemotherapy in treatment
Anorectal physiology
Anorectal ultrasound
Faecal incontinence
Chronic constipation
Intestinal fistulae
Colonic bleeding
Radiation enterocolitis
Other small bowel conditions
Colonic obstruction
Colonic perforation
The use of staplers

LAPAROSCOPIC SURGERY AND MINIMAL ACCESS SURGERY

Laparoscopic anatomy of the abdomen
Diagnostic laparoscopy
Physiology of pneumo-peritoneum Dangers of pneumoperitoneum
Principles of diathermy
Informed consent for laparo-scopic procedures
Pre and post operative management of laparoscopic cases
Port complications
Technology of video imaging, cameras, insufflator etc.
The methods of manipulation of images
Laparoscopic instruments, clips, staplers and port types
Management of equipment failure
Ultrasound interpretation, internal and external techniques
Recognition and management of laparoscopic complications
Use and dangers of diathermy
Anaesthetic problems in laparoscopic surgery
Medico-legal implications of video-endoscopic surgery

Theory and pracice of choledocho-scopy
Theory of different forms of diathermy
Laparoscopic ultrasound
Advanced instrumentation and equipment
Endoscopic suturing devices
Theory, uses and dangers of lasers and other energy sources e.g. harmonic scalpel
Creation and maintenance of new endoscopic spaces
Use of assistance robots and robotic instruments

TRANSPLANTATION with special reference to RENAL AND HEPATIC DISEASE

Pathology of renal and hepatic disease
Patho-physiology of renal and hepatic failure
Peritoneal- and haemo-dialysis
Management of fluid and electrolyte disorders
Selection of patients for transplantation
Post-operative management
Immuno-pathology of rejection
Management of rejection
Immunosuppression
Opportunist infections
Immunosuppression and cancer
Transmission of viral and fungal diseases
Tissue typing
The HLA system
Bladder dysfunction

HEPATOPANCREATOBILIARY SURGERY

• Gallstones and complications
• Biliary stricture
• Obstructive Jaundice
• Neoplasms of the Liver, Biliary Tract and Pancreas
• Pancreatitis, acute and chronic, complications
• Liver injuries
• Portal Hypertension
• Hydatid disease
• ESRD and Liver transplatation

UPPER GI TRACT

Neoplasms of the upper GI tract

Management of perforations of the upper GI tract
Management of intestinal obstruction
Management of GI bleeding
Oesophageal motility disorders
Oesophageal Strictures
Gastro-oesophageal reflux and its complications
Peptic ulceration and its complications
Radiation enteritis
Abdominal trauma
Principles of screening for cancer
The use and limitations of multimodality treatment for upper GI cancer
Oesophageal motility disorders
Other small bowel conditions
Principles of Small bowel resection
Sutured and stapled anastomoses
Genito Urinary Tract
Urinary tract infection.
Urinary Tract Obstruction
Haematuria.
Trauma to the urinary tract.
Urinary calculi.
Retention of urine.
Urinary tract Neoplasm
Disorders of prostate.
Pain and swelling in the scrotum.
Other Scrotal Lesions
Testicular Neoplasm

NEUROSURGERY

Cranial, spinal and peripheral nerve tumors
Head Injury
Spinal and peripheral nerve injuries
Hydrocephalus
Cerebrovascular Accidents
Infections
Recent advances

CARDIAC AND THORASIC SURGERY

Myocardial revascularization
Valvular Disorders
Peripheral vascular disease
Reno vascular disease

Secondary Hypertension
Inflammatory Lung Disease
Chest Wall lesions
Thoracic Neoplastic Disease
Chest Trauma
Pleural Diseases

ORTHOPEDICS

Principles of Orthopedic Trauma
Casts and braces
Nerve injuries
Hand Infections
Principles of Traction
Amputations
Principles of Rehabilitation
Congenital Lesions
Bone and Joint Infections

OTHER AREAS

Biostatistics, Research Methodology and Clinical Epidemiology
Ethics
Medico legal aspects relevant to the discipline
Health Policy issues as may be applicable to the discipline

CLINICAL POSTINGS

Surgical Posting: Each candidate is posted in different surgical units soon after joining the course

Rotations in Specialty Departments are for a period of minimum 3-6 months & a maximum of one year. This is done after candidate has spent at least 1 year in learning basic ward work and surgical skills in the surgical unit.

The postgraduate student rotates through all the clinical units in the department. In addition, following special rotations are also undertaken:

Mandatory Postings (minimum 15 Days in each)

Cardiothroracic/ Thoracic Surgery
Orthopedic Surgery
Neuro Surgery

He should have assisted at least 2 procedures in the above mentioned areas

The rest of the postings in other specialties should be as per the choice of the candidates or as per interim arrangement and if no other areas of posting is being undertaken by the candidate the above mentioned mandatory postings should be increased to a period of minimum one month each.

Rotational Postings (Optional)

Radiology (2 weeks)
Anaesthesia (2 weeks)
Gynae & Obs. (2 weeks)
Emergency (2 weeks)
Urology (6 weeks)
Pediatric Surgery (6 weeks)
ICU (6 weeks)
Bariatric Surgery (6 weeks)
Minimally Invasive Surgery (6 weeks)

If the institution does not have these departments, they should have a local tie up with a suitable hospital for imparting this training.

Competencies

Objectives

To provide a comprehensive and structured training programme in general surgery and to enable trainees to achieve the training and experience necessary for independent practice.
The PG should be able to take proper history, conduct physical examination, perform or request for relevant investigations. He should be able to interpret these investigations to arrive at a working diagnosis along with a list of differential diagnosis. He should be able to develop and management plan which should be well documented and any emergency management should be initiated immediately if required.
Communicate with patient. Discuss operative plan, possible management options, postoperative complications etc and be able to take informed consent
Perform minor operative procedures and common major general surgical operations independently
Evaluate and manage trauma and acute surgical emergencies.
Undertake Critical care
Undertake wound management

The skills should be differentiated into:

Essential
Desirable

Surgical Skills: Essential

Scrubbing(surgical hand wash and donning of gowns and gloves) & Patient part preparation and draping

Working knowledge of sterilization of OT instruments including Laparoscopic Set
Knowledge of Surgical Material, sutures and Instruments
Electro Surgical Units
Shifting of OT patients
WHO Safety check list implementation
Acquisition of basic surgical skills to perform minor/medium surgeries independently Suprapubic cystostomy
Cystolithotomy
Varicocele
Orchidectomy
Excision of Cyst & I&D
Excision of Breast Lump
Surgery of Hydrocele
Appendectomy
Herniotomy
Hernia repair (ventral & groin) and management
Umblical hernia
Exploratory laparotomy in different conditions
Haemorrhoidectomy
Fistulectomy
Fissurectomy
Circumcision
Skin grafting
Stoma Formation

Desirable

Urethral Dilatation
Ureterolithotomy

Basic Ward Procedures

Essential

Insertion of intravenous cannula, Nasogastric tube, urinary catheters
Removal of Tubes and Drains
Abdominal Paracentesis, Pleural Tap
Venous Cutdown
Wound dressings

Desirable

Taking blood samples

ICU Procedures Essential

Insertion of CVP line, arterial lines, endotracheal intubation
Intercostal Drainage
Tracheostomy
Knowledge of Ventilators and Monitors
Prescribing TPN
Taking an ABG Sample and its Interpretation -E

Minor Surgical Procedures Essential

Hydrocele surgery
Lymph node biopsy
Excision of superficial swellings
Ingrowing toe nail
Banding of Haemrrhoids
Vasectomy
Trucut Biopsy

Emergency Room Procedures Essential

Peritoneal lavage
Suturing of lacerations
Drainage of abscesses
Wound Debridement
Reduction and Plaster application of Common simple fractures and dislocations
Use of external fixators in compound fractures
Skeletal traction
Anal Dilatation and Sphincterotomy
Preoperative Workup and Postoperative Care

Desirable

Focussed Abdominal Sonography for Trauma

Major Operative Procedures

Perform Independently/ Assistance:

The following list is not exhaustive. The Trainee should try to get the maximal operative exposure possible. The range of exposure will also depend upon the type of surgeries a particular unit (where the Trainee is posted) is performing.

Routine

Essential

Cholecystectomy
Groin Hernia Repair
Mastectomy
Breast Lump Excision
Suprapubic cystostomy

Bowel Resection
Feeding Gastrostomy and feeding jejunostomy
Emergency Nephrectomy
Orchidopexy

Desirable

Microdochectomy
Radical Duct Excision
Hemithyroidectomy
Cystogastrostomy
Bowel Anastamosis
Cysts and Sinuses of the Neck
Pyelolithotomy
Ureterolithotomy
Varicose vein surgery and Vein harvesting

Emergency: Essential

Appendectomy
Laparotomy for intestinal Obstruction
Trauma Laparotomy
Splenectomy
Closure of Peptic Ulcer Perforation
Enteric Perforation
Amputations
Tracheostomy

B)Assist/Observe

The below mentioned skills and procedures are desirable for a DNB General Surgery resident:

Vascular

Reconstructive arterial surgery.
Aneurysm Surgery

The Head

Parotidectomy, submandibular gland excision

Neck and Endocrine Glands

Thyroidectomy, parathyroidectomy, congenital or developmental problems
Adrenalectomy
Surgery for endocrine pancreatic tumours

Paediatric Disorders

Common paediatric surgical disorders: cleft lip and palate; pyloric stenosis; intussusception; hernia; maldescent of testis; torsion; and diseases of the foreskin.

Plastic And Reconstructive Surgery

Types of skin grafts, flaps, tissue expanders
Reconstructive surgery for head and neck, breast, bedsores and abdominal wall defects

C)Surgical Audit (Essential)

Bio Statistics
Surgical practice & medical legal aspects
Ethical surgical trials
Bio Medical Waste Management
Communication Skills

THESIS PROTOCOL & THESIS

The candidates are required to submit a thesis at the end of three years of training as per the rules and regulations of NBE.

Guidelines for Submission of Thesis Protocol & Thesis by candidates

Research shall form an integral part of the education programme of all candidates registered for DNB degrees of NBE. The Basic aim of requiring the candidates to write a thesis protocol & thesis/dissertation is to familiarize him/her with research methodology. The members of the faculty guiding the thesis/dissertation work for the candidate shall ensure that the subject matter selected for the thesis/dissertation is feasible, economical and original.

Guidelines for Thesis Protocol

The protocol for a research proposal (including thesis) is a study plan, designed to describe the background, research question, aim and objectives, and detailed methodology of the study. In other words, the protocol is the ‘operating manual’ to refer to while conducting a particular study.

The candidate should refer to the NBE Guidelines for preparation and submission of Thesis Protocol before the writing phase commences. The minimum writing requirements are that the language should be clear, concise, precise and consistent without excessive adjectives or adverbs and long sentences. There should not be any redundancy in the presentation.

The development or preparation of the Thesis Protocol by the candidate will help her/him in understanding the ongoing activities in the proposed area of research. Further it helps in creating practical exposure to research and hence it bridges the connectivity between clinical practice and biomedical research. Such research exposure will be helpful in improving problem solving capacity, getting updated with ongoing research and implementing these findings in clinical practice.

Research Ethics: Ethical conduct during the conduct and publication of research is an essential requirement for all candidates and guides, with the primary responsibility of ensuring such conduct being on the thesis guide. Issues like Plagiarism, not maintaining the confidentiality of data, or any other distortion of the research process will be viewed seriously. The readers may refer to standard documents for the purpose.

The NBE reserves the right to check the submitted protocol for plagiarism, and will reject those having substantial duplication with published literature.

PROTOCOL REQUIREMENTS

All of the following will have to be entered in the online template. The thesis protocol should be restricted to the following word limits.

Title : 120 characters (with spacing) page
Synopsis [structured] : 250-300
Introduction : 300-500
Review of literature : 800-1000
Aim and Objectives : Up to 200
Material and Methods : 1200-1600
10-25 References [ICMJE style]

It is mandatory to have ethics committee approval before initiation of the research work. The researcher should submit an appropriate application to the ethics committee in the prescribed format of the ethics committee concerned.

Guidelines for Thesis

The proposed study must be approved by the institutional ethics committee and the protocol of thesis should have been approved by NBE.

The thesis should be restricted to the size of 80 pages (maximum). This includes the text, figures, references, annexures, and certificates etc. It should be printed on both sides of the paper; and every page has to be numbered. Do not leave any page blank. To achieve this, following points may be kept in view:

The thesis should be typed in 1.5 space using Times New Roman/Arial/ Garamond size 12 font, 1” margins should be left on all four sides. Major sections viz., Introduction, Review of Literature, Aim & Objectives, Material and Methods, Results, Discussion, References, and Appendices should start from a new page. Study proforma (Case record form), informed consent form, and patient information sheet may be printed in single space.
Only contemporary and relevant literature may be reviewed. Restrict the introduction to 2 pages, Review of literature to 10-12 pages, and Discussion to 8-10 pages.
The techniques may not be described in detail unless any modification/innovations of the standard techniques are used and reference(s) may be given.
Illustrative material may be restricted. It should be printed on paper only. There is no need to paste photographs separately.

Since most of the difficulties faced by the residents relate to the work in clinical subject or clinically-oriented laboratory subjects, the following steps are suggested:
1. The number of cases should be such that adequate material, judged from the hospital attendance/records, will be available and the candidate will be able to collect case material within the period of data collection, i.e., around 6-12 months so that he/she is in a position to complete the work within the stipulated time.
2. The aim and objectives of the study should be well defined.
3. As far as possible, only clinical/laboratory data of investigations of patients or such other material easily accessible in the existing facilities should be used for the study.
4. Technical assistance, wherever necessary, may be provided by the department concerned. The resident of one specialty taking up some problem related to some other specialty should have some basic knowledge about the subject and he/she should be able to perform the investigations independently, wherever some specialized laboratory investigations are required a co-guide may be co-opted from the concerned investigative department, the quantum of laboratory work to be carried out by the candidate should be decided by the guide & co-guide by mutual consultation.

The clinical residents are not ordinarily expected to undertake experimental work or clinical work involving new techniques, not hitherto perfected OR the use of chemicals or radioisotopes not readily available. They should; however, be free to enlarge the scope of their studies or undertake experimental work on their own initiative but all such studies should be feasible within the existing facilities.

The DNB residents should be able to freely use the surgical pathology/autopsy data if it is restricted to diagnosis only, if however, detailed historic data are required the resident will have to study the cases himself with the help of the guide/co-guide. The same will apply in case of clinical data.

Statistical methods used for analysis should be described specifically for each objective, and name of the statistical program used mentioned.

General Layout of a DNB Thesis:

Title- A good title should be brief, clear, and focus on the central theme of the topic; it should avoid abbreviations. The Title should effectively summarize the proposed research and should contain the PICO elements.

Introduction- It should be focused on the research question and should be directly relevant to the objectives of your study.

Review of Literature - The Review should include a description of the most relevant and recent studies published on the subject.

Aim and Objectives - The ‘Aim’ refers to what would be broadly achieved by this study or how this study would address a bigger question / issue. The ‘Objectives’ of the research stem from the research question formulated and should at least include participants, intervention, evaluation, design.

Material and Methods- This section should include the following 10 elements: Study setting (area), Study duration; Study design (descriptive, case-control, cohort, diagnostic accuracy, experimental (randomized/non- randomized)); Study sample (inclusion/exclusion criteria, method of selection), Intervention, if any, Data collection, Outcome measures (primary and secondary), Sample size, Data management and Statistical analysis, and Ethical issues (Ethical clearance, Informed consent, trial registration).

Results- Results should be organized in readily identifiable sections having correct analysis of data and presented in appropriate charts, tables, graphs and diagram etc.

Discussion–It should start by summarizing the results for primary and secondary objectives in text form (without giving data). This should be followed by a comparison of your results on the outcome variables (both primary and secondary) with those of earlier research studies.

Summary and Conclusion- This should be a précis of the findings of the thesis, arranged in four paragraphs: (a) background and objectives; (b) methods; (c) results; and (d) conclusions. The conclusions should strictly pertain to the findings of the thesis and not outside its domain.

References- Relevant References should be cited in the text of the protocol (in superscripts).

Appendices -The tools used for data collection such as questionnaire, interview schedules, observation checklists, informed consent form (ICF), and participant information sheet (PIS) should be attached as appendices. Do not attach the master chart.

Thesis Protocol Submission to NBE

DNB candidates are required to submit their thesis protocol within 90 days of their joining DNB training.

Enclosures to be submitted along with protocol submission form:
1. Form for Thesis Protocol Submission properly filled.
2. Thesis Protocol duly signed.
3. Approval letter of institutional Ethical committee. (Mandatory, non receivable of any one is liable for rejection)

Thesis Submission to NBE

As per NBE norms, writing a thesis is essential for all DNB candidates towards partial fulfillment of eligibility for award of DNB degree.
DNB candidates are required to submit the thesis before the cut-off date which shall be 30th June of the same year for candidates appearing for their scheduled December final theory examination. Similarly, candidates who are appearing in their scheduled June DNB final examination shall be required to submit their thesis by 31st December of preceding year.
Candidates who fail to submit their thesis by the prescribed cutoff date shall NOT be allowed to appear in DNB final examination.
Fee to be submitted for assessment (In INR): 3500/-
Fee can be deposited ONLY through pay-in-slip/challan at any of the Indian bank branch across India. The challan can be downloaded from NBE website www.natboard.edu.in
Thesis should be bound and the front cover page should be printed in the standard format. A bound thesis should be accompanied with:
1. A Synopsis of thesis.
2. Form for submission of thesis, duly completed
3. NBE copy of challan (in original) towards payment of fee as may be applicable.
4. Soft copy of thesis in a CD duly labeled.
5. Copy of letter of registration with NBE.

A declaration of thesis work being bonafide in nature and done by the candidate himself/herself at the institute of DNB training need to be submitted bound with thesis. It must be signed by the candidate himself/herself, the thesis guide and head of the institution, failing which thesis shall not be considered.

The detailed guidelines and forms for submission of Thesis Protocol & Thesis are available at www.natboard.edu.in.thesis.php.

LOG BOOK

A candidate shall maintain a log book of operations (assisted / performed) during the training period, certified by the concerned post graduate teacher / Head of the department / senior consultant.

This log book shall be made available to the board of examiners for their perusal at the time of the final examination.

The log book should show evidence that the before mentioned subjects were covered (with dates and the name of teacher(s) The candidate will maintain the record of all academic activities undertaken by him/her in log book .

Personal profile of the candidate
Educational qualification/Professional data
Record of case histories
Procedures learnt
Record of case Demonstration/Presentations
Every candidate, at the time of practical examination, will be required to produce performance record (log book) containing details of the work done by him/her during the entire period of training as per requirements of the log book. It should be duly certified by the supervisor as work done by the candidate and countersigned by the administrative Head of the Institution.
In the absence of production of log book, the result will not be declared.

Leave Rules

DNB Trainees are entitled to leave during the course of DNB training as per the Leave Rules prescribed by NBE.
A DNB candidate can avail a maximum of 20 days of leave in a year excluding regular duty off/ Gazetted holidays as per hospital/institute calendar/policy.
MATERNITYLEAVE:
1. Afemale candidate is permitted a maternity leave of 90 days once during the entire duration of DNB course.
2. The expected date of delivery (EDD) should fall within the duration of maternity leave.
3. Extension of maternity leave is permissible only for genuine medical reasons and after prior approval of NBE. The supporting medical documents have to be certified by the Head of the Institute/hospital where the candidate is undergoing DNB training. NBE reserves its rights to take a final decision in such matters.
4. The training of the candidate shall be extended accordingly in case of any extension of maternity leave being granted to the candidate.
5. Candidate shall be paid stipend during the period of maternity leave. No stipend shall be paid for the period of extension of leave.
Male DNB candidates are entitled for paternity leave of maximum of one week during the entire period of DNB training.
No kind of study leave is permissible to DNB candidates. However, candidates may be allowed an academic leave as under across the entire duration of training program to attend the conferences/CMEs/Academic programs/Examination purposes.

DNB COURSE

NO. OF ACADEMIC LEAVE

DNB 3 years Course (Broad & Super Specialty)

14 Days

DNB 2 years Course (Post Diploma)

10 Days

DNB Direct 6 years Course

28 days

Under normal circumstances leave of one year should not be carried forward to the next year. However, in exceptional cases such as prolonged illness the leave across the DNB training program may be clubbed together with prior approval of NBE.
Any other leave which is beyond the above stated leave is not permissible and shall lead to extension/cancellation of DNB course.
Any extension of DNB training for more than 2 months beyond the scheduled completion date of training is permissible only under extra- ordinary circumstances with prior approval of NBE. Such extension is neither automatic nor shall be granted as a matter of routine. NBE shall consider such requests on merit provided the seat is not carried over and compromise with training of existing trainees in the Department.
Unauthorized absence from DNB training for more than 7 days may lead to cancellation of registration and discontinuation of the DNB training and rejoining shall not be permitted.
Medical Leave
1. Leave on medical grounds is permissible only for genuine medical reasons and NBE should be informed by the concerned institute/hospital about the same immediately after the candidate proceeds on leave on medical grounds.
2. The supporting medical documents have to be certified by the Head of the Institute/hospital where the candidate is undergoing DNB training and have to be sent to NBE.
3. The medical treatment should be taken from the institute/ hospital where the candidate is undergoing DNB training. Any deviation from this shall be supported with valid grounds and documentation.
4. In case of medical treatment being sought from some other institute/hospital, the medical documents have to be certified by the Head of the institute/hospital where the candidate is undergoing DNB training.

NBE reserves its rights to verify the authenticity of the documents furnished by the candidate and the institute/hospital regarding Medical illness of the candidate and to take a final decision in such matters.
1. Total leave period which can be availed by DNB candidates is 120+28 = 148 days for 6 years course, 60+14=74 days for 3 years course and 40+10 = 50 days for 2 years course. This includes all kinds of eligible leave including academic leave. Maternity / Paternity leave can be availed separately by eligible candidates. Any kind of leave including medical leave exceeding the aforementioned limit shall lead to extension of DNB training. It is clarified that prior approval of NBE is necessary for availing any such leave.
2. The eligibility for DNB Final Examination shall be determined strictly in accordance with the criteria prescribed in the respective information bulletin.

EXAMINATION

FORMATIVE ASSESSMENT

Formative assessment includes various formal and informal assessment procedures by which evaluation of student’s learning, comprehension, and academic progress is done by the teachers/ faculty to improve student attainment. Formative assessment test (FAT) is called as “Formative “as it informs the in process teaching and learning modifications. FAT is an integral part of the effective teaching .The goal of the FAT is to collect information which can be used to improve the student learning process.

Formative assessment is essentially positive in intent, directed towards promoting learning; it is therefore part of teaching. Validity and usefulness are paramount in formative assessment and should take precedence over concerns for reliability. The assessment scheme consists of Three Parts which has to be essentially completed by the candidates.

The scheme includes:-

Part I:- Conduction of theory examination

Part-II :- Feedback session on the theory performance Part-III :- Work place based clinical assessment

Scheme of Formative assessment

PART – I

CONDUCT OF THEORY EXAMINATION

Candidate has to appear for Theory Exam and it will be held for One day.

PART – II

FEEDBACK SESSION ON THE THEORY PERFORMANCE

Candidate has to appear for his/her Theory Exam Assessment Workshop.

PART – III

WORK PLACE BASED CLINICAL ASSESSMENT

After Theory Examination, Candidate has to appear for Clinical Assessment.

The performance of the resident during the training period should be monitored throughout the course and duly recorded in the log books as evidence of the ability and daily work of the student

1.Personal attributes:

Behavior and Emotional Stability: Dependable, disciplined, dedicated, stable in emergency situations, shows positive approach.
Motivation and Initiative: Takes on responsibility, innovative, enterprising, does not shirk duties or leave any work pending.

Honesty and Integrity: Truthful, admits mistakes, does not cook up information, has ethical conduct, exhibits good moral values, loyal to the institution.
Interpersonal Skills and Leadership Quality: Has compassionate attitude towards patients and attendants, gets on well with colleagues and paramedical staff, is respectful to seniors, has good communication skills.

2.Clinical Work:

Availability: Punctual, available continuously on duty, responds promptly on calls and takes proper permission for leave.
Diligence: Dedicated, hardworking, does not shirk duties, leaves no work pending, does not sit idle, competent in clinical case work up and management.
Academic ability: Intelligent, shows sound knowledge and skills, participates adequately in academic activities, and performs well in oral presentation and departmental tests.
Clinical Performance: Proficient in clinical presentations and case discussion during rounds and OPD work up. Preparing Documents of the case history/examination and progress notes in the file (daily notes, round discussion, investigations and management) Skill of performing bed side procedures and handling emergencies.

Academic Activity: Performance during presentation at Journal club/ Seminar/ Case discussion/Stat meeting and other academic sessions. Proficiency in skills as mentioned in job responsibilities.

FINAL EXAMINATION

The summative assessment of competence will be done in the form of DNB Final Examination leading to the award of the degree of Diplomate of National Board in General Surgery. The DNB final is a two-stage examination comprising the theory and practical part. An eligible candidate who has qualified the theory exam is permitted to appear in the practical examination.

Theory Examination

The theory examination comprises of Four papers, maximum marks 100 each.
There are 10 short notes of 10 marks each, in each of the papers. The number of short notes and their respective marks weightage may vary in some subjects/some papers.
Maximum time permitted is 3 hours.
Candidate must score at least 50% in the aggregate of Four papers to qualify the theory examination.

Candidates who have qualified the theory examination are permitted to take up the practical examination.
The paper wise distribution of the Theory Examination shall be as follows:

PAPER 1:

Basic sciences applied to the specialty
Principles of General Surgery
Perioperative care
Trauma and critical care
Research Methodology

PAPER 2:

Elective Orthopedics
Skin and Subcutaneous Tissue / soft tissue
Head and Neck
Breast and Endocrine

PAPER 3:

Vascular
Abdominal

PAPER 4:

Genitourinary and other subspecialites
Transplantation
Recent Advances

a)Practical Examination:

Maximum Marks: 300.
Comprises of Clinical Examination and Viva.
Candidate must obtain a minimum of 50% marks in the Clinical Examination (including Viva) to qualify for the Practical Examination.
There are a maximum of three attempts that can be availed by a candidate for Practical Examination.

First attempt is the practical examination following immediately after the declaration of theory results.
Second and Third attempt in practical examination shall be permitted out of the next three sessions of practical examinations placed alongwith the next three successive theory examination sessions; after payment of full examination fees as may be prescribed by NBE.
Absentation from Practical Examination is counted as an attempt.
Appearance in first practical examination is compulsory;
Requests for Change in center of examination are not entertained, as the same is not permissible.
Candidates are required not to canvass with NBE for above.

Declaration of DNB Final Results

DNB final is a qualifying examination.
Results of DNB final examinations (theory & practical) are declared as PASS/FAIL.
DNB degree is awarded to a DNB trainee in the convocation of NBE.

RECOMMENDED TEXT BOOKS AND JOURNALS

Essential

Bailey and Love’s Short practice of Surgery
Textbook of Surgery by David C Sabistion Jr. WB Saunders Co Or Schwartz-Principles of Surgery
Textbook of Operative Surgery – Farquharson Eric L
Clinical Methods – K Das
Recent advances in Surgery by Taylor
Applied Anatomy by RJ Last
Hamilton Bailey Demonstration of Clinical signs & Symptoms in surgery
Emergency Surgery By Hamilton Baily