|Year : 2015 | Volume
| Issue : 1 | Page : 39-43
Post graduate training program in ophthalmology in India: Idealistic vs realistic
Shagun Dhaliwal1, Ramesh S Ayyala2
1 Department of Ophthalmology and Visual Sciences, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
2 Department of Ophthalmology, Tulane School of Medicine, New Orleans, Los Angeles, USA
|Date of Submission||24-Sep-2014|
|Date of Acceptance||26-Sep-2014|
|Date of Web Publication||14-Jan-2015|
Ramesh S Ayyala
Department of Ophthalmology, Tulane University School of Medicine, 1430 Tulane Avenue SL-69, New Orleans, Los Angeles 70112
Source of Support: None, Conflict of Interest: None
Purpose: To propose a novel internet based digital course to help standardize post-graduate education in Ophthalmology across all programs in India. Problem: India needs, at the least, 25,000 ophthalmologists by the year 2020, which would require growth at the rate of 300 additional training slots per year. However, lack of standardization and unequal distribution of resources in the training programs resulted in poor quality of training across most programs. We suggest that by examining the post-graduate training programs of the United States of America (USA) and United Kingdom (UK), one can formulate a standardized method of training safe, effective and efficient b>Proposed Solution: We propose that establishing a set of comprehensive, agreed-upon goals of training implemented by most programs would standardize ophthalmology post graduate training in India. These goals are defined by the following competency domains: Clinical training, surgical training, academic activities and resident as a Teacher. The most cost and resource effective way to achieve these goals may be by using internet based novel digital courseware. As exemplified by the training programs of the UK and USA, the proposed courseware will put forth a clearly defined curriculum which includes detailed methods of asessment and feedback.
Keywords: Minimum standards in surgical training, online courseware, post graduate training, standardization
|How to cite this article:|
Dhaliwal S, Ayyala RS. Post graduate training program in ophthalmology in India: Idealistic vs realistic. J Clin Ophthalmol Res 2015;3:39-43
|How to cite this URL:|
Dhaliwal S, Ayyala RS. Post graduate training program in ophthalmology in India: Idealistic vs realistic. J Clin Ophthalmol Res [serial online] 2015 [cited 2021 May 17];3:39-43. Available from: https://www.jcor.in/text.asp?2015/3/1/39/149375
India has shown a unique ability to implement public health programs to eradicate notoriously difficult to control diseases. India has been able to eliminate smallpox entirely and has substantially decreased the incidence of onchocerciasis, trachoma and vitamin A deficiency.  This history suggests that the developing nation of India may be primed to tackle one of its biggest challenges to date: Effective eye care.
Despite a history of successful public health interventions, blindness and effective eye care continue to be problems that plague the Indian health care system. In order to confront this issue India needs, at the least, 25,000-30,000 ophthalmologists by the year 2020, which would require growth at the rate of 300 additional training slots per year.  However, Thomas and Dogra have shown that the poor quality of training has prevented India from meeting this goal.  We suggest that by examining the post-graduate training programs of the United States of America (USA) and United Kingdom (UK), one can formulate a standardized method of training safe, effective, and efficient ophthalmologists in India.
| Problem at Hand|| |
Despite a history of public health interventions, blindness and effective eye care continue to be a problem that plagues the Indian health care system. The latest World Health Organization (WHO) estimates show that India is home to 25% of the world's total blind population with nearly 51% of blindness is due to something as simple as cataract.  Unfortunately, the number of trained ophthalmologists is lagging behind the current need. Currently, the nation has 18,000 ophthalmologists, less than half the number of physicians required to manage the staggering incidence blindness due to cataract alone in this country.  In order to meet this need India needs at the very least 25,000-30,000 ophthalmologists by the year 2020, which would require growth at the rate of 300 additional training slots per year.  However, as Thomas and Dogra have shown the lack of training programs and the poor quality of training has prevented this nation from meeting this goal. 
Previous efforts have been aimed at improving Indian ophthalmology residency programs by providing funding for instructor training, improved facilities, and better instrumentation. However, such efforts have not shown any measurable improvement in resident training or quality of care. In their 2008 study Thomas and Dogra noted that the eight programs included in their paper were recipients of a World Bank sponsored grant program which allowed for two rounds of financial support to be used for educational programs and proper instruments. However, upon re-evaluation of these programs after receiving the two rounds of funding Thomas and Dogra found much of the same issues. Basic eye exams were few and far between, and surgical experience was limited. Ultimately, students continued to report a lack of confidence in their educational foundation. 
| What can we Learn from Post Graduate Training in Other Countries?|| |
We postulated that, although well-intentioned, these funding efforts have proved unsuccessful because they do not address the lack of standardization of training. We propose that by examining the post-graduate training programs of the USA and UK, one can formulate a standardized method of training safe, effective and efficient ophthalmologists in India.
Of all the European nations UK is known to have one of the most rigorous, structured and efficient programs to educate ophthalmologists. The UK's training program is unique from the majority of European countries in that it is governed by a cohesive body, the Royal College of Ophthalmologists (RCO), that not only sets forth clear goals for training but also effectively evaluates training programs to ensure they live up to the prescribed standard. The RCO is able to satisfy the UK's growing need for a skilled pool of ophthalmologists by creating a training program that explicitly identifies prerequisites for progression, involves stepwise introduction of responsibilities, and includes regular assessments of trainee performance. 
Ophthalmology training in the UK is designed as a 7-year run-through specialty training (ST) program, and entry into this program is particularly competitive with ~4 candidates competing for each entry level post with a 100% fill rate. In order to secure quality candidates, entry is a strictly screened process with clearly defined prerequisites. Prior to entering into ST program, applicants are expected, at the very minimum, to have completed two foundation years in general medicine and thus have achieved a basic level of competency in general medical examination. 
This program requires the completion of + 180 learning competencies prior to achievement of the Certificate of Completion of Training (CTT). The first 2 years of training involve exposure to basic clinical ophthalmology. At this early stage trainees are provided with day-to-day structure and early exposure to surgical techniques. Trainees will work through general and specialty clinics and are scheduled at least two sessions per week in the operating theatre. In the first 2 years, trainees will be expected to become comfortable performing the most common ophthalmic procedures and assisting with more complicated cases. As trainees progress, they are gradually introduced to more specialized training, more complicated procedures, and increasing work responsibilities. 
In order to provide a basic level of surgical proficiency for trainees the RCO has included a list of suggested surgical minimums for the most common of procedures. The recommended minimum number of cataract procedures over 7 years has been set at 350. With the structured program set forth by the RCO the majority of trainees' not only meets the minimum number but exceed it. In fact, the median number of cataract procedures performed per trainee over the 7 year program has been consistently greater than 500 over the past 20 years. ,,
The UK program establishes broadly defined learning competencies required for yearly progression while also outlining a structured weekly schedule that will allow trainees to accomplish these competencies. However, it is of no use to set standardized goals of training, if there is no system set in place to assess trainees' achievement of these goals. The UK's training program has been designed with specific benchmark points at which trainees' clinical and surgical skills are assessed. This regular assessment of progress ensures that all trainees attain a certain minimum of knowledge and skill and ensures that the training program is effective in instilling at least this minimum standard. Assessments are performed on a yearly basis as well as a weekly or even daily basis. The major exams of this training program are the FRCOphth Part 1 and 2 taken after year 2 and 7, respectively. These exams are designed to evaluate trainees' achievement of the learning outcomes outlined by the curriculum and include a written, practical, and oral component. Trainees are also expected to have established a firm understanding of refraction fairly early in their training, and are must attain the Refraction Certificate by the third year of training. Outside of these milestone exams trainees' are regularly assessed through Case Based Discussions, Direct Observation of Procedural Skills, and the Objective Assessment of Surgical and Technical Skills. In addition, a yearly assessment panel will ensure trainees have completed the learning outcomes required of them at their current stage of training. 
From our examination of the UK's training program, it is evident that its strength lies in its ability to standardize the education process and thus consistently produce quality ophthalmologists. This consistency is achieved via a three-pronged approach: Defining clear goals of training, putting forth an explicitly outlined curriculum that advances these goals, and conducting regular assessments of the trainees' achievement of these goals. Unsurprisingly, this approach to training is quite similar to that outlined by the ophthalmology residency program of the US. Given the US reputation as innovators in the field it is of particular use to compare its residency program to the long-standing tradition of ophthalmologic training in the UK.
The US program's singular achievement is its ability to create truly comprehensive ophthalmologists in a compressed time frame. Although, the 3 year program may appear abridged in comparison to the 7 year UK program, the majority of graduates (86%) felt comfortable practicing as comprehensive ophthalmologists upon graduation.  The Accreditation Council for Graduate Medical Education (ACGME) has been able to achieve this goal of efficiently training qualified comprehensive ophthalmologists by creating a program that establishes a formally defined set of learning competencies, stresses graduated and progressive responsibility, and provides frequent evaluation and feedback.
Ophthalmology residency in the US is a 3-year program that requires 1 year of general internship training prior to entry. It is a competitive field with a stringent screening process to select for only the most apt candidates. Entry into ophthalmology residency in the US requires, at the very least, strong pre-clinical and clinical grades throughout medical school as well as high USMLE scores. 
The ACGME strives for standardization of its curriculum by setting forth broadly defined competency domains, that are subdivided into 40 + subdomains, all of which are necessary for progression through training. The ACGME is able to ensure the achievement of these competencies by creating specific requirements for trainees' exposure to clinical, surgical and scholarly activities and performing frequent assessment of trainees' participation in these activities.
There is no dictum regarding the week-to-week schedules of US residents, instead there is a roughly defined outline for progression that values a comprehensive understanding of the field. Residents are gradually entrusted with increasing levels responsibility as they progress through the residency program, so that upon graduation they are comfortable taking on the mantle of a self-sufficient ophthalmologist. It is expected that initial surgical experience will be minimal with the primary focus of training on clinical patient care during the first year. However, clinical responsibilities and surgical experience steadily increases to the point where senior residents will be expected to function close to independently in the clinic setting and be fairly comfortable with most common surgical cases. In order to achieve this transformation from novice junior resident to self-sufficient senior resident, the ACGME has defined specific goals for both the surgical and clinical aspects of their curriculum.
Residents are required to complete a minimum of 3000 outpatient visits, with at least 1000 of those performed under direct supervision. To ensure that trainees' are provided the necessary tools to achieve competency as a clinician, it is also stipulated that each resident have at least one examining lane for patient visits as well as the diagnostic equipment necessary to perform a complete exam. Furthermore to guarantee that trainees will graduate as truly comprehensive ophthalmologists, trainees' are required to rotate through all of the various ophthalmologic subspecialties over the course of a year.
The surgical portion of the training program is defined by a set of specifically outlined surgical numbers to allow for experience with the most common of ophthalmologic procedures (cataract, laser, corneal procedures, strabismus, glaucoma, oculoplastics, and trauma). The minimum number of required cataract surgeries is 86, however for the most part the majority of graduates complete training with approximately 120 + cataracts. 
Uniquely, the ACGME has also placed a fairly significant stress of scholarly activity and didactic learning with the goal of developing physicians who have a firm medical knowledge base as well as an understanding of academic ophthalmology. Specifically, trainees' must complete a minimum of 360 hours of basic and clinic science teaching as well as attend regular journal club sessions, pathology conferences and case presentation sessions.
The ACGME has taken great efforts to create a residency program capable of training physicians with a solid basis in clinical, surgical, and academic ophthalmology, however, this program would not be complete without a system of assessment. The ACGME has developed a three-tiered approach to evaluation, involving assessment of the resident, faculty, and the program. Residents must be provided with an evaluation upon completion of every rotation, a semi-annual evaluation by a clinical competency committee, and a summative evaluation on completion every competency milestone. In addition, an objective evaluation of medical knowledge, the Ophthalmic Knowledge Assessment Program exam, is recommended. An evaluation of both the faculty and the program is required yearly, and must include participation by fellow residents and faculty. Interestingly, this system of assessment has not only allowed residency programs the opportunity for self-scrutiny and improvement; it has also allowed the ACGME to pin-point particular curricula which are worthy of notice. For example the innovative Iowa Ophthalmology Wet Laboratory curriculum that is now commonplace throughout residency programs. 
This examination of the US and UK's ophthalmology training program reveals striking similarities between the two nations' approach to standardization of graduate medical education. Essentially, both programs are able to achieve this goal of standardized education by defining clear learning goals from the outset, setting forth a detailed curriculum, and estabilishing specific methods of assessment. We propose that this same approach can be succesfully applied to graduate medical education in India.
| Proposed Intervention|| |
The most overwhelming problem facing post-graduate medical training in India has been the implementation of a standardized curriculum across a vastly disparate educational landscape. In order to create a comprehensive training program that is able to provide this standardized experience we believe that one must take a cue from the training programs of the US and UK. Both countries have based their training programs upon clearly defined learning competencies. We propose that graduate medical education curriculum in India be divided into four broad learning compentencies: Clinical training, Surgical training, Academic activities, and Resident as a Teacher. And of course, as exemplified by the training programs of the UK and US, we believe that this proposed curriculum must also include specific goals for asessment and feedback.
We propose an online courseware that establishes a basic curriculum that allows trainees' to achieve some aspects the aforementioned learning competencies. This curriculum will also include a method of assessment and feedback. We have outlined below how the proposed online courseware will address each of these aspects of residency training:
Clinical and surgical training
Although independent home institutions will be primarily responsible for providing clinical and surgical exposure we will implement minimum standards to ensure a basic level of exposure, and our courseware will provide a supplement to these experiences. An online archive of surgical videos with accompanying narration and step-by-step instruction will be made available (both in DVD format and online). Case studies of both unusual and basic disease presentations accompanied by algorithms of management will be included for resdients' use. In order to encourage institutions to provide trainees' these basic surgical and clinical experiences, students will be asked to maintain a log of their experiences using our secure online system and will be asked to evaluate the clinical and surgical experience their program provides. Programs/residents falling behind the minimum standards will be identified and encouraged to rectify the situation every quarter.
Proposed minimum clinical and surgical requirements for post graduate residents
Training prior to graduation: We propose that every resident should fulfill the following clinical and surgical minimums prior to graduation. It is our belief that by strictly adhering to these minimum requirements, that quality of resident education would dramatically improve across the country, while ensuring a comprehensive training.
The proposed clinical minimums include Comprehensive eye examinations: At least 1000/per year; Neuro-Ophthalmology × 100 cases × 3 years; Ocular pathology × at least attend a complete course; if possible review at least 10 specimens × 3 years; Refraction: 1000 × 3 years; Gonioscopy: 1000 × 3 years; Review of HVF: 100 × 3 years; Review of OCT: 100 × 3 years; Review of FAs: 100 × 3 years; Review of Corneal topography; corneal pachymetry; Specular microscopy report; wave front report -× 50 × years.
The proposed surgical minimums include Cataracts: 80 cases as primary surgeon (PS) 40 SICS and 40 Phaco/PCIOL and at least 120 as assistant surgeon (AS); Glaucoma surgeries: Trabeculectomy × 10 (PS); 15 Trabeculectomies; Glaucoma drainage device Implantation (AS); Glaucoma Lasers: 10 (PI, ALT, Peripheral Iridoplasty); Corneal surgery: 2 PKP (PS); 5 PKP; DSAEK (AS); Refractive surgery: Total of six (AS + PS); Retinal Injections: 10 (PS); Retinal lasers: 10 (PS); Primary vitrectomy/Retinal detachment surgery: 1 (PS); 10 (AS); Plastics: 20 (PS) - Ectropean, Entropean, Chalazion; other lid lesion; Ptosis; Strabismus: 20 muscle surgeries (PS); Trauma: 5 (PS) and 10 (AS) - Lid lacerations; corneal or corneo-scleral lacerations.
The proposed courseware will be able to implement a standardized academic curriculum which will include:
- Didactic Lectures: Weekly lectures in each ophthalmologic subspecialty with a board review lecture series covering each subspecialty made available prior to end of year board exams.
- Journal Club: One per year per sub-specialty, 9-10 overall
- Scholarly Activities: Research leading to presentations in regional or national meetings/publications
- Weekly Grand Rounds: At least two cases to be discussed following a presentation by the post graduate
- Wet Lab: Surgical practice sessions
Didactic lectures will be pre-recorded and available to stream from the course website at institutional facilities thus allowing each student to individualize the learning process to his or her own needs. A board review style lecture series will be made available at the end of the academic year prior to administration of the yearly board exam. During borad review lectures, students will be able to post questions on online discussion boards and receive real-time feedback from faculty. Our courseware will also allow institutions to participate in weekly Grand Rounds discussions, teleconferenced between institutions so that all students may benefit from a discussion of diverse patient cases. Grand Rounds discussion will then be recorded and uploaded to our courseware for later viewing by students.
| Resident-To-Resident Teaching|| |
Perhaps the most vital aspect of learning during the residency experience is resident-to-resident teaching. Our courseware will provide the opportunity to teach and learn from residents all around the country. This will not only expand knowledge of disease presentation and management, but also teach residents how to become better teachers themselves. The proposed courseware will provide interactive discussion boards on which residents can answer each other's questions and provide support while negotiating the residency process. Residents will also be instructed to maintain a daily/weekly blog. Here they will be able to bring up, for example, interesting case presentations, useful surgical tips, and comment on the day to day life of a resident.
| Feedback, Evaluation and Surveys|| |
The proposed standardized curriculum will include several points of assessment. Each didactic lecture will be administered with a pre- and post-test available via the website to provide both the trainee and faculty an evaluation of progress. With frequent lectures and assessments, residents will be able to identify problem areas early on and thus rectify these issues sooner rather than later. Ideally, we hope the pre-test will serve as a point of group discussion during class sessions. Pre- and post-lecture tests will provide immediate, short-cycle feedback to the progress of each trainee. Long-cycle feedback will be provided in the form of a board style exam at the end of the academic year. A yearly independent survey will be administered to each resident to provide qualitative feedback to administrators to identify possible areas of improvement. A discussion board devoted to specific product related questions and concerns will be open to both student and faculty. Our digital courseware will store the results of both short- and long-term feedback so that trainees may track their progress and so that faculty may compare the progress of their students to those at other institutions.
India has a strong tradition of progress in the field of health care. Countless lives have been saved from such preventable diseases as onchocerciasis, trachoma, and vitamin A deficiency. Blindness is now the next frontier for Indian healthcare, and in order to educate the next generation of Indian physicians in this struggle to establish effective eye care, a standardized ophthalmologic training program is nothing short of vital.
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