Steps to standardize ophthalmology residency programs in India.

Specialty medical training worldwide has evolved from an unstructured apprenticeship of unlimited duration to the modern, time-bound, curriculum-based and competency-driven model, with certification of the trainee and accreditation of the trainer.[123] Advanced medical training in India has been traditionally apprenticeship-based and the changeover to the contemporary system has been unenthusiastic, slow, patchy, and mostly incomplete.[45678910111213] Residency training programs in our country have an immense and untapped potential – clinical material is vast, teachers are experienced, and students are the best among their fraternity.[4] However, there is a striking disparity in the standard of infrastructure, quality of faculty, system of training, and mode of evaluation among the residency programs, which necessarily affects the final output.[45678910111213] A judicious investment of resources and efforts in standardizing the residency programs and a system-based approach will likely yield very rich dividends and positively affect the overall quality of health care in the country.[4]

Structural and Functional Alterations

Standardization of ophthalmology residency programs would involve structural and functional alterations. Adequate infrastructure, diagnostic and surgical equipment, facilities for patient care, substantial volume of patients, trained faculty, and creation of a teaching environment are the basic structural prerequisites that each training facility must systemically invest on. Logical steps in functional alterations include (1) adaptation of standard common curriculum, (2) incorporation of competency-based learning, (3) structured, objective and standardized formative and summative assessment, (4) certification of the trainee, and (5) accreditation of the training facility.[14] While provision of optimal structural support is a local issue that can be resolved at the level of the individual organization or the respective state government, functional alterations are systemic in nature and involve regulatory authorities such as the Universities, Medical Universities, Medical Council of India (MCI) (or National Medical Commission in its new form), and union and state governments. It will need focused advocacy on the part of the professional organizations (All India Ophthalmological Society [AIOS] and Indian Medical Association) to hustle through some of the reforms. Since the reforms essentially involve all the medical specialties, broad collaboration, ground level coordination, and a concerted effort may be required. The logical and systematic evolution of the residency training in the United States to what it is today shows us the path.[1516]

Standard Common Curriculum

Adaptation of common national curriculum is the basic need and the first logical step in standardizing ophthalmology residency in India. We have made substantial progress in this regard.[1718] The AIOS National Curriculum is a modification of the International Council of Ophthalmology (ICO) curriculum and is a collaborative and a consensus-driven effort.[19] It is being presented in its near-final structure in this issue of Indian Journal of Ophthalmology.[17] Broad components of the curriculum include (1) basic medical sciences, (2) clinical ophthalmology, (3) optics and refraction, (4) ophthalmic super-specialties, (5) ophthalmic pathological/microbiological/biochemical sciences, (6) community ophthalmology, (7) research methodology, (8) medical ethics and professionalism, and (9) management skills.[17] Each of these has specific inherent basic, standard, and advanced goals to be achieved in postgraduate year 1, 2, and 3, respectively.[17] Practical competencies in diagnostic tests, investigation procedures, and surgical procedures are clearly listed and a minimum desired number for optimal training is prescribed.[17]

Standard curriculum across the residency programs would set a common minimal training agenda that the trainers and trainees can refer to. It would further drive standardization of evaluation and certification. Obtaining regulatory approval for nation-wide implementation of the standard curriculum may be a time-consuming process. While this formal process is on, it may be good if the individual institutions and universities start implementing the new curriculum at local and regional levels.[4]

Competency-Based Learning

Residents and faculty have a major role to play in having their training transformed into a wholistic experience incorporating the six Accreditation Council for Graduate Medical Education (ACGME) competencies – patient care and procedural skills, medical knowledge, system-based practice, practice-based learning and improvement, professionalism, and interpersonal and communication skills [Table 1].[3] Each of the components of competency-based learning may be customized for India and implemented in a staged manner.

Table 1

Six Accreditation Council for Graduate Medical Education competencies for ophthalmology residency programs

Assessment

Structured, objective and standardized formative and summative assessment of the trainee is an integral part of residency training. A 360° assessment should encompass personal attributes, didactic knowledge, clinical skills, surgical skills and academic performance, and embody the six components of competency-based learning. The ACGME-American Board of Ophthalmology (ABO) Milestones project is an effort in this direction.[202122] Milestones include knowledge, skills, attitudes, and other attributes for each of the ACGME competencies organized in a developmental framework from less to more advanced [Table 2].[202122] These are descriptors and targets for resident performance as the resident progresses from entry into residency toward completion. For each reporting period, review will involve selecting one of the numbered milestones that best describes the resident's current performance level.[202122] Milestones describing patient interviewing (history-taking) skills, gonioscopy, strabismus surgery, and interpersonal skills are shown in [Tables 3-6] just as examples.[2122] A complete compilation of milestones is available online for immediate use.[2122]

Table 2

Accreditation Council for Graduate Medical Education-American Board of Ophthalmology milestones for semi-annual formative assessment based on six components of competency-based learning

Table 3

Accreditation Council for Graduate Medical Education-American Board of Ophthalmology milestones - patient care and procedural skills, PC 1 – patient interview

Table 6

Accreditation Council for Graduate Medical Education-American Board of Ophthalmology milestones – interpersonal and communication skills, ICS 2 – communicate effectively with physicians, other health professionals, and health-related agencies – comprehensive, timely, and legible medical records; consultation requests; care transitions; conflict management

A general interpretation of levels for the ophthalmology milestones is as follows:[202122]

Level 1: Demonstrates milestones expected of a resident who has had some education in ophthalmology

Level 2: The resident is advancing and demonstrating additional milestones

Level 3: The resident continues to advance and is demonstrating additional milestones; the resident consistently demonstrates most milestones targeted for residency

Level 4: The resident has advanced so that he or she now substantially demonstrates the milestones targeted for residency. This level is designed as the graduation target

Level 5: The resident has advanced beyond performance targets set for residency and is demonstrating “aspirational” goals which might describe the performance of someone who has been in practice for several years. It is expected that only a few exceptional residents will reach this level.

Assessment tools used to evaluate the milestones include 360° global evaluation, Ophthalmic Clinical Evaluation Exercise, chart audit/review, chart-stimulated recall, Objective Structured Clinical Examination (OSCE), focused skills assessment, simulation, oral/written examination, portfolio, case logs, outcome and assessment information set, Global Rating Assessment of Skills in Intraocular Surgery, surgical skills assessment, Ophthalmology Surgical Competency Assessment Rubric (OSCAR), video review, On-call assessment tool, and Organizational Capacity Assessment Tool. A recommended starter toolbox is as follows:[14]

Patient care – OSCE and patient surveys

Medical knowledge – written and oral examinations

Practice-based learning – record review, chart audit, and portfolios

Interpersonal skills – OSCE, direct observation, and patient surveys

Professionalism – OSCE and 360° global ratings

System-based practice – 360° global ratings

Surgery – OSCAR, OSCE, video review, and portfolio.

The AIOS National Curriculum lists out the assessment strategy, scoring pattern, and timelines in detail.[17] As we further evolve, we may have to streamline to integrate the objectives of competency-based learning into the formative assessment strategy. The steps involved may be as follows:

Without reinventing the wheel, we may simply customize the milestones and the incumbent assessment tools to Indian residents and build this into our residency programs. Comprehensive formative assessment is ideally performed during and after each clinical rotation

The OSCAR is a standardized, internationally-valid tool to teach and assess an ophthalmologist's competence in performing surgery.[23] This behavioral and skill-based rubric allows the evaluator to objectively assess the resident's competence in performing a specific procedure.[23] OSCAR rubrics are available currently for extracapsular cataract extraction, phacoemulsification, pediatric cataract surgery, small incision cataract surgery, strabismus, lateral tarsal strip surgery, trabeculectomy, and vitrectomy.[23] These may be used for in-program evaluation of surgical skills

An annual centralized online Ophthalmic Knowledge Assessment Program (OKAP) designed to measure the ophthalmic knowledge of residents relative to their peers using a set of standardized multiple-choice questions may be evolved by the AIOS. Short of it, OKAP International is already offered by the American Academy of Ophthalmology and is readily available to interested residency programs[24]

It is strongly recommended that each resident maintains a logbook (portfolio) to help track individual progress. Royal College of Ophthalmology's e-Portfolio is an eminent effort in systematizing and modernizing the portfolio.[25] It may be suitably customized to support the attributes of the AIOS National Curriculum

Structure for an exit examination at the end of residency is very well laid out in the AIOS National Curriculum.[17] It would be ideal to have a single national exit examination so that the quality can be benchmarked.

Certification

Certification, incorporating profession-driven standards and requirements, is granted to those who meet a series of accredited medical training requirements in ophthalmology and complete an intensive evaluation process. The basic requirements for certification are that there should be a formal certification authority (such as the ABO) and a well-defined process.[26] It would take organized efforts to build in the concept and process of certification and time-bound recertification into the Indian medical education system.

Currently, the ICO examinations provide a method of individual certification.[27] The examinations promote the excellence of eye care worldwide by encouraging individuals to acquire and maintain the highest standard of practice of ophthalmology and are the only worldwide medical-specialty examinations.[27] Hundreds of residents from India voluntarily participate in the ICO examinations every year.

Certification currently remains an aspirational goal in India. At best, we could move toward an informal and a voluntary certification process spearheaded by AIOS. We could perhaps explore the prospects of initiating a common Indian National Certification Examination based on the attributes of AIOS National Curriculum, and thereafter engage in positive advocacy to enthuse the regulatory authorities to formally implement it. Ophthalmology has been the first mover for certification in the United States in 1916, and it can be the trendsetter in India as well, albeit well over a century later.

Accreditation

Robust accreditation of the training programs is the most important missing link in standardizing medical subspecialty training in India. Accreditation is broadly used to understand the “Quality Status” of an institution. Accreditation status indicates that the training facility meets the standards of quality as set by the accreditation authority in areas of educational processes and outcomes, curriculum, teaching/training, learning, evaluation, faculty, research, infrastructure, learning resources, organizational governance, financial health, etc. The MCI and proposed National Medical Commission are supposed to be the accreditation authorities in India. Despite MCI inspections over the years, there is no evident standardization of ophthalmic training facilities (both structure and function) in India.

ACGME has already moved toward the Next Accreditation System (NAS) in the United States.[28] Under the NAS, ACGME will accredit US residency programs and systematically track steady resident progress in the common and specialty-specific competency-based milestones.[28] It is understandably a well thought-out and an integrated system of competency-based learning, assessment using milestones, and that, feeding to accreditation.[28] The ICO has worked to provide tools to establish accreditation systems in countries where the concept does not exist or is at best rudimentary.[27] It has developed “ICO International Guidelines for Accreditation of Ophthalmology Training Programs” and “ICO Accreditation Self-assessment Template.”[2930] These are two powerful tools that can be offered for voluntary use in India. AIOS may indulge in strong and strategic advocacy to help incorporate the system of accreditation in its true form and spirit into the functions of the proposed National Medical Commission.

Energetic and enthusiastic incorporation of the national curriculum for training, competency-based learning, robust formative and summative assessment, common certification of the trainees, and rigorous accreditation of the training programs are much needed to standardize ophthalmic training in India and take it to the next level. Voluntary adaptation of the national curriculum perhaps may be the all-important first catalytic step in this predictably long, but a potentially a rewarding journey.

Table 4

Accreditation Council for Graduate Medical Education-American Board of Ophthalmology milestones – patient care and procedural skills, patient examination, PC 2 – specific skills (gonioscopy)

Table 5

Accreditation Council for Graduate Medical Education-American Board of Ophthalmology milestones – patient care and procedural skills, operating room surgery, PC 7 – specific procedures (strabismus)