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Community Eye Care

Status of Speciality Training in Ophthalmology in India

Murthy, G V S MD; Gupta, Sanjeev K MD; Bachani, Damodar MD; Sanga, Lalit MD; John, Neena MCA; Tewari, Hem K MD

Author Information
Indian Journal of Ophthalmology: Apr–Jun 2005 - Volume 53 - Issue 2 - p 135-142
doi: 10.4103/0301-4738.16182
  • Open

Abstract

Human resources form the central component of all health systems, consuming a major share of allocated resources.1 Attaining health objectives depends largely on provision of effective, efficient, accessible, viable high-quality services by personnel present in sufficient numbers and appropriately distributed across different geographical regions.2

It is believed that there are more than 10,000 trained ophthalmologists in India.3 There is a lack of supporting evidence on the quality of ophthalmic speciality education, which is needed to better plan for human resource development. This is necessary to identify training needs to achieve the goal of VISION 2020.

Materials and Methods

The study was conducted between April 2002 and March 2003. Traditionally, ophthalmology training has been the preserve of postgraduate medical schools in India (mostly government financed). Recently there has been an increase in the number of privately funded medical schools. In India, there are two options for speciality training in general ophthalmology. Graduates with basic allopathic medical training can opt to pursue a postgraduate degree (MD/MS) for 3 years or a postgraduate diploma (DOMS/DO) for 2 years. A statutory body, the Medical Council of India regulates both courses. In addition, medical graduates also have the opportunity to undergo specialised training by working at accredited institutions for a period of 3 years and then appear for an examination conducted by a statutory body (the National Board of Examinations, which awards a Diplomate of the National Board).

We obtained a list of all allopathic medical schools and accredited training institutions offering programmes in 2001 from the Medical Council of India, National Board of Examinations and other supplementary sources.

Pre-tested questionnaires were mailed to the Directors / Principals/ Medical Superintendents of 110 postgraduate medical schools and 33 accredited training institutions. Thus all existing institutions in the country were covered. Six weeks later, follow-up action was instituted and the institutions, which had not responded were contacted again (by post/ e-mail/ telephone). The process was repeated at least thrice over a 6-month period. The questionnaires were required to be filled by the Head of the Ophthalmology Department, verified by the Principal / Director/ Medical Superintendent of the medical schools and the accredited training institutions and returned to the Community Ophthalmology Department at the Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi.

All questionnaires were coded and entered using MS Access database. Data were exported to Stata 8.0 for data cleaning and analysis.

Results

Responses were received from 128 (89.5%) of the existing 143 institutions in 2001. One hundred and five (95.4%) out of the 110 postgraduate medical schools responded and 23 (69.7%) of the 33 accredited training institutions responded.

Of the postgraduate medical schools, only a quarter were privately funded, and of the accredited training institutions, 22 (95.7%) of the 23 were privately funded [Table 1].

T1-14
Table 1:
Profile of training institutions

Annually 771 ophthalmology students were admitted to medical schools (MD/MS;DO/DOMS), and 61 were admitted to the Diplomate (DNB) course. Extrapolating to all training institutions, an estimated 810 training slots were available in medical schools and 90 in other training institutions. The intake was far higher in postgraduate medical schools [Table 1]. In more than three out of four postgraduate medical schools there were more than two students facilitated by a trained faculty as against one in three in the accredited training institutions [Table 1].

Most training institutions had in-house library facilities with subscriptions to national or international ophthalmology journals [Table 2]. Subscription to international journals was poor in most institutions; only 53 (41.4%) institutions reported subscribing to more than two journals. Very few postgraduate medical schools conducted sub-speciality training courses or fellowships [Table 2].

T2-14
Table 2:
Academic, clinical skill augmentation and research facilities

Less than one in six institutions undertook research projects. This was reflected by the fact that only 11 (8.6%) of 128 institutions had more than five publications in international peer reviewed journals [Table 2].

Both types of institutions reported similar outpatient consultations in a calendar year [Table 3]. In a third, outpatient consultations were less than 50 on a working day. With respect to admission capacity, accredited training institutions had more. The number of beds available per student was three times higher among the Diplomate training institutions [Table 3].

T3-14
Table 3:
Clinical profile of institutions

To assess surgical training facilities, overall surgical turnover was analysed for cataract surgery as well as other surgeries like glaucoma, squint, dacryocystorhinostomy (DCR), lid, keratoplasty, etc. In addition, surgical output per trainee was assessed for different procedures. The ratio of specific surgery per student is a composite indicator of surgical exposure during training as it includes surgeries observed, assisted or conducted under supervision. Diplomate training institutions offered higher surgical exposure to trainees, compared to the postgraduate medical schools [Table 3].

Equipments considered critical for training both in relation to diagnosis and therapy were assessed [Table 4]. All Diplomate training institutions reported having access to a variety of critical diagnostic equipment.

T4-14
Table 4:
Functional equipment at institutions

Discussion

India produces a large number of ophthalmologists annually. These trained professionals serve the needs of India and also support services in many countries in Middle East and South East Asia. However, the quality of training infrastructure and facilities has never been systematically evaluated. Most available information on human resource development in ophthalmology is based on anecdotal evidence. It has generally been stated that teaching methodology has remained essentially unchanged and training the trainers is still in its infancy.4 This is particularly true of India. With the increase in the scope and complexity of interventions and technological innovations in diagnostic and therapeutic ophthalmology, a change in the traditional teaching patterns is essential. This change should harness new technology without compromising on quality of education. An evaluation of the ophthalmology residency programs in the US observed that maintaining high quality residency education is an increasing challenge in the face of an extraordinary explosion of new information and technology in ophthalmology.5

Nearly 900 ophthalmologists are trained in India every year. It has been estimated that India needs 25,000 ophthalmologists by 2020 to achieve the goals of VISION 2020: The Right to Sight.6 This would entail an additional 300 training slots every year to meet the projected human resource needs.6 Traditionally postgraduate medical education was administered through public funded postgraduate medical schools. However, in the changing economic milieu and due to the increasing costs of health care and medical education, most public funded institutions (financed by Government sources) are unable to cope with the heightened demands on human resources and infrastructure. The major input needed for existing postgraduate medical schools is a revamp of the system to improve the overall quality of training so that available infrastructure is used optimally. It is imperative that the productivity of practicing ophthalmologists be increased significantly so that they function more efficiently and effectively.3

It was observed that current training facilities in all training institutions were based on conventional teaching modalities, and the use of facilities like wet labs was poor. Most libraries in the training institutions, especially in the public sector, had inadequate facilities. The future of training should look at combining conventionally taught components with the use of up-to-date multimedia resources, including books, course guides, videotapes, audiotapes, television, e-conferencing and discussion groups as well as access to web-based learning.7

Surgical exposure is essential in speciality training; trainees should have adequate exposure during the formative years. Ophthalmology speciality training should not only train ′cataract surgeons′ but also provide learning opportunities to students by exposing them to a good surgical mix. Unfortunately, it was observed that exposure to all surgical procedures other than cataract was inadequate in most institutions, especially in postgraduate medical schools. Though the quantum of cataract surgery is bound to be high because cataract is the most common cause of blindness in India,8 it should not bias service delivery in tertiary care institutions where budding ophthalmologists spend their formative years.

Overall, it was observed that speciality training in Ophthalmology in India exhibited both strengths and weaknesses. The biggest strength has been the establishment of a network of tertiary care institutions both in public and private sectors. Issues that need urgent attention however, include harnessing new technology in medical education, improving productivity of training institutions and revamping infrastructure to meet student needs. There is a need to formulate newer learning objectives and training norms including faculty-student ratios, number of surgeries to be observed, assisted in and performed for different surgical procedures and for different diagnostic and therapeutic procedures.

These academic institutions should undertake high quality need-based research as the training period is the only opportunity for the students to pick up skills related to research methodology which are necessary for all future ophthalmologists. The basic aim should be to improve overall quality of training for both service delivery and research in the country.

Appendix: The questionnaire

WHO- NPCB Medical College/DNB Recognized Institution Questionnaire (To be filled by Head of Department of Ophthalmology)

SECTION A:

1. Name of Institution .............................................................................................................................

2. City ......................................................................................................................................................

3. State....................................................................................................................................................

4. Postal Code ........................................................................................................................................

5. Telephone No. (with STD code) ........................................................................................................

6. Fax No. ...............................................................................................................................................

7. Email of Head of Ophthalmology Dept. ............................................................................................

8. Type of Institution ............................................................................................................................... (Govt. owned/private/charitable non profit body/Others(specify) ...................................................................................................................................

9. Is the college/institution recognized by MCI for MBBS? Yes / No ...................................................

10. Is the college/institution recognized by MCI for postgraduation in ophthalmology?Yes/No ...........

11. Is the college/institution recognized by the National Board of Examinations for Diploma of the N.B.E.? Yes/No ............................................................................................................................................................

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6. Ophthalmology/Blindness Control Section, Government of India. National Programme for Control of Blindness- India. Vision 2020: The Right to Sight. Plan of Action, Ophthalmology/Blindness Control Section Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, New Delhi, India. 2002:1–32
7. McKimm J, Jollie C, Cantillon P. Web Based learning BMJ. 2003;326:870–3
8. Ophthalmology/ Blindness Control Section, Government of India. National Survey on Blindness and Visual Outcomes after Cataract Surgery 2001-2002. National Programme for Control of Blindness, Directorate General Health Services, Ministry of Health Family Welfare, Government of India, New Delhi. 2003:1–80

Proprietary Interest: None

Keywords:

Medical Education; Ophthalmology; Human Resource Development; Manpower; Health Services Research

© 2005 Indian Journal of Ophthalmology | Published by Wolters Kluwer – Medknow