Knowledge Shared Is Knowledge Squared: Use of Technology and Multimodal Curricula Globally

There are multiple challenges to the provision and accessibility of high-quality and affordable health care in low and middle-income countries (LMICs). One important component of improving healthcare outcomes in LMICs is the development and implementation of effective medical education curricula. Successful training programs have the potential not only to enhance the quality of healthcare providers but also to increase the quantity of providers with the skills needed to care for patients with complex diseases. Training providers to be competent in the use of technology such as ultrasound and flexible bronchoscopy has the potential to expand and improve the care of patients with pulmonary diseases in resource-restricted settings.

In this issue of ATS Scholar, Vanderburg and colleagues sought to examine the effectiveness of a lung ultrasound (LUS) training program at a public hospital in Sri Lanka, a facility where computed tomography is only intermittently available (1). Notably, the participants were recent medical graduates without LUS experience. In addition, they received their training from a local board-certified radiologist already employed at that public hospital. Using didactic presentations, online modules, and hands-on instruction examining patients with a variety of lung aeration patterns, the trainees learned how to acquire LUS images and use a 12-zone LUS scoring protocol to quantitatively assess degrees of aeration loss. Subsequently, a collection of independently trainee-performed and -scored LUS studies were audited by the LUS expert, with subsequent analysis demonstrating high interoperator agreement. It should be noted that this was a small study, and the results could be highly dependent on the instructing radiologist who provided the training. However, it is also noteworthy that the program was locally conducted, without the need to bring in international personnel. In a time and place in which pandemics can limit travel and further constrain already limited resources, Vanderburg and colleagues have shown the feasibility of a low-cost, LMIC-initiated training program equipping its own local providers to use a relatively low-cost tool with a wide range of potential applications. Given the increasing availability and portability of ultrasound equipment, successful regionally run curricula such as this one give hope for future initiatives that are not only clinically meaningful but also sustainable.

Also in this issue of ATS Scholar, Karmali and colleagues investigated the effect of a multimodal fiberoptic bronchoscopy training program in Uganda, an LMIC, on providers’ knowledge and clinical skills (2). The training incorporated didactics, simulations, and deliberate practice-based proctoring followed by a 12-question multiple-choice assessment (before and after training) and a measure of procedural competency using the validated Bronchoscopic Skills and Tasks Assessment Tool. They demonstrated that overall knowledge improved following participation in the curriculum in 2019 and, when assessed 3 years later, there was a sustained increase in knowledge among those who had participated in the original study. The authors highlight the high prevalences of tuberculosis and HIV in Uganda and the fact that noninvasive diagnostic methods have limited yield and may not prompt appropriate therapy, resulting in increased healthcare costs and morbidity. Medical care in LMICs is typically human-intensive but less resource-intensive because of the lack of access to equipment and a reduced number of physicians trained to perform procedures such as bronchoscopy. However, illnesses that require greater resources are not limited to high-income countries, nor are they limited by language or geopolitical boundaries. Thus, using resources and education from one region and applying it to another can change outcomes, improve patient care, and ultimately reduce overall cost. Of note, the coronavirus disease (COVID-19) global pandemic demonstrated how a successful training program like this can be sidelined with the inability to travel, diversion of human resources to other needs, and the necessity to pivot to remote education.

Both studies effectively used multimodality curricula to educate others on the use of technology—ultrasound or fiberoptic bronchoscopy—with the goals of improving patient outcomes, maintaining sustainable programs in resource-limited settings, and reducing knowledge decay over time. Given what we have learned in the past 3 years, it would be of great interest and benefit to change portions of these training programs into virtual components that could be used in LMICs and to help bring education in ultrasound and bronchoscopy to a broader cohort of learners through asynchronous learning, which could be followed by a train-the-trainer model whereby simulations and proctoring could be conducted by individuals in country rather than healthcare providers traveling from the United States. We should continue to strive to make the biggest impact in a sustainable way to reduce healthcare inequity between high-income countries and LMICs while increasing the number of healthcare providers in LMICs who can care for patients with complex diseases using advanced technologies.