Residency training in India: Time for a course correction

A number of communications in the recent months have brought into sharp focus the many deficiencies that afflict the Ophthalmology residency training in India.[1,2] The difficulties and the limitations pertain to ophthalmic and teaching infrastructure, human resources, and the teaching programs. Wide variability in the quality of academic programs was a glaring problem.

A study of medical colleges by the Academic and Research Committee of the All India Ophthalmological Society (AIOS) in 2000 provided evidence of huge gaps in ophthalmic infrastructure and the lack of subspecialty services.[3] Another survey of the medical colleges in India in 2005 pointed to the deficiencies in academics and research. It showed that 20% of the institutions had no ophthalmic journals, 60% had two or less international journals, and only 8.6% had > 5 international publications in the last 3 years.[4] A study from the state of Andhra Pradesh revealed that there was no significant change in the residency training in eight medical colleges in two evaluations 8 years apart (1998 and 2006) after provision of modern instrumentation and training. The intervention did not make a difference to the quality of postgraduate training or help to make the residents confident of setting up their practice.[5]

The studies which sought the perception and experience of residents and young ophthalmologists corroborate these observations. A survey from Maharashtra (2008) pointed to dissatisfaction of residents with their residency programs. There was poor emphasis on surgeries other than cataract.[6] In another recent survey, the final-year residents from South India (2014) expressed the need for improved training across all aspects of ophthalmology. There was a big difference between the numbers of surgeries they performed and the numbers they felt would have been ideal.[7] Another study from the same region showed that nearly half of the final-year residents had not experienced wet lab/simulation lab training. More than 50% of the residents had not performed any extracapsular cataract extraction, phacoemulsification, squint, trabeculectomy and dacryocystorhinostomy or any other oculoplastic surgery. Forty percent of the residents expressed their lack of satisfaction with their surgical training.[8] A study of young ophthalmologists completing their residency from 2014 to 2016 by the AIOS revealed that nearly a quarter (24.5%) felt that their teaching program was not adequate. It also showed a wide variation in the support for academics and research in the medical colleges.[9]

Has the residency training shown a measurable progress in the recent years? Six years ago the AIOS introduced postgraduate teaching programmes in all five zones of the country during my tenure as president, which have been running successfully. Many other PG teaching programmes have also been initiated in this period. Have the programmes shown any impact? The communication by Biswas et al.[10] in this issue is an attempt to look at the changes over the years. This article[10] brings out persistent shortcomings in the present state of residency training even though there has been some improvement. The 21^st-century-trained ophthalmologists perceived training such as refraction, orthoptic evaluation, pediatric visual acuity testing, fluorescein angiography, optical coherence tomography, and use of retinal LASERs to be inadequate (median perception rating ≤ 5). Fifty percent had performed 1 or less phacoemulsification, no trabeculectomy, no strabismus surgery and 2 or less eyelid surgeries.

The continuing wide variability in standards of residency training across the country points to the need for a major rethinking and a course correction. A basic need for the course correction would be the creation of a fresh curriculum for residency as stressed by Gupta and Honavar in their recent editorials in the journal.[1,2] The other important element would be ensuring a strong enforcement of the curriculum which would require a more robust system for accreditation of residency programs and a uniform nationwide exit examination.

This issue carries salient features of a proposed National Curriculum of Ophthalmology, which is based on a workshop by the AIOS in 2011 that adapted the International Council of Ophthalmology residency curriculum in the context of the needs of the country.[11,12] The curriculum is based on the premise that a well-structured curriculum should lay down all the ingredients including the minimum requirements of infrastructure, medical as well as teaching, tools and resources of education, human resources (numbers, qualifications, experience), and the course content. The curriculum includes research methodology and community ophthalmology. It incorporates the aspects of communication skills, professionalism, ethics and management which includes financial as well as practice and hospital management.

The course content outlines the cognitive and technical skills that are necessary for a modern comprehensive ophthalmologist. It lays down the minimum acceptable diagnostic and therapeutic (including surgical) procedures that a resident should perform in his/her period of training. It outlines a well-defined mechanism for formative and summative assessment. It incorporates rubrics for evaluation of surgical skills and clinical examination, assessment of the affective domain, internal assessment which includes maintenance of log books and the outlines for an exit examination.

The National Curriculum of Ophthalmology by AIOS formed an important input for the recommendations made by the curriculum committees of the National Board of Examination and Medical Council of India (MCI) (The author was a member of both committees).

Laying down a curriculum however can only be a step for moving in the right direction. The real test lies in how well it is implemented. There are huge obstacles to implementation of a residency curriculum in the country in the current scenario. These include deficiencies in infrastructure (medical/ophthalmic equipment and teaching), human resources (numbers, training, and motivation) as well as the structure and mechanism for enforcing the curriculum.

A new National Medical Commission Act which proposes replacement of the MCI and constitution of a new postgraduate medical board is in the offing. Does this portend a better future for residency training? This is still an unanswered question and only the future holds the Key !

About the author

Dr. A.K. Grover is the recipient of Padmashri Award by the President of India for his services to Ophthalmology. He is the Chairman, Department of Ophthalmology at Sir Ganga Ram Hospital and Vision Eye Centres, New Delhi, India. Dr. Grover is Chairman of Subspecialty Education Committee, International Council of Ophthalmology, Councilor at large of the Asia Pacific Academy of Ophthalmology and Vice President of the Ocular Trauma Society of India. He is a past President of the Asia Pacific Society of Ophthalmic Plastic and Reconstructive Surgery, Oculoplastics Association of India and the All India Ophthalmological Society (AIOS). He is an impeccable clinician, a gifted surgeon, an academician of repute, a dedicated teacher and a visionary leader. Indian Journal of Ophthalmology is proud to have him on the Editorial Board and represent the speciality of Ophthalmic Plastic Surgery. Ophthalmic education has been a passion for Dr. Grover. As chairman, Academic and Research Committee and as president of the AIOS, he took several initiatives including a nationwide survey on residency training, development of residency and subspecialty curricula and annual post graduate teaching programmes in each zone of the country.