Radiology Education as a Global Health Service Vehicle

“The world is full of intractable problems. Often, we let that paralyze us. Instead, let it spur you to action.”

– Melinda Gates ¹

Introduction

While globalization has increased the reach of many medical specialties, access to radiology across the globe has historically remained limited, perhaps because of radiology's dependence on bulky, expensive technologies ^2,3. Approximately three to four billion individuals worldwide lack access to basic radiology services, and only 25% of people in low- to middle-income countries (LMICs) have access to cancer diagnostic services ^4,5. In 2018, 70% of global cancer deaths occurred in LMICs. Projections indicate increasing incidence of cancer in LMICs (estimated 70% breast cancer incidence by 2030^4,6), which, given existing health care disparities, could have devastating outcomes ^4,6.

As many LMICs increase their investment in imaging technology, motivated radiologists from high-income countries (HICs) are partnering with health care practitioners in LMICs to decrease health disparities. Volunteer radiologists from HICs frequently concentrate on research, clinical, and quality improvement projects. However, there is an ongoing need for accompanying education to maximally benefit LMIC radiologists; for example, surveyed African American health care practitioners ranked training programs as the highest-value priority (75%)⁷.

Postgraduate radiology training programs in LMICs face numerous challenges, including lack of medical equipment, poor standardization and/or implementation of training curricula, and a lack of formally trained subspecialty instructors ^8–11. Iyawe et al identify these challenges as crucial and recommend they be addressed through alternative models of subspecialist radiology training “with foreign collaboration when needed” ¹¹. Various models of transnational radiology education projects exist. Drawing on my experience with the Radiological Society of North America (RSNA) Global Learning Centers and my personal and institutional involvement with global health projects, here I offer suggestions for ensuring the success of global radiology education projects involving collaborations between HIC and LMIC radiologists.

Select an Appropriate Collaborating Site

Primary considerations in selecting an appropriate collaborating site include safety, enthusiasm, and readiness. Funding and political/governmental influences may impact the ability to collaborate. The existence of multidisciplinary and administrative support for both local and foreign partners can substantially improve chances of project success.

Many international radiology organizations, academic institutions, large private radiology groups, and nongovernmental organizations in HICs have pre-existing relationships with vetted LMIC sites. For example, RSNA Global Learning Centers have created subspecialty training programs at local sites in LMICs¹². Radiologists may leverage existing institutional relationships or personal relationships to volunteer for ongoing education projects or gauge interest in creating a radiology educational adjunct to an existing research project.

Conduct a Baseline Needs Assessment

We approach global health projects with a focus on value-based care, as embodied in Radiology 3.0 ¹³. A baseline needs assessment is critical to identify the high value needs of the LMIC collaborating site. Assessments may cover routinely available medical imaging technology and software, imaging practice protocols, national healthcare referral patterns, concerns of local healthcare practitioners, and previously tried approaches. The needs of various stakeholders (trainees, faculty, administration, other health care team members) and national and institutional regulatory guidelines are considered. Evaluation of the current curriculum is important; curriculum design is discussed below. Various needs assessment tools are available and may be modified as needed ^14,15.

In my experience, results of the baseline needs assessment often lead to substantial changes to the initial project idea.

Follow Best Practices for Curriculum Design

There is a robust history of HIC-based radiologists offering radiology training to LMICs in person (such as during short-term visiting professorships) or through standalone online webinars. Such volunteer-led teaching activities may be most impactful when they follow best practices for curriculum design, such as learner-directed selection of topics and depth, up-front determination of objectives, continuous curriculum evaluation, and incorporation of faculty and learner feedback ¹⁶.

An important consideration in curriculum design is that in-person teaching is susceptible to disruptions due to health and safety concerns, as occurred during the COVID-19 pandemic. Internet access is near ubiquitous in LMICs, and use of teleconferencing software has grown exponentially since the start of the pandemic, which increases options for virtual delivery of education. For example, in the Breast Imaging Curriculum for LMICs, an ongoing RSNA-funded project, we are using both synchronous and asynchronous teaching where prerecorded web-based material is complemented with live interactive webinars.

Other curricular considerations include the following:

• In LMICs, some imaging may be performed by lay health workers; thus, it may be beneficial to include such individuals in radiology education ¹⁷.

• In team-based education projects, use of a standard lecture format with predetermined objectives promotes cohesion and minimizes overlap and repetition.

• Incorporation of learner assessment into education projects helps test their effectiveness and improves learning ^18,19.

• Inclusion of features like closed captioning makes learning accessible to more learners.

• HIC-based radiologists may have greatest impact by partnering with LMIC teaching hospitals, which can provide supplemental education and on-site real-time supervision for clinical translation.

• At the start of and during an education project, feedback can drive improvement. For example, formal outcome measurements showed that implementing a modified Breast Imaging Reporting and Data System in Uganda for non-radiologist health care workers improved interpretation of findings and reduced unnecessary biopsies ^17,20. Conference presentations and publications about a project can also generate useful feedback in comments from peer reviewers.

Customize the Program for the Local Environment

HIC-based radiologists participating in global radiology education must be attentive to the specific challenges faced by LMICs. For example, in the RSNA-led women's imaging fellowship program in Tanzania and Breast Imaging Curriculum for LMICs, we found that mammography was unavailable at several participating sites (as is the case in many LMICs). Thus, we have prioritized lectures on ultrasound. Once mammography becomes available, the curriculum will be adjusted to include foundational concepts in mammography.

In many LMICs, there is little to no subspecialty training for radiologists. In those LMICs, programs such as Road to IR may be helpful. Road to IR is an international consortium of health care professionals from multiple US universities, including Yale, Emory, and Duke, that established the first interventional radiology (IR) training program in sub-Saharan Africa in Tanzania ²¹. Road to IR has developed customized protocols and interventions that match the general LMIC environment and can be customized for specific locations.

Emphasize Collaboration

Global radiology education projects are best approached with an emphasis on collaboration between the LMIC and HIC partners.

One way to emphasize collaboration as opposed to HICs being “in charge” is for team members from HICs to practice within their scope. For example, we welcome involvement of students from HICs but encourage them to assume responsibilities in LMICs like the responsibilities they would be allowed to assume at their home institutions.

Another way to emphasize collaboration is to design learning materials that are beneficial not only for LMIC learners but also for HIC learners. Trainees at our institution in Houston benefited from a collaboratively designed course for Singapore (an HIC) when the COVID-19 pandemic disrupted our existing in-person teaching sessions ²². Trainees in HICs could also benefit from courses designed for LMICs as they provide information about practice patterns in low resource environments.

Costs may be approached collaboratively, such that both the local and foreign partners are committed. Shared responsibilities can include funding, housing, responsibility for lectures, and monitoring compliance with administrative regulations.

Beyond sharing resources, it is beneficial to share credit. For many years, “parachute science” has been criticized. This term is used to describe an “extractive practice” in which researchers from HICs publish work performed in LMICs without recognizing partners’ contributions ²³. This practice disadvantages LMICs in terms of publications, funding opportunities, and power in deciding the direction of future projects ²³. Recently, The Lancet strengthened its emphasis on collaboration by announcing that it will reject papers with “data from Africa that fail to acknowledge African collaborators” ²⁴. Incorporating professional development and mentorship (e.g., research skills), into educational projects maximizes their benefits for LMIC participants, which can improve interest in ongoing collaboration^25,26.

Transparency is beneficial: we encourage LMIC partners to reveal any related ongoing collaborations to avoid opposing projects.

Design for Economic Stability and Longevity

For any global health project, especially one involving volunteers and external funding, there will be concern about economic sustainability ²⁷. An economically sustainable project will need consistent funding, consistent human resources (volunteer or staff), and demonstrable positive impact on health care outcomes, which may influence the ability to obtain subsequent funding. Thus, focusing on these elements during project planning is critical.

While performing a single short-term, in-person trip is a good entry point to global radiology education, such trips are controversial because of concern that the resulting projects may not have lasting effects at the LMIC site. Radiologists interested in global radiology education ideally should aim for ongoing, sustainable contributions. When a project will be time-limited, radiologists should clearly disclose that fact. A particularly important aim is creating a pathway for sustainability of LMIC stakeholder involvement. A variety of approaches can be used to improve the uptake and longevity of an education project.

Strategic partnerships, such as with ministries of health, nongovernmental organizations, industry, and private groups, can increase project longevity. Existing programs by international radiology organizations will have staff experienced in the language, culture, and socioeconomic and demographic conditions of the nation of interest and have strong relationships with hospital and government authorities; such staff members may be instrumental in building strategic partnerships. Strategic partnerships can be beneficial for securing funding, navigating regulatory guidelines, and cementing relationships with project stakeholders and beneficiaries. For example, the above-mentioned RSNA Global Learning Centers’ subspecialty training programs in LMICs partner with local lawmakers to make the training a formal requirement for licensure ¹². This practice builds in additional support from the local faculty and ensures an ongoing pipeline of trainees.

Education projects affiliated with international radiology organizations have access to a continuous supply of volunteer faculty, which can help ensure longevity. Other helpful measures include incorporation of certification or continuous medical education credits.

Using a team-based approach at both the foreign and host institutions ensures that the demands of a project do not become overwhelming or the project ends following the departure of a single individual, which in turn makes education projects more long-lasting. For Road to IR, incorporating HIC-based nurses, technologists, medical students, residents, and radiologists has led to a strong local presence, successful outcomes, and longevity ²⁸.

Providing protected time for participation by LMIC and HIC-based participants may also be beneficial ^22,29. An increasing number of young US-based early-career radiologists and radiology residents indicate strong interest in participating in global radiology education ². The current American Board of Radiology examination schedule allows greater flexibility in the fourth year to pursue elective interests. Several US institutions offer a global radiology elective to trainees (under the supervision of a practicing radiologist). Cross-generational collaboration between established radiologists and early-career radiologists and residents can increase the longevity of education projects.

Giving HIC-based radiologists credit for participation can improve program sustainability. While residents often have protected time for global health electives, many practicing radiologists may not. Creating “global radiology” tracks for faculty with accompanying protected time, promotion/assessment criteria, and access to professional development funds can improve program success and increase program-related publications. Such publications provide visibility of ongoing projects, promote future collaborations, and motivate ongoing participation.

Benefits for Radiologists from HICs Participating in Global Health Initiatives

There are many benefits for HIC-based radiologists participating in global health initiatives, including network building, exposure to a greater breadth of diseases, and development of creative problem-solving skills needed to adapt to a low-resource environment. Loss of meaning in work is known to drive radiologist burnout; participation in global health initiatives could help radiologists find that meaning and improve radiologist wellness ³⁰.

While HIC-based radiologists interested in contributing to radiology projects in LMICs may be overwhelmed by the vast need, entry to education as a global health service vehicle is more possible now than ever.

Conclusion

Well-designed global radiology education projects may not only improve radiologist training and patient care in LMICs but may also benefit radiology trainees and radiologists in HICs by allowing them to build their networks, expand their skills, and find additional meaning in their work.