Foetal Radiology Education in India: The need for a new direction

Authors & Affiliations:

Rijo Mathew Choorakuttil, Chairperson, Samrakshan National Program, IRIA, & Founder Chief, AMMA Center for Diagnosis and Preventive Medicine, Kochi, Kerala

Sharon Baisil, Assistant Professor, MOSC Medical College, Kolenchery, India & Faculty, AMMA Healthcare Research Gurukul, Kochi, India

Praveen Nirmalan, Chief Research Mentor, AMMA Education Research Foundation & Faculty, AMMA Healthcare Research Gurukul, Kochi, India.

Corresponding Author: Rijo Mathew Choorakuttil, Chairperson, Samrakshan National Program, IRIA, & Founder Chief, AMMA Center for Diagnosis and Preventive Medicine, Kochi, Kerala

E-mail: samrakshaniria@gmail.com

Background

India has an estimated 27 million live births each year and an average of nearly 76,000 live births each day. (1) Most childbirths are institutional and offer the possibility of better control over childbirth outcomes. (2)

The prevalence of congenital malformations in new-born babies range from 1.9% to 2.72% and approximately 6,21,000 babies are born every year in India with congenital anomalies. (3) Heart defects are the most common congenital defects reported with a prevalence of 65.86 (range 37.72-114.77) per 10,000 births. (4) The prevalence of neural tube defects is estimated as 27.44 (11.73-64.08) per 10,000 births. (4)

An estimated 3.5 million of 27 million babies born every year in India are born premature or too soon. (1) India reports a declining but still high prevalence of small for gestational age (SGA) babies (36.5%) and a high neonatal death rate attributable to babies born with SGA. The prevalence of Intrauterine growth restriction (IUGR) was reportedly 54% and nearly 1 in 5 live-born babies were estimated as low birth weight in India. (2) Pregnancy-induced hypertension remains a major maternal and foetal health problem in India with an estimated prevalence of 5 to 8%.(5)

The perinatal mortality and morbidity rates remain high in India although they have declined slowly and steadily over the decades through sustained efforts by various stakeholders. (2)

Samrakshan is a national program of the Indian Radiological and Imaging Association (IRIA) that aims to reduce perinatal mortality in India through preventative, diagnostic and therapeutic efforts primarily focused on pre-eclampsia and foetal growth restriction. (6) The program, launched in July 2019, has several components including training and mentoring, documentation and research, outreach and synergistic approaches involving various stakeholders in perinatal care, and health education. (6) The program aims to integrate the latest evidence-based practices in foetal radiology with a specific aim to improve the quality and uptake of foetal doppler studies especially in Tier 2 cities, towns, and rural areas. Samrakshan is currently active in over 25 districts of 10 states in India and has screened over 6000 pregnant women at different trimesters of pregnancy. Samrakshan is consolidating its research and evaluation processes to include regional hubs in southern, western, eastern, central, and northern India.

Several interesting observations have come from the 1^st year of Samrakshan.  These include, but are not limited to,

• The major orientation of Foetal Radiology services in India is towards the detection of congenital and structural abnormalities and the Targeted Imaging for Foetal Abnormalities or the TIFFA scans. This focus remains a priority even though pre-eclampsia, foetal growth restriction, stillbirths, preterm births, and low birth weight are greater public health problems in India.
• Foetal Doppler studies are not routinely practised by all Foetal Radiology practitioners for all pregnant women in all trimesters. A limitation in the routine practice of foetal doppler is that foetal assessments are often based on the referral requirement from the primary physician managing the childbirth.
• The awareness of possible preventative and therapeutic approaches in Foetal Radiology must increase among all stakeholders involved with the management of pregnancy and childbirth.
• There is a need for local population derived assessment standards, pragmatic standardization of protocols and improved documentation of outcomes across India.

The Problem Statement

Are the current approaches towards Foetal Radiology training in India sufficient to address the challenges around perinatal outcomes in India?

Current Scenario in Foetal Radiology Education

Foetal Radiology education in India is currently offered as

1. Training provided during the postgraduate residency programs
2. Post-residency short- and long-term courses
3. Post-residency Fellowship programs
4. Didactic Webinars, workshops, and conferences

These programs are time-bound and follow a structure and process-based system where the training experience is defined by exposure to specific content for specific periods that may be followed by specific assessments tailored towards the understanding of the content. The current approach is an offshoot of the Flexnerian “revolution” that changed the delivery of medical education in the 1900s. (7)  The structure and process-based curriculum focus on knowledge acquisition are driven by the teacher with a hierarchical teacher to student approach and emphasize on summative assessments and a fixed time frame to complete the program. (8)

Structure and Process or Competence-Based Education?

Are a structure and process based pedagogical approach the best for the delivery of medical education?

Several studies from various parts of the world have highlighted the increasing prevalence of preventable medical errors. (9–11). Medical errors are complex and interlinked between the competence and skills of the individual, the system that produces and nurtures the decision-making skills of the individual and the compliance of the recipient to instructions among other factors. A major limitation of the structure and process-based pedagogical approach is its dependence on a time framework. The time framework can limit the ability of the learner to gain optimal competence in that area and the ability to provide medical education across the continuum of the medical practitioner. The focus on knowledge acquisition and assessments based on knowledge acquisition limits the ability to verify if the acquired knowledge is translated appropriately to practice. The learning is teacher-driven and therefore susceptible to the bias of the teacher concerning competencies and skills. These lead to a major limitation of the medical education system-the gap between knowledge acquisition and better or improved health metrics for populations.

Competence-based medical education (CBME) is described as “a disciplined approach to specify the health problems to be addressed, identify the requisite competencies required of graduates for health-system performance, tailor the curriculum to achieve competencies, and assess achievements and shortfalls.”(12)  CBME aims to prepare physicians for a practice that is focused on outcomes and organized around competencies based on societal and patient needs. (13) CBME de-emphasizes time-bound training with greater flexibility, accountability and learner-centred approaches built into the system. (13) CBME requires a continuous evaluation of competencies and their alignment with the needs of the populations and health systems at the local level. (14) CBME acknowledges that the needs of populations and health systems will vary widely across the globe. CBME essentially aims for better health and healthcare provision and at a lower cost. (15)

The fundamental principles of CBME include(16)

• Education based on the health needs of the population served
• The primary focus of education should be the desired outcomes for the learner
• The formation of a physician should be seamless across the continuum of education, training, and practice.

The emphasis of learning shifts towards the application of the knowledge acquired and includes clinical competencies and other critical competencies including the development of a professional identity, professionalism, and communication, advocacy, scholarship, leadership, and practice and system improvement. (17–21) Competency can be described as a complex set of behaviours built on knowledge, skills, attitudes, and reflected as a personal ability that integrates these measurable and discrete objectives. (8)

Competency-based curricula include the following(16)

• An orientation towards outcomes
• Learner-centred approach. The learner drives the process, and the teacher is a facilitator
• Non-hierarchical path of learning. Both teacher and learner are responsible for the content and path of learning
• Application of knowledge rather than acquisition alone
• Multiple assessments based on actual, authentic scenarios
• Criterion-referenced assessments
• Variable time. The achievement of competence more important than the ability to achieve it within a fixed time frame.

Can competence be evaluated? Is there a strict cut off or a minimum threshold that discriminates between competence and incompetence?

Five stages of competence have been described by Chambers and Glassman(22)

1. Novice-focuses on isolated facts that tests can evaluate
2. Beginner- synthesis and integration of information learned in seminars, in labs, and through supervised work are evaluated via simulations
3. Competent- functions as an independent learner and practices in a realistic work setting. Evaluation is authentic and comprises portfolios that contain ratings of supervisors, exemplary products, and test cases
4. Proficient- Professional identity and norms characterize proficiency, which is achieved by socialization and specialized training and evaluated by work-related markers; and
5. Expert- the highest level of competence—has an internalized, patient-oriented focus, learns through self-direction, and relies on self-assessment and internalized standards of evaluation.

The success of CBME requires several commitments from medical educators

• Commitment to teaching, assessing, and being a real role model for the broad range of identified competencies. These competencies must reach beyond the traditional silos of patient care and medical knowledge and integrate with concepts of professionalism, communication, advocacy, scholarship and research, ethics, leadership and practice and system innovation and improvement. The curriculum has to address quality improvement and learners must have the opportunity to actively participate in quality improvement work with mentors who apply these principles in real life.
• Balance patient safety with the professional development of learners. The curriculum should provide the structure and support to learners to progress from supervised to unsupervised work. The curriculum and supervisory framework must align the competence of the learner with an appropriate degree of supervision and safety of the patients within a controlled environment.
• Transparency with all stakeholders. CBME aims at an outcome-oriented approach and the voice of the patient-either individually or collectively- must be integrated to achieve desired patient-centred outcomes. The curriculum should teach and encourage learners to acquire and apply the skills to evaluate outcomes with a primary focus on patient needs.
• Empower Learners. CBME demands that the “teacher” facilitate and help the learner take responsibility and ownership of their learning. Different people learn differently and CBME aims to accommodate these different trajectories for optimal individualized and consequently collective outcomes.
• Use effective and efficient assessment strategies and tools. Conventional pedagogy has a fixed, scheduled approach to assessments often at a single time and in a simulated environment. CBME has multiple assessment frames and points and seamlessly integrate across multiple time points and in actual working environments. Assessment strategies must closely align with the constructs or the behaviours in health care we are attempting to measure and explicitly address what one is attempting to assess.
• Commit to transit learners from one phase to another based on competence rather than a fixed time frame. Learners who are progressing quickly can be pushed further along the developmental continuum from novice toward expert during the course allowing some people to graduate at a level of performance that is considered proficient or beyond in certain areas. Learners must not be allowed to progress merely because they have put the requisite time into the process of education and training. Decisions about progression must be based on the demonstration of required competencies. Assessment of learners’ performance over time in the required competencies can inform planning concerning the duration of training.
• Evaluate the impact of the curriculum based on the performance of the learner in real-life situations after completion of the course. These will include workplace assessments, the effectiveness of programs and practice, patient outcomes, research and development and the impact of the practice on the health of the population-individually and collectively.
• Commit to Faculty development
• Commit to collaboration

Can Foetal Radiology training in India transition to a CBME model?

Several gaps exist in the current structure and process based pedagogical approach for foetal radiology in India. The focus of the current pedagogical approaches is on knowledge acquisition and assessment of knowledge acquisition. It is a moot point if the knowledge acquisition has transformed into widespread improved health outcomes for populations. Certainly, the perinatal statistics and the output of research or innovative approaches towards perinatal problems in India do not suggest that the structure and process pedagogical approach is yielding optimal results. The lack of reliable and valid population-based normative indices and metrics for growth and development of the fetus in India and the relative lack of local population derived strategies to improve perinatal outcomes is a failure of the current structure and process based pedagogical approach.

We feel that Foetal Radiology pedagogical approaches in India should now start to focus on a transition towards competency-based education. There are several challenges to make this transition. The scope of work of a foetal radiologist in India is to be defined. Competencies that account for the multidisciplinary work of a foetal radiologist must be defined clearly and assessment strategies and tools developed. Clinician educators and professional body leaders must commit to a systematic learner-centred and patient-centred pedagogical approach and a collaborative approach that builds teams. The skills for self-acquisition of knowledge and self-evaluation of outcomes must form an integral part of the pedagogical process.

Samrakshan has started the process of competency-based education as part of its programmatic approach. Training programs of Samrakshan are followed by participatory case discussions, sharing of technical and skill-related details, protocols, guidelines, and evidence as part of encrypted group discussions. These discussions are learner-driven and the role of Samrakshan faculty is to facilitate the discussions, point towards available resources and to provide an interactive learning environment. Post-training, participants are encouraged to document case details and submit these data forms (with patient details anonymized) using an online portal to the central team. The data documentation and submission form allow self-evaluation of the conceptual understanding and its translation to clinical practice, assessment of outcomes and for shared learning based on individual and collective results. The transmitted data is analysed and converted into scientific manuscripts with the involvement of every participant who submits data forms. This process has progressed to the development of district-level hubs focused on evaluating parameters and research based on local population needs. The process has helped develop competency in research, scholarship, and system improvements. The results of data analysis from individual participants has led to the identification of several new findings of clinical and public health importance pertinent to the population of India. Participants of Samrakshan have developed multilingual health education material targeting the public as well as peers and colleagues in a multi-disciplinary setting as part of developing competency in communication and multidisciplinary synergy. Participants in Samrakshan also organize health education and awareness meets at different levels as part of developing competencies in professional identity, leadership, and advocacy. The collection of childbirth outcomes with a specific focus on perinatal outcomes is an integral part of Samrakshan. These programmatic elements of Samrakshan are participant-driven and facilitated by the core leadership team.

The perinatal statistics of India have shown promising improvement over several decades. These improvements have resulted in a slow yet steady decline in important adverse parameters. However, these improvements are focused on mortality and do not reflect the scope of challenges faced with an increased morbidity profile along the spectrum of mild to severe. Perinatal health has long term individual effects and even intergenerational effects that can affect the long-term health and wellbeing of populations in India. The practice of medicine is increasingly multidisciplinary and isolated silos of excellence may soon be obsolete as diseases and factors affecting wellbeing have multidisciplinary origins and effects. It is time clinician-educators of Foetal Radiology in India revisit the outcomes of the current pedagogical approaches and design appropriate strategies that optimally impact the health of the population in India.

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