GLAUCOMA SUBSPECIALTY CURRICULUM
1. PREAMBLE
1.1. COECSA Background
The College of Ophthalmology of Eastern Central and Southern Africa (COECSA) is a specialized virtual College founded in 2012 after a successful voluntary merger between the Eastern Africa College of Ophthalmologists (EACO) and Ophthalmological Society of Eastern Africa (OSEA).
The College seeks to work in tandem with regional and global initiatives and to support international commitments including Sustainable Development Goals (SDGs), WHO Vision2020: the Right to Sight; WHO AFRO Road Map for scaling up HRH; 4th EAC Development Strategy; national eye care plans in the region, and national development plans, towards Universal Health Coverage (UHC).
COECSA plays a critical role in the sector because of its mandate and available expertise in eye care at different levels. Its work augments what other partners are doing and provides a basis for further intervention in other areas that COECSA is not involved in. COECSA’s products such as research, curricula, standards, quality assessments, and policy reviews provide the basis to further programmatic intervention. COECSA, therefore, places premium on partnership and collaboration because it is the synergy that is brought by working with others that produces sustainable results. This is the reason why COECSA sees itself as a catalyst for action by many actors.
COECSA’s mandate is to: Support development of human resource for health through quality training in ophthalmology; set standards for professional ophthalmic practice; facilitate continuing professional development; contribute to health policy development; advocate for relevant policy changes in the region; promote research which advances ophthalmology in the region; and, create a forum for the ophthalmic practitioners to promote the profession and exchange skills and knowledge
Its Mission is: To improve the number and quality of eye care workers in Eastern, Central and Southern Africa through training, leadership and promoting standards of practice, research and advocacy.
The Vision is: Eye health for all in Eastern, Central and Southern Africa.
The Goal of COECSA is: Skilled and motivated eye health work force for quality eye care in Eastern Central & Southern Africa region.
1.2. Curriculum Model
The Fellowship in subspecialty curriculum is a hybrid model that promotes the following curriculum tenets:
• Integration (horizontal & vertical)
• Thematic/systematic Courses
• Small group learning methods
• Student-centred & Student-directed Learning
• Optimum use of IT learning technologies
• Primary care models (& health promotion approaches)
1.3. Curriculum Goal, Objectives and Outcomes
The Fellowship in subspecialty programmes provides essential intellectual and clinical information (i.e. cognitive and technical/surgical skills) that are necessary for ophthalmic personnel. The curriculum is a content outline for a fund of knowledge. It is not designed to be all-inclusive but rather a guideline for the subspecialty training.
1.4. Core Competences
Core competencies include:
· Patient Care
· Medical Knowledge
· Practice-based Learning and Improvement
· Communication Skills
· Professionalism
· Systems-based Practice
2. INTRODUCTION/RATIONALE
COECSA with support from the Commonwealth Eye Health Consortium (CEHC) through the LSHTM embarked on a project to roll out regional Clinical Fellowship Programmes that will provide a well- defined clinical experience in Glaucoma specialty with recognised expertise. The programme is aimed to forestall the challenge of long periods of training abroad and maximize on the available pool of resources, both human resources and infrastructure.
The Glaucoma Subspecialty Clinical Fellowship has been designed in line with the existing COECSA Curriculum as well as theICO Subspecialty Curriculum for Training in Glaucoma. This curriculum was developed to ensure it is up to date and captures all the areas required for comprehensive Glaucoma Clinical experience which includes the expected hours of coverage for key competencies. The fellowship training is generally focused on additional in-depth understanding and management of glaucoma beyond that obtained in residency training.
3. STRUCTURE OF THE PROGRAMME
3.1. Goal
To provide the best possible advanced training / experience for the diagnosis, medical and surgical management of glaucoma that is based in Sub Saharan Africa.
3.2. Specific Objectives
a) To review and develop knowledge, skills and approaches relevant to etiology, pathogenesis, diagnosis, treatment, and prevention of glaucoma.
b) To understand the classification and pathophysiology of primary open angle and angle closure glaucomas as well as various secondary glaucomas
c) To understand the classification pathophysiology, diagnosis and management of congenital glaucoma.
d) To review the management of co‐existing cataract and glaucoma.
e) To develop good judgment regarding medical, laser, and surgical treatment of various complicated types of glaucoma.
f) To understand the side effects and complications inherent in the above therapies and options and to be able to prevent and/or best manage side effects and complications.
g) To become familiar and experienced with the use of diagnostic equipment for the diagnosis and differential diagnosis of various glaucomas.
h) To instill a deep rooted sense of responsibility for glaucoma patients who often require lifelong follow‐up care with appropriate support services.
i) To demonstrate the highest ethical standards when developing rapport with and engaging in treatment of glaucoma patients.
j) To understand the value of basic, clinical, and population research in furthering the understanding of etiology, diagnosis, and the treatment of glaucoma.
k) To participate in at least one glaucoma‐related research project and present at major regional or international ophthalmic meeting.
l) To participate in teaching of medical students and residents
m) To understand principles behind leadership and management roles related to the practice of glaucoma (in an academic and community practice setting). To appreciate considerations in the optimal utilization of finite resources.
n) To submit for publication at least one paper in a peer‐reviewed ophthalmic journal during the course of the fellowship.
3.3. Duration
The clinical fellowship will take place for a minimum of 12 months. Where the course is conducted by two (2) collaborating institutions, the program is to be done in two halves of 6 months at each training institution. Extension of the training period greater than 3 months, or an extended leave of absence, should have prior approval
3.4. Admission requirements
Advertisements of the fellowship will be done by COECSA and the training institution. The advertisements MUST contain the selection criterion, a breakdown of the Fees, the living allowance for the participant, if they are selected for the course. The following are the minimum requirements for admission to the Glaucoma Fellowship:
i. The applicant must be a COECSA fellow or meet the following guidelines:
o The fellowship is primarily only open to fellows (1st Priority). Fellows will be admitted at a Subsidized rate.
o Second option is members of COECSA in good standing – These will be admitted at a Higher Fee agreed on in liaison with the Executive Committee.
o Third option – Licensed, Qualified Ophthalmologists outside the region at a Much Higher Fee as agreed on in liaison with the executive committee
ii. An ophthalmologist who has worked for a minimum 2 years in a busy working environment
iii. Must have a valid medical board registration for their country
iv. Must have done at least 10 Trabeculectomy in glaucoma surgery
v. Must have done at least 100 Small Incision Cataract Surgery (SICS)
vi. The applicant must obtain a letter from the head of his/her home institution that assures that there will be an enabling environment of practice upon completion of the fellowship.
vii. A Motivation letter from the applicant
viii. Must pass an interview
ix. NOTE: Institutions with some candidates already in training at the time of accreditation, will be handled on a case by case basis as follows:
a. At the accreditation stage, the training institution will submit names of candidates in training.
b. The candidates will then be assessed against COECSA’s admission and exit criteria to ascertain if they meet the minimum requirements for a COECSA fellowship/specialist qualification.
3.5. Selection Process
All applications shall be reviewed by a selection panel from COECSA and the training institutions. The panel will consist of:
§ The COECSA Education & Accreditation Committee,
§ 2 Glaucoma Specialists, and
§ COECSA Education and Training Officer (ex -officio).
NOTE: If the 2 specialists agree, the applicant is admitted into the program; if the 2 specialists do not agree, the applicant is not admitted into the program; if one of the specialists agrees and the other specialist does not agree, the panel will discuss the admission of that applicant.
3.6. Delivery Methods
The program will take place in Centres or multiple collaborating Centres that have been accredited by COECSA. The actual training can take place in one (1) Centre or in multiple collaborating Centres following an agreement between the institutions. Where training is conducted in two training institutions:
- the admitting institutions assumes full responsibility for the candidates training. This will include, but not limited to verification and documentation of such training undertaken at the partner institution.
- If during the course of the training, any of the two institutions involved in the training decides to be accredited as a standalone training centre, a consideration will be made at the end of the training cycle.
The program director/trainer is responsible for the structure and content of the educational program. He/she must provide a statement of objectives, methods of implementation, and procedures for assessment of the program by the faculty and the fellows, as per course description and assessments in this curriculum.
3.7. Assessment
Training evaluation forms have been developed for training assessment purposes (see appendix B: Training Evaluation Forms). The valuation will be on four levels, as follows;
a) Program and Faculty Evaluation
The educational effectiveness of the fellowship program will be evaluated annually in a systematic manner. In particular, the quality of the curriculum and the extent to which the fellows have met the educational goals must be assessed. Teaching faculty will be evaluated on a regular basis. Faculty members who serve as clinician, scientist, and professional role models should be evaluated. Evaluation of faculty should include teaching ability, commitment, and clinical knowledge. There must be a formal mechanism by which fellows participate in this evaluation. Written evaluations by fellows, through mechanisms that promote candor and maintain confidentiality as much as possible, should be utilized in the evaluation of both the program and faculty.
b) Fellow Evaluation
There must be regular evaluation of the fellow’s knowledge, skills, and overall performance, including the development of professional attitudes consistent with being a physician.
The program director, with the participation of members of the faculty, shall:
a. At least semi-annually evaluate the knowledge, skills, professional growth, and curriculum development for each fellow using appropriate criteria and procedures.
b. Communicate each evaluation to the fellow in a timely manner.
c. Advance fellows to positions of higher responsibility on the basis of evidence of their progressive development of knowledge, skills, and professionalism.
d. Maintain a permanent record of evaluation for each fellow and have it accessible to the fellow and other authorized personnel.
e. Keep tracking information of the former fellows’ curriculum and career development and include this information in the record of each former fellow.
c) The program director must provide a written, final evaluation for each fellow who completes the program. The evaluation must include a review of the fellow’s performance during the period of training and should verify that the fellow has demonstrated sufficient professional ability to practice competently and independently. This final evaluation should be part of the fellow’s permanent record maintained by the institution.
3.8. Exit Criteria
o Stage 1: Final Training Evaluation by the Training Institution/programme director, who will make recommendation to the COECSA subspecialty panel
o Stage 2: Evaluation by the COECSA subspecialty selection panel, who will make recommendation to the College Senate. The panel will consist of:
- The COECSA Education &Accreditation Committee,
- 2 Glaucoma Specialists, and
- COECSA Education and Training Officer (ex-officio).
- NOTE: The glaucoma specialists in the panel conducting the evaluation shall not be from the training institution.
o Stage 3: Validation and Approval by the College Senate
3.9. Fellowship Award
The award and title for the participant upon completion of the program which will be given by COECSA in conjunction with the training institution is Glaucoma Specialist [COECSA]
3.10. Unsuccessful Trainee (Deferment and Training Extension)
In the event that a trainee does not meet the minimum requirements for qualification, at the end of the training period;
a) There will be an extension of the training by 3 months in order to meet the requirements.
b) In the event that after the 3 months extension the candidates does not meet the above minimum requirements, training will discontinue.
4. FACULTY/TRAINER QUALIFICATIONS & RESPONSIBILITIES
4.1. Qualifications
The following are the qualifications for a faculty member or trainer/director:
a) Must be a COECSA fellow or equivalent
b) Must be a COECSA registered faculty who has completed at least 2 COECSA/RCOph Train the Trainers Courses
c) Must be a member of the Glaucoma Community of Practice, if not a member, he/she must be approved by the CoP
d) Any assisting faculty must be a trained glaucoma specialist approved by the community of practice
4.2. Requirements
a) Required to possess appropriate educational qualifications, including certification in ophthalmology and glaucoma-fellowship training.
b) Required to have at least 3 years of clinical experience in glaucoma followinghis/her fellowship training.
· In rare circumstances, in regions where there may not be a fellowship-trained program director, a senior ophthalmologist may have 10 or more years experience in substantial (greater than 50%) glaucoma practice, including contribution to the literature in the way of clinical or basic research. Such a clinician should be considered an appropriate primary supervisor.
c) Should be engaged in ongoing basic and/or clinical science research in the area of glaucoma, as demonstrated by regular publications in peer-reviewed journals and/or presentation of research material at national and international meetings.
d) Required to have a clinical practice with at least 50% of patients who have glaucoma and glaucoma-related disorders.
e) Required to have an academic appointment on the faculty of the affiliated ophthalmology-residency program or affiliated institution.
f) Required to be licensed to practice medicine in the state or country where the institution that sponsors the program is located.
4.3. Responsibilities of the fellowship trainer/director
a) Required to design and supervise the educational experience.
NOTE: Programs must be provided with the additional professional, technical, and clerical personnel needed to support the administrative and educational activities of the program.
5. COURSE DESCRIPTION (SYLLABUS/MINIMUM REQUIREMENTS FOR QUALIFICATION)
For a trainee to have qualified, s/he must meet the following minimum standards during the fellowship:
5.1. Clinical Components
i. History Taking - The fellow must have in-depth knowledge to inquire about common and rare clinical conditions that may be associated with worsening disease, covering glaucomatous and non-glaucomatous causes of vision loss.
ii. Clinical Examination Skills - The fellowship must be organized to provide training that will equip the fellows to regularly perform evaluations and consultations, including history and examination, which involve the techniques of ophthalmology specific to glaucoma and related ocular and systemic conditions.
iii. Technical Clinical Examinations- The fellow should become proficient in the indications for and interpretation of results of specialized diagnostic testing appropriate to the subspecialty of glaucoma, including but not limited to the following:
a. Tests of visual function, including evaluation of visual disability using standard automated perimetry and Goldmann perimetry.
b. Tests of optic nerve and retinal nerve fiber layer structure, including examination of the optic nerve, disc photography, and familiarity with optical imaging techniques, such as optical coherence tomography (OCT) and Heidelberg retinal tomography (HRT).
c. Assessment of intraocular pressure.
d. Evaluation of the anterior chamber angle with gonioscopy and available anterior segment imaging techniques such as [AS-OCT] and ultrasound biomicroscopy [UBM]).
e. Assessment of other risk factors, such as corneal thickness.
iv. Therapeutics- The fellow must become familiar with the indications for and limitations of pharmacological, laser, and surgical therapies that may be recommended for patients with glaucoma and related conditions.
v. Clinical Experience- The fellow should become proficient in the diagnosis and management of glaucoma. This should be based on differential diagnostic skills development, knowledge of test indications and interpretations, in addition to individualized care based on indications and limitations of pharmacological, laser, and surgical therapies in any patient.
5.2. Didactic Components
ü Fellows are required to make use of the available resources for learning such as the list of books including eBooks, journals and relevant literature on glaucoma.
ü Fellows should participate in clinical conferences and didactic lectures in glaucoma and related topics that are separate from patient-care activities within the parent institution, including presenting cases and lectures, and participating in grand rounds and other departmental conferences.
ü Fellows are expected to participate in 30 hours of such time per year. Fellows should have basic knowledge of statistics for interpretation of published literature and conducting their own research.
ü Fellowship preceptors must emphasize the principles of ethical and humane treatment of patients in accordance with the Code of Ethics. Preceptors and faculty should communicate these principles in both didactic and clinical aspects of the fellowship training.
5.3. Supervision
ü Fellows must be appropriately supervised in patient care services by qualified faculty. The program director must ensure, direct, and document appropriate supervision of fellows. Attending physicians who supervise fellows must be available to the fellows and have sufficient experience with the severity and complexity of patient conditions. Fellows who supervise residents that treat glaucoma patients should have an attending physician readily available.
ü Patient interactions may be later reviewed with the fellow for appropriateness of care, including review of prepared consultation letters.
5.4. Duty Hours and Conditions of Work
ü Duty hours and night and weekend call for fellows must reflect the concept of responsibility for patients and provide for adequate patient care. Fellows must not be required to regularly perform excessively difficult or prolonged duties.
5.5. Scholarly Activity
ü The fellowship must take place in a scholarly atmosphere where resources are available that allow the fellows to participate in scholarly activities, such as research. Fellows should participate in the development of new knowledge and evaluate research findings. The responsibility for establishing and maintaining an environment of inquiry and scholarship rests with the faculty. While not all members of the faculty must be investigators, the staff as a whole must demonstrate broad involvement in scholarly activity. Faculty activity should include:
i. Active participation in clinical discussions, rounds, and conferences in a manner that promotes a spirit of inquiry and scholarship. Scholarship implies an in-depth understanding of basic mechanisms of normal and abnormal states and the application of current knowledge to practice.
ii. Participation in journal clubs and research conferences.
iii. Active participation in regional, national, or international professional and scientific societies, particularly through presentations at meetings and publications in peer-reviewed journals.
iv. Participation in research, particularly in projects that are funded following peer review and/or result in publications or presentations at regional, national, or international scientific meetings.
v. Offering of guidance and technical support (eg, research design, statistical analysis) for fellows involved in research.
vi. Provision of support for fellows participation in scholarly activities.
vii. Adherence to the Declaration of Helsinki on the Rights of Research Human Subjects and to the Association for Research in Vision and Ophthalmology’s Guidelines for Use of Research Animals.
5.6. Fellow Research Activities
Fellows should be exposed to opportunities to develop research skills by planning and executing at least 1 research project with set milestones. A