Teaching the Teachers

July 14, 2003

Not long after the Taliban regime was overthrown in Afghanistan last year, 150 doctors, including nearly 75 women in chadors, attended the first course on ultrasound in Kabul. Despite intermittent electricity and no running water or air conditioning, the

Not long after the Taliban regime was overthrown in Afghanistan last year, 150 doctors, including nearly 75 women in chadors, attended the first course on ultrasound in Kabul. Despite intermittent electricity and no running water or air conditioning, the physicians-most of whom had never attended a medical meeting before-spent an entire week learning about ultrasound principles and practices.

Now, with donated gray-scale and color machines, the obstetricians, internists, and radiologists are performing ultrasound in Afghan hospitals. And Dr. Hashin Wahaaj, who trained at Jefferson Ultrasound Research and Education Institute (JUREI) in Philadelphia and then waited 10 years in the border town of Peshawar, Pakistan, to return to his country, is finally establishing an Afghan ultrasound training center in the capital city.

Through international, national, and regional medical and radiology organizations and private educational institutions, radiologists like Wahaaj are teaching physicians, radiographers, and technologists how to perform and interpret diagnostic studies.

- In biennial congresses, the International Society of Radiology, a confederation of 75 national societies ranging from the 30,000-strong American College of Radiology to the nine-member Mongolian Society of Radiology, has instructed 5000 physicians in China, 5000 in India, and 1500 in Mexico over the last few years.

- The Pan American Health Organization (PAHO) has trained an estimated 2000 individuals in the past 15 years in seminars, workshops, congresses, and conferences at international, national, and regional levels as well as in radiological physics centers.

- The World Health Organization has established a "train the trainers" program to improve the quality and quantity of diagnostic imaging in Kenya, and it is working to create additional centers in West Africa and the Southern Pacific region.

- The RSNA's visiting professors program sends teams of two or three radiologists abroad to conduct up to six educational programs every year. Since 2001, visiting professors have traveled to Bolivia, Uruguay, Nicaragua, Singapore, New Zealand and Fiji, Colombia, Peru, and Guatemala. Later this year, teams will be educating radiologists and technologists in South Africa, Kenya, and El Salvador.

- The International Breast Ultrasound School, based in Baden, Switzerland, conducts four to six breast ultrasound seminars a year in the U.S., Europe, Asia, and South America.

- Fontys University in Eindhoven, the Netherlands, has taught ultrasound to more than a dozen participants in each of 17 courses in Tanzania and 11 courses in Ghana since 1996.

- The JUREI provides onsite classroom and hands-on instruction in ultrasound for more than 1000 physicians from as many as 60 countries every year. Its Teaching the Teachers program trains 2500 people around the world in 53 affiliated ultrasound education centers, including Albania, Afghanistan, Bangladesh, China, and Mongolia.

- The International Society of Radiographers and Radiological Technologists (ISRRT) holds a world congress in radiography and radiation safety every two years for as many as 1000 radiographers from around the world and conducts hands-on workshops for up to 40 radiographers in developing nations every year.

- In addition to its triennial world congress on diagnostic ultrasound, the World Federation for Ultrasound in Medicine and Biology conducts workshops on safety and sponsors as many as 10 members from developing countries at its world congresses.

But every success story also reflects the enormity of the task. The WHO estimates that between 25% and 30% of all medical procedures worldwide depend on imaging to make a diagnosis, but many parts of the world have little or no access to contemporary radiological equipment. University hospitals may have basic x-ray or ultrasound machines and, in the best cases, an old-fashioned CT. But district hospitals often have only one or two x-ray or ultrasound units, said Dr. Harald Ostensen, coordinator of the WHO's Diagnostic Imaging and Laboratory Technology Branch.

The discrepancy in diagnostic imaging capacity between developed and emerging nations and from one part of a country to another can be staggering. Accra, the capital of Ghana, is a bustling international city with steel and glass high-rises, sprawling government buildings, two-story colonial houses perched on stilts, and a sleek, modern national hospital. But medical facilities are scant at the edges of Accra, where modern buildings give way to mud huts covered by woven palm fronds, plywood, corrugated metal, or packing cases. And they're nearly nonexistent along the dusty roads where women with babies strapped to their backs peddle plantains and yams, clothing, and small electrical appliances from open-air stands.

The Panchasayar section of Calcutta, the first British capital of India, boasts multidisciplinary specialty hospitals with several hundred beds, CCUs, adult and neonatal ICUs, and contemporary imaging equipment: fourth-generation CT scanners, color Doppler ultrasound, echocardiography, and cardiac catheterization laboratories. In distant agricultural and carpet-weaving areas of India, however, hospitals with double-digit bed totals and a handful of x-ray or ultrasound units serve more than 250 patients a day from more than 20 villages. Until a few years ago, only tertiary-care hospitals in India had automatic film processors. Community health centers used handheld tanks and spread images on bushes to dry in the sun, said Otha Linton, executive director of the ISR.

And even the most rudimentary diagnostic imaging equipment is outdated in most areas of the world. Although the Russian Health Service has 32,000 x-ray units, 230 angiography units, 200 MRIs, 400 CTs, and about 14,000 ultrasound systems, 70% of the x-ray units are more than 10 years old, said Dr. Valentin Sinitsyn, chair of radiology at the Moscow Medical Academy. The availability of diagnostic equipment is especially acute in the small villages and towns of frigid Siberia.

The lack of state-of-the-art imaging devices complicates traditional educational programs, which bring individuals from developing countries to Europe or the U.S. for a few months of training. People who work in small hospitals that have only basic radiography and electricity three times a week are often unable to translate the high-technology scenarios they encounter in the West to the situation at home. Many either stay in the host country or try to return to it as soon as they can, contributing to a radiology brain drain at home, Ostensen said.

Few of the scores of radiology textbooks and other educational materials produced every year are appropriate for two thirds of the individuals who work with x-ray and ultrasound around the world. They may be fluent only in Bantu or Swahili or another widely spoken but not widely published language. Educational support on the Internet is no help in areas where telephone service is hit or miss and ISP access costs $40 an hour.

Internal political, socioeconomic, and health problems add further layers of complexity. The WHO's efforts to create a train-the-trainers center of excellence in West Africa with the French Society of Radiology have been delayed because of more than 13 years of civil war in Liberia, unrest in Sierra Leone, and rebel activity in the northern and western portions of the Ivory Coast. Massive movements of refugees between countries and epidemics of cholera, meningitis, and yellow fever have exacerbated the turmoil in those regions.

Although a great deal could be accomplished with generous budgets, radiology training programs often have difficulty raising money. Radiology education is rarely a priority for individuals and countries that are marshaling limited resources to combat malaria and AIDS.

Programs following the train-the-trainers concept are reaping results, however. According to a study of the effectiveness of the Teaching the Teachers diagnostic ultrasound program at Thomas Jefferson University, participants generally doubled their knowledge. The mean entry score for 112 individuals on an uncued examination covering basic physics, ultrasound interpretation of abdominal studies, and ob/gyn and other sonographic visualizations was 35%. At the end of the 12-week program, test scores rose to 73%.

Radiologists and radiographers from dozens of hospitals in Kenya are traveling to the WHO radiology education center of excellence in Nairobi. There they can learn the fundamentals of x-ray and ultrasound and take that knowledge back home. Small increases in imaging performance and interpretation can make a huge difference.

"If you can increase basic levels of knowledge just a little, you achieve a lot in terms of diagnosing and managing pneumonias, accidents, and broken legs. If you can increase knowledge about simple x-ray and ultrasound techniques, you can manage most of the things in your hospital," said Dr. Holger Pettersson, cochair with Ostensen of the WHO's Global Steering Group for Education and Training in Diagnostic Imaging.

TRAINING IN RADIOGRAPHY

Individuals who perform x-ray studies in remote parts of the world have to be self-sufficient. They must make sure their equipment is running smoothly because a repairperson or consultant is weeks away. And they can't turn to standard sources of information because many of their problems are unfamiliar to professionals in the developed world who have access to many more resources.

The WHO, for that reason, has focused its radiology educational and training efforts on practical, down-to-earth basics such as when the x-ray table should be cleaned and water in the processing equipment changed. And it is collaborating with local educators and experts who are willing to develop an ongoing radiology education curriculum and do the actual hands-on training to improve x-ray imaging in their countries.

Its first venture, a center of excellence in Nairobi, was initiated two years ago when lecturers from South Africa provided a clinical course of instruction to radiographers and radiologists who would become the next-level trainers. About nine months later, the Kenyan government selected senior radiographers who would form the center's nucleus and would plan and conduct educational workshops for others across the country.

Alfonce Nyalla is one of them. One of the first train-the-trainer radiographers educated in November 2001, Nyalla is secretary of the eight-member center of excellence steering committee. In March 2002, he and other committee members trained 40 radiographers and radiologists from 16 provincial and district hospitals in quality assurance and quality control, pattern recognition, equipment maintenance and handling, radiation protection and protective materials, reject film analysis, and service delivery. They plan to work with 90 people from six other sites this summer. When the steering committee evaluated the original 16 sites in October 2002, it found that radiology practice had improved in most places.

Radiology centers practice on a small scale in the Great Rift Valley, which runs between two ranges of 30 active and semiactive volcanoes, hot springs, and alkaline lakes, bisecting Kenya down the center. About 85% of sites in Kisumu, Nyeri, Kericho, and at Kenyatta National Hospital have x-ray QA and QC programs, Ostensen said. In Kisumu and Kenyatta National Hospital, those programs include reject film analysis, which involves program setting, methods, data collection and analysis, actions, and recommendations. It also covers faulty equipment testing for light leakage, safelight defects, sensitometric tests, and baseline maintenance. Radiology programs in Kakamega and Kericho have standard formats for image interpretation, according to Nyalla.

The next step is for radiographers and radiologists in these small hospitals to plan courses for the rest of the staff in their own institutions and in other facilities in their geographic areas, with support from Nairobi and the WHO. Department by department, village by village, region by region, the knowledge should start to reach the entire country.

On the other side of the world, the radiological health program of the PAHO has been providing practical training to physicians, medical physicists, engineers, and diagnostic and therapeutic technologists in radiological physics centers. The first opened in Caracas, Venezuela, in 1993 as a consortium of the radiology and radiotherapy departments of the Central University of Venezuela and the Venezuelan Institute for Scientific Research. It was later absorbed by the university. The second followed in 1995 at the Autonomous University of Honduras in Tegucigalpa. The PAHO hopes to add a network of similar centers, improving the standard of radiology in the 35 diverse countries of Latin America and the Caribbean.

The ISRRT, comprising more than 70 member societies worldwide, began holding world congresses in 1962 and international teachers' seminars in 1966. This year, it will host its fifth radiography and radiation safety workshop in Africa and will add another in India.

The workshops, which began in Arusha, Tanzania, follow a problem-solving approach that asks radiographers to work with ISRRT instructors to resolve the difficulties they face in day-to-day practice. Too often "Western" ways just won't work in developing countries, said Shirley Hundvik, director of education. The most pressing needs of a radiographer in an African bush hospital, for example, could be a bigger barrel to capture rainwater, a way to reduce film fogging when the darkroom safelight filter is broken, and suggestions for conserving the hospital's limited supply of film.

"There are many good schools of radiography throughout Africa, and radiographers do superb work. But they work under extreme conditions. That's why it's so important that we act as resource people and help them develop solutions that will work in their area," Hundvik said.

Those solutions might include processing film in the dark rather than covering a safelight with a piece of yellow paper, using a thermometer to make sure the temperature of the water is cool enough during processing, or clocking film development during wet line processing.

ULTRASOUND EDUCATION

Approximately 25% of all imaging studies throughout the world are done with ultrasound because all a radiographer or radiologist needs to use it is a room, a cot, and a little power. Ultrasound equipment doesn't cost much to buy or maintain, and it's durable and portable. It can travel into the smallest village and, in a pinch, run on batteries.

But even in larger cities in developing countries, most ultrasound machines are gray-scale, with color Doppler the exception. It was only three years ago, for example, that the first color Doppler machine arrived in the increasingly urbanized but still nomadic Mongolia. And with little or no infrastructure or experience, physicians and paramedical personnel in these nations have difficulty taking full advantage of ultrasound technology.

As recently as 1996, newly donated ultrasound machines remained in their cartons at many hospitals in Kenya because no one knew how to operate them. The government of the Netherlands asked Fontys University of Professional Education in Eindhoven to establish a two-week course in ultrasound for Kenyan physicians, and the university has been involved in ultrasound education in Africa ever since.

Fontys conducted eight courses in Kenya and two in Malawi for the Dutch government, rehabilitated a school of radiography, and established a train-the-trainers ultrasound program in Tanzania. It also held one-year follow-up refresher programs for previous students between 1996 and 2000.

In 1998, the university provided 17 courses of ultrasound training for 98 hospitals in Tanzania that had been equipped with ultrasound equipment by Philips Medical Systems. This year, in conjunction with Philips, it is creating short courses in ultrasound training and setting up a school for medical imaging in 65 hospitals in Zambia. Most recently, Fontys, along with the Ministry of Health and a university in Ghana, selected a number of people who will be trained to teach others about ultrasound in a three-week program. The university will also create two ultrasound schools there in Kumbasi and Accra.

To tailor its radiology programs to each country, Fontys assesses hospitals' diagnostic equipment and treatment capabilities. Courses in Egypt will include ultrasound, CT, MRI, and digital imaging, and an upcoming project in Uganda will cover color Doppler and MRI. Uganda is one of the fastest growing countries in Africa.

All educational programs concentrate on practicalities. After teaching medical officers, midwives, radiographers, and physicians about the underlying physics of ultrasound, Dr. Willem van Prooijen, who developed the Fontys radiology programs in 1996, and about 20 other teachers show how to methodically perform scans.

The educators downplay pathology because learning about normal ultrasound findings is so helpful for diagnosing disease in these countries, van Prooijen said. While about 70% of people scanned with ultrasound in Holland have no pathology, 90% of patients in Africa have morbid conditions before they go to a hospital for treatment. Pathology therefore tends to be more prominent and easier to detect.

"When you ask a doctor how to scan a liver, most times he will say, 'I'm going to look for this and this and this.' We tell them, 'Now you are going to look at the normal tissue of the liver, and to scan the liver you have to move in several directions. From that normal view, we will teach you how abnormalities are shown,'" van Prooijen said.

Students undergo one week of training in a skills lab or training facility in their capital city and one week of practical experience in a university hospital. The skills lab in Tanzania has two rooms with six Philips ultrasound units and one x-ray machine that reflect the kinds of equipment used in the country. Training centers in Ghana and Zambia that are affiliated with universities have four to eight ultrasound machines for training.

The Jefferson ultrasound program educates more than 1000 students in ultrasonography by bringing them to its Philadelphia site, which houses two classrooms, a media center, conference room, video learning center, and library. It provides access to hospital clinical ultrasound facilities, case materials, and consultant support.

The JUREI Teaching the Teachers program began in the early 1990s. The course instructs physicians from emerging nations around the world who have ultrasound experience as well as the desire to train others in the technology. Over the years, the program has instructed more than 2500 physicians and created more than 50 affiliated educational centers worldwide, including a program in the only medical school in Ulan Bator, capital of Mongolia.

Teaching the Teachers was originally funded by the U.S. Agency for International Development and the Open Society Institute. With grant support from the RSNA research and education fund targeted at educating physicians in sub-Saharan Africa, the program has taught a dozen physicians from Africa and established ultrasound education centers in Nigeria and South Africa. It plans to add three to five more training centers, said Dr. Barry B. Goldberg, chief of ultrasound at Thomas Jefferson and director of the JUREI.

Teaching the Teachers offers both theoretical and practical training over a period of 12 weeks. Lectures and skills development sessions covering the operation and maintenance of ultrasound equipment show participants how to handle a transducer, adjust imaging settings, and troubleshoot equipment malfunction. The program also includes lectures and film review sessions on interpreting ob/gyn, abdominal, and other types of imaging studies and a review of effective teaching techniques.

The JUREI avoids the brain drain by carefully selecting candidates who are dedicated to perfecting their skills in ultrasound and to teaching other practitioners about the technology, and who have the infrastructure to support sonographic imaging and instruction at home. Out of hundreds of physicians, all but one have gone back to their native countries, Goldberg said.

JUREI staff also provide ongoing support to affiliated ultrasound education centers. In site visits, faculty evaluate the centers' educational facilities, materials, and equipment and conduct lectures. The JUREI offers long-distance consultation and review of images from complicated cases and provides a newsletter and online ultrasonography texts through the Sonoworld.com Web site.

To assess how well teachers trained through the Teaching the Teachers program are educating others in ultrasonography, the JUREI tests their knowledge of basic science as well as their ability to apply that knowledge to clinical situations. A series of written examinations compare baseline familiarity with ultrasound upon entry into the program with knowledge three and six months after completion. In uncued examinations, which Goldberg said are 15% more difficult than standard multiple-choice tests, physicians are asked to identify the salient features on a sonogram, describe sonographic characteristics appropriately, and come up with an interpretation. From a baseline level of about 34%, participants in the Teaching the Teachers program improved their knowledge by 40% in three months and 51% in six months.

The JUREI administers the same type of test to students taught by graduates of Teaching the Teachers programs to learn how to focus new educational materials and improve overall teaching. It invites the heads of affiliated ultrasound education centers to the annual Leading Edge in Ultrasound meeting, which provides up-to-date information on the latest developments in ultrasound.

Teaching the Teachers is not a one-time, throw-everything-but-the-kitchen-sink-at-them type of educational experience.

"We select the best from our group, and when we send them back, we help get educational materials and equipment and support for their audiovisual needs. We also provide and grade exams to see how our teachers and their students are doing, supplement any weak areas, and provide upgrades and training," Goldberg said.