The Sandwich fellowship: a subspecialty training model for the developing world

Geographic Representation of Authorship in Ophthalmic Research from Low- and Middle-Income Countries

PURPOSE

Low- and middle-income countries (LMICs) are underrepresented in ophthalmic research, despite carrying the highest burden of visual impairment. To assess the representation of local authors in global ophthalmic research, this cross-sectional, bibliometric analysis measured the proportion of LMIC-affiliated authorship in LMIC-based ophthalmic research.

METHODS

We sampled original, primary research conducted in LMICs and published in 1 of 7 high-impact ophthalmic journals between 2017 and 2021. For each article, we extracted the number and name of country study site(s), country affiliation(s) of first and last author, proportion of LMIC-affiliated authors, funding sources, and study design.

RESULTS

Of the 1,333 studies exclusively conducted in LMICs, 89.4% of first authors and 80.6% of last authors were exclusively LMIC-affiliated. Representation of LMIC-affiliated first authors were lower in studies based in low-income countries (25.0%) or in sub-Saharan Africa (26.5%), published in journals with higher impact factors (68.0% in Ophthalmology), funded by high-income countries (HICs) (41.4%), or conducted in both LMICs and HICs (27.1%). The United States, United Kingdom, and Australia had the 3rd, 6th, and 8th largest shares of last authors. There were only 12 single-country studies conducted in low-income countries, namely Ethiopia, the Gambia, Guinea, Liberia, the Niger, and Sierra Leone. Of these countries, only three held first authorship and one held last authorship.

CONCLUSIONS

Although LMIC-based ophthalmic research has demonstrated higher local authorship representation compared to other fields, underrepresentation can be exacerbated by country income level, journal "prestige," and degree of HIC involvement. These discrepancies highlight the need for more equitable data ownership in global ophthalmic research.

Capacity-building partnerships for surgical post-graduate training in low- and middle-income countries: a scoping review of the literature with exploratory thematic synthesis

In recent years, international surgical programmes have moved away from vertical service delivery and towards collaborative, capacity-building partnerships. The aim of this review was to provide a map of the current literature on international surgical training partnerships together with an exploration of factors influencing their implementation. Three bibliographic databases were searched for peer-reviewed reports of surgical training partnerships between organizations in high- and low or middle-income countries to July 2018. Reports were sorted in an iterative fashion into groups of similar programmes, and data were extracted to record the intervention strategies, context, financing, reported results and themes around implementation. Eighty-six reports were grouped into five types of programme: full residency training, bi-institutional twinning partnerships, diagonal/sub-specialist programmes, focused interventions or courses and programmes using remote support. Few articles were written from the perspective of the low-middle income partner. Full residency programmes and some diagonal/sub-specialist programmes report numbers trained while twinning partnerships and focused interventions tend to focus on process, partners' reactions to the programme and learning metrics. Two thematic networks emerged from the thematic synthesis. The first made explicit the mechanisms by which partnerships are expected to contribute to improved access to surgical care and a second identified the importance of in-country leadership in determining programme results. Training partnerships are assumed to improve access to surgical care by a number of routes. A candidate programme theory is proposed together with some more focused theories that could inform future research. Supporting the development of the surgical leadership in low- and middle-income countries is key.

Leadership development facilitated by the "sandwich" and related glaucoma fellowship programs

PURPOSE

The purpose of this paper is to evaluate leadership training in the Sandwich Glaucoma Fellowship (SGF), a program in which fellows learn skills in a developed world institution and their home country to become leaders in glaucoma care.

DESIGN/METHODOLOGY/APPROACH

This paper is a retrospective, qualitative and quantitative evaluation. Participants of the SGF between 2007 and 2019 were provided a survey eliciting demographic information, leadership training exposure, development of leadership competencies and feedback for the fellowship program.

FINDINGS

Seven of nine alumni responded. The fellowship strongly impacted leadership competencies including integrity (8.8, 95% CI 7.8-9.8), work ethic (8.64, 95% CI 7.7-9.6) and empathy (8.6, 95% CI 7.7-9.5). A total of 85% of alumni indicated positive changes in their professional status and described an increasing role in mentorship of colleagues or residents as a result of new skills. Lack of formal leadership training was noted by three respondents. Informal mentorship equipped fellows practicing in regions of Sub Saharan Africa with competencies to rise in their own leadership and mentoring roles related to enhancing glaucoma management. Suggested higher-order learning objectives and a formal curriculum can be included to optimize leadership training catered to the individual fellow experience.

ORIGINALITY/VALUE

Leadership is necessary in health care and specifically in the context of low- and middle-income countries to bring about sustainable developments. The SGF contains a unique "Sandwich" design, focusing on the acquisition of medical and leadership skills. This evaluation outlines successes and challenges of this, and similar fellowship programs. Other programs can use a similar model to promote the development of skills in partnership with the fellows' home country to strengthen health-care leaders.

Characterising transnational ophthalmic surgical partnerships by engagement and training

BACKGROUND

Transnational ophthalmic partnerships exist between high-income countries (HICs) and low- and middle-income countries (LMICs) in varying capacities. We analyzed partnership stakeholders to better understand and address disparities in ophthalmic surgical care.

METHODS

An international Web search was conducted to identify surgeons, foundations or organisations participating in ophthalmic delivery and/or capacity building from 2010 to 2019. Partnerships were defined through clinical activities, education and training and/or research support. Descriptive data on current ophthalmic partnerships were collected from published reports, literature reviews and information on stakeholder webpages. Partnerships were classified by the extent of engagement and training: grade I 'engagement' represented documented partnerships of at least 1 year and grade I 'training' limited or poorly defined skills transfer programmes, while grade III 'engagement' represented partnerships with well-documented fiscal investment and/or research productivity and grade III 'training' established training programmes. Data were analysed using descriptive statistics and geospatially depicted on Tableau (Mountain View, CA) and ArcMap software (Redlands, CA).

RESULTS

In total, 209 unique HIC-LMIC partnerships encompassing 92 unique countries were described. The most common HIC partners were from North America (123; 59%), followed by Europe (75; 36%). The most common LMIC partners were from Africa (102; 49%), followed by Asia-Pacific (54; 26%) and Latin America (44; 21%). Additionally, partnerships most frequently provided services in cataract (48%), glaucoma (25%) and diabetic retinopathy (25%). The most common 'engagement' classifications were grade I (36%) or II (40%); the most common 'training' classifications were grade I (61%) or II (23%).

CONCLUSION

Transnational ophthalmic partnerships exist with varying degrees of both engagement and training. Partnerships are stronger in research collaboration and direct services, and weaker in LMIC-directed training programmes.

Leadership Development in Ophthalmology: Current Impact and Future Needs

Importance There is a lack of peer-reviewed literature on leadership development programs (LDP) in ophthalmology. Research into LDP demographics, outcomes, and methodology is needed.

Objective The aim of the study is to evaluate the extent to which LDPs targeting ophthalmologists meet the needs of emerging leaders.

Design The design type of the study is cross-sectional analysis.

Setting This study involves international setting.

Participants The participants involved were ophthalmologists at any career level.

Methods Routine internet search was used to identify LDPs targeting ophthalmologists. LDPs identified were categorized by the outcome data available into four levels based on prior literature. Participants were assessed using previously validated software for gender (Gender-API, 2020) and race or ethnicity (NamSor, 2020)

Results Nine programs were identified which were classified into LDP generations. The first LDP in ophthalmology was the American Academy of Ophthalmology (AAO) LDP, which served as the nidus for the formation of four multinational LDPs, together forming the Global LDP. These LDPs were similar in size and scope; program size ranging from nine to 30 participants; a length of 1 to 2 years; with similar curricular offerings; with funding primarily derived from cost-sharing with a nominating society. The second generation of ophthalmology LDPs in the United States has targeted female scientists or faculty (Women's LDP by ARVO) and academic ophthalmology leaders (Academic LDP by Association of University Professors of Ophthalmology).

The AAO's LDP appears increasingly diverse with approximately 13% women at inception, gradually increasing from 40 to 65% women in the last 5 years (n = 389). There has also been a notable increase in ethnic diversity.

Conclusion and Relevance AAO LDP is the preeminent leadership training program for ophthalmologists, and it has influenced the creation of a new generation of LDP offerings. There remains a paucity of LDP evaluation metrics and reported outcomes. Newer iterations are successfully targeting academic leadership and attempting to address known disparities in gender and race or ethnicity. Further expansion of LDPs and related research can ensure equity and diversity in the pipeline.

Establishing Surgical Care Sustainability in Sub-Saharan Africa for Global Child Health: Insights From Pediatric Cardiac Surgical Capacity-Building Programs in Ethiopia and Côte d'Ivoire

The global surgery research team of the JW LEE Center for Global Medicine, Seoul National University College of Medicine, introduced team-based health workforce training programs for pediatric cardiac surgery in Ethiopia and Côte d'Ivoire. A team-based collaborative capacity-building model was implemented in both countries, and details of the program design and delivery were documented. The research team shared their experiences and identified achievements, lessons, and challenges for cardiac surgical interventions in Sub-Saharan Africa. Future directions were put forward to advance and strengthen the low-and middle-income countries "Safe Surgery."

Ophthalmology training in sub-Saharan Africa: a scoping review

Sub-Saharan Africa is home to 12% of the global population, and 4.3 million are blind and over 15 million are visually impaired. There are only 2.5 ophthalmologists per million people in SSA. Training of ophthalmologists is critical. We designed a systematic literature review protocol, searched MEDLINE Ovid and Embase OVID on 1 August 2019 and limited these searches to the year 2000 onwards. We also searched Google Scholar and websites of ophthalmic institutions for additional information. We include a total of 49 references in this review and used a narrative approach to synthesise the results. There are 56 training institutions for ophthalmologists in eleven Anglophone, eleven Francophone, and two Lusophone SSA countries. The median duration of ophthalmology training programmes was 4 years. Most curricula have been regionally standardised. National, regional and international collaborations are a key feature to ophthalmology training in more than half of ophthalmology training programmes. There is a drive, although perhaps not always evidence-based, for sub-specialisation in the region. Available published scientific data on ophthalmic medical and surgical training in SSA is sparse, especially for Francophone and Lusophone countries. However, through a broad scoping review strategy it has been possible to obtain a valuable and detailed view of ophthalmology training in SSA. Training of ophthalmologists is a complex and multi-faceted task. There are challenges in appropriate selection, capacity, and funding of available training institutions. Numerous learning outcomes demand curriculum, time, faculty, support, and appropriate assessment. There are opportunities provided by modern training approaches. Partnership is key.

North-South surgical training partnerships: a systematic review

Background

Fostering the success of surgical trainees from low- and middle-income countries (LMICs) plausibly addresses the existing workforce deficit in a sustainable manner, but it is unclear whether and how these trainees are targeted as strategic learners for educational exchanges. The purpose of this review was to assess the quality and outcomes of existing literature on exchanges of surgical trainees between high-income countries (HICs) and LMICs.

Methods

We conducted a systematic review of reported instances of surgical training exchanges between HICs and LMICs. After database searching, 2 independent reviewers evaluated titles, abstracts and manuscripts. Selected studies were critically appraised with the use the Critical Assessment Skills Programme Qualitative Checklist and analyzed for trainee level, institutions, countries and subspecialties, as well as reported outcomes of the exchange.

Results

Twenty-eight reports met the inclusion criteria and were analyzed. Most publications (18 [64%]) detailed North-to-South exchanges; 1 exchange was bidirectional. General surgery was the most common discipline identified, with 9 other subspecialties described involving learners at all phases of training. Reports were generally of good quality, although outcomes were reported variably, and most authors failed to acknowledge the ethical implications of their study.

Conclusion

The articles identified described a variety of surgical exchanges across disciplines, learner types and host/home countries. Few of the exchanges prioritized the learning of surgical trainees from LMICs. There is an increasing need to formalize these exchanges via clear goals and objectives, as well as to prioritize the proper matching of educational goals with local clinical needs.

Level of evidence

V - Evidence from systematic reviews of descriptive and qualitative studies.

Oculoplastic surgical services in Nigeria: status and challenges

PURPOSE

To assess the status and challenges of oculoplastic surgical services in Nigeria.

METHODS

An IRB-exempt, web-based survey was distributed to Ophthalmological Society of Nigeria members via e-mail. Information regarding demographics, type and location of practice, subspecialization training, availability and barriers of oculoplastic surgical services, pattern of oculoplastic diseases and surgical procedures was obtained. Responses were analyzed using standard statistical methods.

RESULTS

Forty-four percent (155/356) of ophthalmologists invited completed the online survey. Of these respondents, 104 (67.1%) do provide oculoplastic surgical services with 8 (5.2%) trained in oculoplastic surgery. Respondents reported most commonly treating eyelid trauma (98.1%), orbital inflammatory diseases (92.1%) and lacrimal system disorders (86.5%) with globe removal procedures (98.1%), eyelid reconstruction (92.1%) and lacrimal drainage procedures (84.5%) being the most common procedures performed in their practices. Barriers to availability of oculoplastic surgical services identified by respondents were few trained oculoplastic surgeons (92.9%), lack of training centers (70.3%) and accessibility of services (60%). On multivariable analysis, predictors of availability of oculoplastic surgical services were greater number of years in practice (P < 0.001) and subspecialty training (P < 0.001).

CONCLUSIONS

The availability and geographical distribution of oculoplastic surgical services in Nigeria are suboptimal with training deficiencies identified as the main challenge. Strategies to improve availability of oculoplastic care should entail a sustainable training program for this emerging subspecialty and physician deployment to under-resourced areas of the country.

An overview of advances in global maternal health: From broad to specific improvements

After the declaration of the Millennium Development Goals in 2000 by the United Nations, many stakeholders allocated financial resources to "global maternal health." Research to expand care and improve delivery of maternal health services has exponentially increased. The present article highlights an overview, namely 10 of the health system, clinical, and technology-based advancements that have occurred in the past three decades in the field of global maternal health. The list of topics has been selected through the cumulative clinical and public health expertise of the authors and is certainly not exhaustive. Rather, the list is intended to provide a mapping of key topics arranged from broad to specific that span from the global policy level to the level of individual care. The list of health system, clinical, and technology-based advancements include: (10) Millennium Development Goals and Sustainable Development Goals; (9) Development of clinical training programs, including the potential for subspecialty development; (8) Prenatal care expansion and potential; (7) Decentralized health systems, including the use of skilled birth attendants; (6) Antiretroviral therapy for HIV; (5) Essential medicines; (4) Vaccines; (3) mHealth/eHealth; (2) Ultrasonography; and (1) Obstetric hemorrhage management. With the Sustainable Development Goals now underway, the field must build upon past successes to sustain maternal and neonatal well-being in the future global health agenda.

Professional paradox: identity formation in qualified doctors pursuing further training

CONTEXT

Many newly qualified specialists and subspecialists pursue additional training. Although their motivations are many, the pursuit of further training as an alternative to unemployment is an emerging trend. Paradoxically, doctors continue as trainees with a consultant's credentials, and without the guarantee of eventual employment. This study explores seven doctors' experiences, the effects of further training on their professional identity formation (PIF), and how these effects are reconciled on a personal and professional level.

METHODS

This phenomenological study involved interviews with seven qualified Canadian specialists (three were female) who pursued additional training in response to a lack of available positions in their respective specialties. Template analysis generated theoretical constructs of influences on their PIF, and characteristics of their lived experiences.

RESULTS

Four themes shaped PIF: setting and context; language and communication; responsibilities and privileges; and participants' visions of their future selves. Professional identity formation (PIF) continued to develop in further training, but was inconsistently affirmed by participants' communities of practice. Four major themes characterised training experiences: prescription; managing multiple masters; limiting access to others and community ties; and constantly questioning the value of extra training.

CONCLUSION

Qualified doctors traverse professional paradoxes as they seek further education with no guarantee of employment and provide consultant-level care as 'trainees'. An identity dissonance emerges that may continue until a clear identity is prescribed for them. Although disruptive to these doctors' PIF and personal and professional lives, the long-term effects of additional training are unknown. Its utility and influence on securing employment and future job satisfaction are areas for further research.

Rapid learning curve assessment in an ex vivo training system for microincisional glaucoma surgery

Increasing prevalence and cost of glaucoma have increased the demand for surgeons well trained in newer, microincisional surgery. These procedures occur in a highly confined space, making them difficult to learn by observation or assistance alone as is currently done. We hypothesized that our ex vivo outflow model is sensitive enough to allow computing individual learning curves to quantify progress and refine techniques. Seven trainees performed nine trabectome-mediated ab interno trabeculectomies in pig eyes (n = 63). An expert surgeon rated the procedure using an Operating Room Score (ORS). The extent of outflow beds accessed was measured with canalograms. Data was fitted using mixed effect models. ORS reached a half-maximum on an asymptote after only 2.5 eyes. Surgical time decreased by 1.4 minutes per eye in a linear fashion. The ablation arc followed an asymptotic function with a half-maximum inflection point after 5.3 eyes. Canalograms revealed that this progress did not correlate well with improvement in outflow, suggesting instead that about 30 eyes are needed for true mastery. This inexpensive pig eye model provides a safe and effective microsurgical training model and allows objective quantification of outcomes for the first time.

A partial economic evaluation of blended learning in teaching health research methods: a three-university collaboration in South Africa, Sweden, and Uganda

Background

Novel research training approaches are needed in global health, particularly in sub-Saharan African universities, to support strengthening of health systems and services. Blended learning (BL), combining face-to-face teaching with computer-based technologies, is also an accessible and flexible education method for teaching global health and related topics. When organised as inter-institutional collaboration, BL also has potential for sharing teaching resources. However, there is insufficient data on the costs of BL in higher education.

Objective

Our goal was to evaluate the total provider costs of BL in teaching health research methods in a three-university collaboration.

Design

A retrospective evaluation was performed on a BL course on randomised controlled trials, which was led by Stellenbosch University (SU) in South Africa and joined by Swedish and Ugandan universities. For all three universities, the costs of the BL course were evaluated using activity-based costing with an ingredients approach. For SU, the costs of the same course delivered with a classroom learning (CL) approach were also estimated. The learning outcomes of both approaches were explored using course grades as an intermediate outcome measure.

Results

In this contextually bound pilot evaluation, BL had substantially higher costs than the traditional CL approach in South Africa, even when average per-site or per-student costs were considered. Staff costs were the major cost driver in both approaches, but total staff costs were three times higher for the BL course at SU. This implies that inter-institutional BL can be more time consuming, for example, due to use of new technologies. Explorative findings indicated that there was little difference in students’ learning outcomes.

Conclusions

The total provider costs of the inter-institutional BL course were higher than the CL course at SU. Long-term economic evaluations of BL with societal perspective are warranted before conclusions on full costs and consequences of BL in teaching global health topics can be made.

Beyond homogenization discourse: Reconsidering the cultural consequences of globalized medical education

INTRODUCTION

Global medical education standards, largely designed in the West, have been promoted across national boundaries with limited regard for cultural differences. This review aims to identify discourses on cultural globalization in medical education literature from non-Western countries.

METHODS

To explore the diversity of discourses related to globalization and culture in the field of medical education, the authors conducted a critical review of medical education research from non-Western countries published in Academic Medicine, Medical Education and Medical Teacher from 2006 to 2014. Key discourses about globalization and culture emerged from a preliminary analysis of this body of literature. A secondary analysis identified inductive sub-themes.

RESULTS

Homogenization, polarization and hybridization emerged as key themes in the literature. These findings demonstrate the existence of discourses beyond Western-led homogenization and the co-existence of globalization discourses ranging from homogenization to syncretism to resistance.

CONCLUSIONS

This review calls attention to the existence of manifold discourses about globalization and culture in non-Western medical education contexts. In refocusing global medical education processes to avoid Western cultural imperialism, it will also be necessary to avoid the pitfalls of other globalization discourses. Moving beyond existing discourses, researchers and educators should work towards equitable, context-sensitive and locally-driven approaches to global medical education.

Sub-specialization in plastic surgery in sub-Saharan Africa: capacities, gaps and opportunities

The skill set of a plastic surgeon, which addresses a broad range of soft tissue conditions that are prevalent in sub-Saharan Africa, remains relevant in the unmet need for surgical care. Recently, there has being a major paradigm shift from discipline-based to disease-based care, resulting in an emerging component of patient-centered care; adequate access to subspecialty care in plastic and reconstructive surgery. Given the need for an evolution in sub-specialization, this article focuses on the benefits and future role of differentiation of plastic surgeons into sub-specialty training pathways in sub-Saharan Africa.

Identity formation of occasional faculty developers in medical education: a qualitative study

PURPOSE

Faculty developers play a crucial role in preparing faculty members for their instructional responsibilities. In some programs, faculty developers are clinicians and scientists who only occasionally conduct workshops. The authors examine the identity formation of such part-time faculty developers.

METHOD

From April 2012 through March 2012, structured interviews were conducted with full-time faculty members who, from 2007 to 2012, periodically volunteered to teach workshops in the University of California, San Francisco School of Medicine's faculty development program. This qualitative study used a modified grounded theory approach.

RESULTS

The authors interviewed 29 occasional faculty developers who had 1 to 22 years of experience conducting faculty development programs. All faculty had an educator identity along with their professional identity. The additional faculty developer identity generally evolved over time and aligned with their identity in one of four ways: compartmentalized, hierarchical, parallel, or merged. Their roles as faculty developers enhanced their status in their work community and influenced the way they worked with others and advanced their careers. Faculty development influences the institutional culture, and the institutional culture supports faculty development.

CONCLUSIONS

Most occasional faculty developers possessed a merged identity that developed over time and was moderated by the topic that they taught. Although experience contributed to this development, both junior and senior faculty developers could have a merged identity. Those who lead faculty development programs can use these findings to recruit and retain faculty developers.

Health professions educators as agents of change in Tanzania: creativity to implement new curricula

Muhimbili University of Health and Allied Sciences (MUHAS) strives to instill in its graduates skills and competencies appropriate to serving the Tanzanian population well. MUHAS leadership, working in collaboration with educators from the University of California San Francisco (UCSF), selected and trained an interdisciplinary group of faculty members to promote effective teaching. We describe the development of this group of faculty change agents - now known as the Health Professions Educators Group (HPEG). The HPEG invigorated the education environment at MUHAS by: engaging many colleagues in special training events that introduced new methods for teaching and assessment; encouraging innovation; and developing strong mentoring relationships. HPEG members piloted courses in education to prepare all postgraduate students as peer educators, teaching assistants, and as candidates for faculty future appointments. Creation of a 'teaching commons' reinforces the new focus on innovative teaching as faculty members share experiences and gain recognition for their contributions to quality education.

Teleglaucoma: improving access and efficiency for glaucoma care

Teleglaucoma is the application of telemedicine for glaucoma. We review and present the current literature on teleglaucoma; present our experience with teleglaucoma programs in Alberta, Canada and Western Australia; and discuss the challenges and opportunities in this emerging field. Teleglaucoma is a novel area that was first explored a little over a decade ago and early studies highlighted the technical challenges of delivering glaucoma care remotely. Advanced technologies have since emerged that show great promise in providing access to underserviced populations. Additionally, these technologies can improve the efficiency of healthcare systems burdened with an increasing number of patients with glaucoma, and a limited supply of ophthalmologists. Additional benefits of teleglaucoma systems include e-learning and e-research. Further work is needed to fully validate and study the cost and comparative effectiveness of this approach relative to traditional models of healthcare.

The use of teleglaucoma at the University of Alberta

The aim of the teleglaucoma service at the University of Alberta is to improve access for people in northern Alberta who have early-stage glaucoma or who are at risk for glaucoma. Two types of teleglaucoma service are offered: remote and in-house. A standardized approach is used to capture patient information (structured histories, examinations and fundus photographs) which is then sent to a tertiary care centre for grading and recommendations. Only one grader reads and makes management recommendations for each case. Reports are sent electronically. A total of 195 cases have been graded through the remote service since 2008. A total of 62 cases have been graded through the in-house service since 2011. The average reporting time for consultations in the in-house service was 7 days, and it was also 7 days for the remote service. We believe that the use of teleglaucoma can improve the way that patients are diagnosed and managed, both in industrialized and developing countries. Teleglaucoma is currently being used as a screening tool at the Aga Khan University Hospital in Nairobi with mobile units equipped with a fundus camera and a visual field machine.

Training nephrologists from developing countries: does it have a positive impact?

In the past 25 years the International Society of Nephrology has sponsored 545 physicians from 83 developing countries to undertake nephrology training in renal units in the developed world. Data collected biennially from past fellows have demonstrated a very positive impact of the program on individual trainees and their home institutions. Many of the trainees have gone on to leadership positions in their home institutions, countries, and regions. Increasingly, fellowships are undertaken in selected developed centers within the fellow's own region, which increases the relevance and utility of the training to the fellow and the fellow's home institution, and lessens the risk of ‘brain drain'.

Assisting cytopathology training in medically under-resourced countries: defining the problems and establishing solutions

Cytology is able to deliver rapid accurate diagnoses with minimal equipment and laboratory infrastructure at minimal cost, and this is especially so for fine needle biopsy (FNB), which is a powerful diagnostic tool in medically resource-poor environments, where histopathology laboratories are small in number and poorly supported financially. The crucial element in the development of cytology services is to train a sufficient number of well trained cytopathologists and cytotechnologists to create a 'critical mass' of personnel who not only provide routine diagnostic services, but also can train an ever expanding number of pathologists, cytotechnologists, and health workers. A review of practical programs to train cytopathologists and cytotechnologists in their own countries will be presented, including a recent series of FNB and cytology tutorials run in sub Saharan Africa. The need for local cytopathology programs and the potential for both local and visiting cytopathologists to provide a faculty will be discussed, as well as a range of possible programs which can bring African pathologists and trainee pathologists to Western institutions for periods of their training. Ideally, the regional Societies of Cytology, including the recently formed West African Society of Cytology, will establish their own diagnostic protocols, training programs, syllabuses, examinations and accreditation and career pathways for both cytopathologists and cytotechnologists, and organize tutorials where they will invite overseas faculty to contribute. Crucially, these new societies will empower cytopathologists and cytotechnologists to approach health services and governments to state the need for cytology services as a cost-effective accurate diagnostic service that enhances patient care.