Aishwarya Khanna, Avyay Sharma
Background
As a teaching fellow in ophthalmology, I have delivered various aspects of the curriculum, including examination skills. Direct Ophthalmoscopy (DO) is currently taught within the ophthalmology placement, and it is a skill that the GMC require medical students to develop competency in. However, perhaps due to the minimal time and exposure within ophthalmology, in what is usually a two-week placement, the students’ confidence in their ability to perform this or indeed identify abnormalities is variable. There is also evidence to show that postgraduate doctors are not confident in this skill (8).
The Royal College of Ophthalmologists (RCO) encourage undergraduates and junior doctors to conduct slit lamp examination (SLE). SLE is not currently taught within the ophthalmology undergraduate curriculum across most schools. This article will discuss the possibility of developing the way we teach medical students to carry out ophthalmology examinations, and if students see value & are interested in this advancement.
Medical student perspectives
To gain a better understanding of their perspective, a digital survey was sent to 60 medical students. In this survey they were asked about how competent they felt in ophthalmology examination techniques (fundoscopy/visual fields/pupil examination), both prior to and following their ophthalmology placement. They were also asked about whether they thought SLE would be useful to learn at an undergraduate level.
Overall, 83.3% of students responded. Before starting placement, 88% of these students said they did not feel competent regarding the skills mentioned above. On completion of placement, 92% of the students felt they were competent in the ophthalmology examination skills taught.
When asked on their thoughts regarding introduction of SLE teaching, 90% agreed that ‘it would be helpful to learn’.
Following these results, a SLE session has been designed and incorporated into the ophthalmology timetable for 3rd year medical students at this particular institution. A suitable learning environment, lesson plan, equipment & facilitators were organised.
Introduction of this extra session has brought teaching more in line with guidance shared by the RCO for skills which junior doctors should be familiar with, one of which includes to “use a slit lamp to view the eyelids, conjunctiva, cornea, iris and lens” (1).
The results from this survey gives confidence to incorporate SLE and replicate the success of the teaching for DO as demonstrated.
Reasons to adapt
This section will look at the potential benefits from adjusting teaching methods in ophthalmology and including SLE teaching to the undergraduate ophthalmology curriculum.
The General Medical Council (GMC) guidance for undergraduate practical procedures states the requirement for competency in DO (GMC, 2019). Students are assessed on their ability to perform this examination whilst applying the correct technique and demonstrate the ability to identify abnormal findings. However, when assessing fundoscopy during OSCEs and WPBAs, it is not possible to visualise what the student is seeing through their instrument, which can pose a query to assessment validity. Additionally, there is little evidence to show that the findings from DO are optimal in detecting common abnormalities (2).
This challenges whether medical students should continue to be trained in DO, or if there are better suited examination techniques available. One example of adaptation, which could prove beneficial, is digital fundoscopy. This allows the examiner to see which areas of the retina the student is visualising in real time. Therefore, digital fundoscopy may be of more value in undergraduate assessment for the time being (4).
A paper by Purbrick and Chong discusses the value of fundus examination teaching and how important is for this examination to be reliable and accurate in order to maximise healthcare for patients (6). They mention that regularly “referrals from emergency departments to ophthalmology are concluded with a statement such as ‘I couldn’t see any obvious abnormalities with the ophthalmoscope, but it was difficult…’”. The paper concludes that from the authors perspective there are two ways to improve examination. The first option being to put more time and resources into training students in fundoscopy, but this may not be wise as there are experienced clinicians who struggle with this skill. The second option being to routinely use fundus photography, which is less demanding to conduct and can still obtain signs accurately.
As mentioned previously in this article SLE is another technique which may prove beneficial to healthcare professionals, especially junior doctors in A+E, where a slit lamp is kept to assess all ocular cases. Incorporating SLE teaching at an undergraduate level could be achieved as students have expressed how successful DO teaching has been, thus they can similarly be taught SLE. If more junior doctors are appropriately trained in SLE, there would be profound benefits such as meaningful referrals into ophthalmology departments, better communication between staff in A&E and ophthalmology, and a reduction in the number of patients that are wrongly sent to eye casualty. These improvements would ultimately result in services becoming more streamlined and help to ease pressures on the NHS.
Ophthalmology is a specialty with continual research and evolving technology in many areas. Technological advancements deserve to be reflected in our educational methods in order to remain relevant and true to the clinical realities (7). Adapting teaching may also play a role in inspiring and incentivising students as they have the opportunity to see the growing potential in this career, from an early stage (5). The underlying values and beliefs held as an educator stand firm in this forward movement (3), introducing SLE teaching would uphold these values and support an advancement within the current curriculum.
Conclusion
Examination of the fundus is an extremely important skill in both primary and secondary care, which when performed accurately and reliably can detect abnormalities, thus interventions can be made earlier in the patient journey and the quality of referrals into the ophthalmology department can be improved. Fundoscopy has been taught to undergraduate students for many years and is becoming increasingly outdated as technology advances in this speciality, additionally it has been shown that postgraduate doctors struggle and cannot perform DO adequately. It is important to note that DO does allow visualization of the fundus if SLE is not available, for example in a remote setting such as general practice, so teaching this examination technique should not be completely neglected. Slit lamp examination is a technique which undergraduate medical students are willing to learn and aligns their curriculum with guidelines set by the RCO. SLE would also have profound benefits for patients and the NHS, as referrals would hopefully become thorough and contain more accurate details, ultimately allowing for the safest, and most time/resource efficient patient care.
SLE can be taught to undergraduate students as fundoscopy teaching has proven successful. This gives teaching staff the confidence to introduce sessions on SLE teaching.
References
- Education and Training, Royal College of Ophthalmologists, 2020
https://www.rcophth.ac.uk/wp-content/uploads/2022/03/Curriculum-UG-RCOphth-220309.pdf - BENBASSAT, J., POLAK, B. C. & JAVITT, J. C. 2012. Objectives of teaching direct ophthalmoscopy to medical students. Acta Ophthalmol, 90, 503-7.
- Donnelly, R., Fitzmaurice, M. (2005) Designing Modules for Learning. In G. O’Neill, S. Moore & B.McMullin(eds.)Emerging issues in the practice of University Learning and Teaching, Dublin, All Ireland Society for Higher Education (AISHE).
- KIM, Y. & CHAO, D. L. 2019. Comparison of smartphone ophthalmoscopy vs conventional direct ophthalmoscopy as a teaching tool for medical students: the COSMOS study. Clin Ophthalmol, 13, 391-401.
- LI, B., MICHAELOV, E., WATERMAN, R. & SHARAN, S. 2022. Ophthalmology as a career choice among medical students: a survey of students at a Canadian medical school. BMC Medical Education, 22, 225.
- PURBRICK, R. M. J. & CHONG, N. V. 2015. Direct ophthalmoscopy should be taught to undergraduate medical students—No. Eye, 29, 990-991.
- SCANTLING-BIRCH, Y., NAVEED, H., TOLLEMACHE, N., GOUNDER, P. & RAJAK, S. 2022. Is undergraduate ophthalmology teaching in the United Kingdom still fit for purpose? Eye, 36, 343-345.
- SCHULZ, C. & HODGKINS, P. 2014. Factors associated with confidence in fundoscopy. The Clinical Teacher, 11, 431-435.