Aishwarya Khanna

‘‘Red Eye’ is a sign associated with several ocular presentations. Many of these are included in the conditions list, forming the ophthalmology curriculum for medical students during their ophthalmology placements at university.

Developing a teaching session on Differential Diagnoses of ‘Red Eye’, based upon teaching and learning principles is therefore of benefit for students when hoping to reach their desired learning outcomes.  A teaching session for ‘Red Eye’ was therefore developed. This design of this teaching session will be explored and critically analysed using the literature from medical education.

For the purposes of this session, we focused on 14 cases of red eye, including; conjunctivitis, acute anterior uveitis, acute angle closure glaucoma, scleritis, episcleritis, subconjunctival haemorrhage, endophthalmitis, keratitis (bacterial & viral), corneal ulcer/abrasion, foreign body, peri orbital cellulitis, orbital cellulitis, blepharitis and chemical injury.

Design of the Intended Learning Outcomes

Lack of clear objectives and expectations is noted to be a common problem with clinical teaching (28). Sharing advantages of the aims and intended learning outcomes (ILO’s), provides significance to the teaching event. This concept is described as ‘orientation’ by Creemers and Kyriakides (7), as part of their eight principles of effective education. This is supported by Gagné (9), who outlines that a good teacher should describe the goals which the session aims to achieve. Simultaneously, students are able to develop an appreciation for how the session can positively impact their stage of learning. Furthermore, Gagné’s Nine events of Instructional Design (10), was used as scaffold for the teaching session, beginning with step 1; ‘Gain Attention’. This is an opportunity to highlight how the session will be of benefit. This emphasized how the topic would be relevant, before outlining how and what we hope to achieve. This was deliberate, to grab the learner’s attention and enable navigation through the session with awareness of key concepts, providing purpose to the material. ‘The goal free effect’ was considered at this point. Although setting goals can lead to the successful completion of tasks, the students may ultimately be learning very little about the subject (13). On balance, it is important for teachers to be aware of this and consider how they will still achieve tasks in the classroom, whilst relating this to wider context, particularly in the medical field. Relevance to ophthalmology was provided in a primary/emergency care setting which they will ultimately require during their foundation years as a junior doctor.

There is strong evidence that high quality instruction leads to the greatest teaching (6). Bloom’s taxonomy (3) was considered when formulating the ILO’s. This pyramid model outlines a hierarchy of learning objectives in order of complexity. It theorises that those given learning outcomes will perform better, for example, organise notes more efficiently, which can help with self-regulated learning (25). Unfortunately, this model could imply certain learning functions, for example, ‘apply’, to be a greater skill than others, such as ‘understand’. This may falsely assume that they are of higher cognitive function (22). The model was revised by Anderson and Krathwohl (1), who incorporated action verbs giving instructional objectives. This design is not as rigid, allowing for overlap between layers, arguably providing better application when designing ILO’s. Teachers have been criticised for providing instruction from the lower end of the pyramid, but teaching is seen to be of more effective when higher levels of instruction used (18). As students at this stage of medical school tend to be at a novice/advanced beginner level (8), instructional verbs from ‘remember’ to ‘analyse’ were utilised. This was deliberate to include a range of difficulty. Simultaneously, caution was taken not to overwhelm the students with concepts that were too challenging, as this is thought to be problematic (28). Therefore, verbs from ‘evaluate’ and ‘create’ were avoided.

The ILO’s for this session were clearly outlined, instructing the students what they should be able to perform following the session;

• List the 14-differential diagnosis for ‘Red Eye’ discussed in this session
• Classify 14 presentations of red eye into ‘Painful’ and ‘Painless’
• Explain the reasoning behind why each diagnosis is appropriate
• Differentiate these form conditions which are less likely, therefore rule them out
• Recognise how these conditions are managed in the clinical setting
• Test understanding using both case examples and exam style questions provided

Concepts from Cognitive Load Theory (CLT) (30) were integrated into the teaching’s session. Content was tailored for limitations of the novice/advanced beginners’ working memory. Attention was given to techniques which; managed the intrinsic, minimized extraneous and maximised germane load, as these methods optimise learning (29).

Design of the Teaching Session Activities

To orientate students there is an initial group activity which required them to label a diagram of the eye.

To reduce extraneous load (32) in the labelling activity, redundancy, temporal and spatial continuity were employed. Labels were not listed on the slide, but instead delivered in spoken words (redundancy). Reducing the amount of text on the slide, meant that the visual pathway was not overloaded, utilising the auditory pathways simultaneously. The same information was not provided via two different cognitive channels unnecessarily, which avoided the split attention effect (15). Narration and diagram were provided at the same time (temporal contiguity), further acting to reduce extraneous load (20). The students labelled their own printed handout of this diagram (spatial contiguity) and referred to this throughout the session, allowing them to visualise exactly where each condition was affecting. This labelling activity also brought learner knowledge to the same level in the form of retrieval practice which ‘stimulated recall’ (Gagne, Briggs and Wagner, 1992) of anatomical structures. This was important because students pre-reading/experience can vary, which can present challenging if teaching a mixed ability group.

Both images and names of the 14 conditions were printed on 14 cards and spread throughout the group. Each condition was discussed by the facilitator and whoever had the particular image card. Paivio’s (21) Dual Coding Theory showed that student use both cognitive pathways to better retrieve information (5). As colour images were used on the cards, it was confirmed that there was no student with colour blindness, however, for some scenarios, resources in black and white may be required to ensure that understanding is not reliant on the colour (14).

The discussion was facilitator led, including presenting signs, symptoms and investigation findings of each condition one after another. The students explained why one diagnosis would be more likely than another, which stimulated germane load (32). Elaborative interrogation was also incorporated to further encourage germane load (16). Conscious of minimising the intrinsic load, only a limited number of key points were mentioned regarding each condition, and it was made clear to the students that this was an overview of many conditions, not an in-depth presentation of each. This did not cause anxiety as it was aimed at an appropriate level, with facilitator support for queries. This activity involves more challenge that the previous labelling task, which is important to prevent boredom and remain in the zone of proximal development (17).

This activity also allows for group participation and peer engagement. Smith et al (27) showed that even in naive groups containing less experienced learners, students improve performance due to greater conceptual understanding. A mixture of facilitator led, and group discussion was incorporated to practice metacognitive and communication skills beneficial for clinical disciplines. This may have risked incorrect information coming from a student, however as this teaching session was facilitator led, those could be corrected for.

Interleaving can improve discrimination between similar topics, and enhance long-term retention and performance (24) maximising germane load. This can be appropriate when discussing different conditions with a similar presentation. It is thought be beneficial in challenging situations, however, overlapping similarity may make it challenging for students to distinguish between similar topics (26), especially at a novice level. This then poses questions to the utility of interleaving across different disciplines (24). Despite interleaving not being supported by the proximal learning framework (17), in this case, facilitator led discussion would stress the differentiating points between the 14 cases of red eye, before clearly categorising them into; ‘painful’ and ‘painless’. Enough time was set aside for this to take place, and the level of difficulty was appropriate. Interleaving seems to work better in academic disciplines, such as medicine, where subtle differentiations are stressed. Limitations seem more prominent, for example, when learning another language. Even if students were to misunderstand concepts when interleaving between differentials of ‘Red Eye’, the classroom environment does not have to be error free. Any misinterpretations faced can be explored with the facilitator (12). It was emphasized that ‘no question is a stupid question’, in hopes to attribute success to effort rather than ability, creating a comfortable environment for learning (6).

 Smith and Karpike (2014) found a very small difference between the use of short-answer questions (SAQ’s) and multiple-choice questioning (MCQ’s), but all types of retrieval practice were shown to enhance learning. Therefore, to assess performance (Gagne, Briggs and Wagner, 1992) a low stakes quiz, with case vignettes and MCQ’s were explored within session, and examination style short answer questions to take home. These activities included more challenging concepts to create desirable difficulty, as challenging students is shown to improve long term learning (2). In support of this, introducing challenge has been known to generate efficient and deeper understanding and prepare the student better for clinical practice (4). Furthermore, the use of quizzing is also thought to improve outcomes in long term memory, in comparison to restudying (19). Consequently, students were made aware that this was a low stake quiz which did not contribute towards a formal assessment and there was no scoring system. This was emphasized to minimise anxiety during the quizzing activity, which has been shown to negatively impact the formation of long-term memory (31). Overall, these techniques aimed to contribute towards better final exam performance (11).

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