Mussa Adil Butt MBBS BSc (Hons)1
1The Princess Alexandra Hospital, Harlow, United Kingdom
Introduction
Sight loss and blindness result in a significant amount of health burden within the United Kingdom (UK) and globally. The Royal National Institute of Blind People estimates that at least half of cases of sight loss in the UK are avoidable. The majority of this is related to refractive error but also untreated cataracts and the management of glaucoma, macular degeneration, and diabetic retinopathy[1]. Direct costs of sight loss to the National Health Service were estimated at £3.0 billion, with inpatient and outpatient costs accounting for half of the expenditure. Indirect costs are associated with the disability and reduction in quality of life secondary to sight loss[2]. Furthermore, it is estimated that 7% of emergency department attendances have an ophthalmic element and approximately 2% of general practice consultations include ocular symptoms[3,4].
The importance of ophthalmic knowledge for physicians to prevent visual loss and disability for their patients is clear. However, as the ophthalmology field becomes more isolated from the rest of medicine, this is reflected in the diminishing allocation given to ophthalmic teaching in undergraduate education. The direct impact is a lack of confidence of physicians to deal with ophthalmic problems and therefore an inability to protect the sight of their patients’.
The Current Situation
Previous surveys have highlighted that the state of undergraduate ophthalmology education is not new. In 1997, Shuttleworth and Marsh highlighted that only 22% of their participant physicians felt their ophthalmic undergraduate teaching was adequate[5]. Another survey by Baylis et al. in 2011, showed that out of 24 UK medical schools only 79% had a compulsory ophthalmology department attachment. Furthermore, the mean length of these attachments was only 7.6 days[6]. The latest survey, conducted in 2019, highlighted that despite over 20 years since this issue was highlighted, 75% of medical students felt their ophthalmic education was inadequate and as a result, 52% stated they did not have confidence in their ophthalmic knowledge. These surveys demonstrate that undergraduate ophthalmic education has been suffering for over two decades resulting in unconfident junior doctors being hesitant in dealing with ocular issues[7].
The General Medical Council (GMC) released ‘Outcomes for Graduates’ in 2018 to be used to shape medical school curriculums. It states under ‘Practical skills and procedures’ that graduates should display competency at performing direct ophthalmoscopy and identifying common abnormalities. However, there is no reference to ophthalmology teaching within the document[8]. As a result, ophthalmology teaching is not given priority in undergraduate curriculums and attachments are variable across institutions.
The inadequate exposure of medical students to the field has been cited as a fundamental reason for students not choosing ophthalmology as their career speciality[9]. The availability of student-selected components allow enthusiastic students to further their interest, but these are only available to a select number of students[10].
Effect of COVID-19
The COVID-19 pandemic has been a great burden on healthcare systems globally. A direct consequence of this has been the disruption to the educational experiences of medical students. Key changes to the curricula include a transition to virtual teaching, cancellation or reduction of clinical attachments and final year students bravely opting to support their local hospitals by graduating early. The cancellation of clinical rotations directly reduces student exposure to ophthalmology, which is already minimal. Some institutions have attempted to compensate for lost teaching time, but marginalised specialities such as ophthalmology are not given priority[11].
The Future of Undergraduate Ophthalmology
The COVID-19 pandemic has led to increased reliance on technology to provide both education and care. Virtual teaching through software such as Zoom has become the norm. This format is usually more convenient for both students and teachers and can even facilitate teaching from national or international specialists. However, it also results in a poorer student experience as there is a lack of interaction with faculty and peers[12]. Some institutions have attempted to overcome this by introducing virtual tutorials which include small group learning. Students found this to be an effective learning experience, however, the challenge of teaching direct ophthalmoscopy remained[13]. The use of simulators such as the EyeSi Direct Ophthalmoscope[14], allows students to perform a funduscopic examination on a variety of cases whilst avoiding direct patient contact. However, these simulators are expensive and are not routinely available in medical schools and hospitals. Wendt et al. created a novel ophthalmology elective for students to address the lack of clinical experience through their virtual curriculum. They plan to include grand rounds, research opportunities, key clinical knowledge, and patient encounters. The elective will be completed with an oral and written examination designed to test students on their knowledge rather than memorization[15]. Their strategy seems promising and may help push other institutions to create similar experiences for medical students.
Conclusion
The state of undergraduate ophthalmology education has been declining. Surveys amongst medical students and physicians have highlighted repeatedly that there is inadequate exposure resulting in a lack of confidence in ophthalmic conditions and skills. The COVD-19 pandemic has generated added pressure for educational institutions and specialities such as ophthalmology are unlikely to be given priority. However, as the use of technology in medicine increases this has also been reflected in medical education. The use of virtual teaching has increased, and some institutions have designed innovative methods to mitigate the reduced clinical experience. The consequence of these issues is medical students who show minimal interest in ophthalmology and do not consider it as a career. Unfortunately, this also results in weak diagnostic ophthalmic skills, and this may risk patient care. As those interested or involved in the field of ophthalmology, we must do our part to raise awareness on this issue and provide support for students who wish to discover more about the speciality.
References
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