visual Journal of
communication in medicine
Matching fundus photographs of classmates. An informal competition to promote learning and practice of direct ophthalmoscopy among medical students Jørgen Krohn1,2, Bård Kjersem2 and Gunnar Høvding1,2 1
Department of Clinical Medicine, Section of Ophthalmology, University of Bergen, Bergen, Norway 2 Department of Ophthalmology, Haukeland University Hospital, N-5021, Bergen, Norway Email: [email protected]
Purpose: To present a new approach for teaching direct ophthalmoscopy to medical students. Methods: At the University of Bergen, four consecutive classes of fourth-year medical students complete a required 9-week ophthalmology course every year. In the present project, one fundus photograph was taken of each student. The photographs were randomly numbered, printed on A4 glossy photo paper, and displayed on the classroom wall. Each student was given a form to fill in the fellow students’ names matching the number of the fundus photographs. They were encouraged to practise direct ophthalmoscopy on their classmates outside formal teaching hours. At the end of the course, they returned the filled-in forms, and those with the highest number of correct matches between the fundus photographs and fellow students received a reward. Results: Between 2011 and 2013, 239 students completed their ophthalmology course. Of these, 220 students (92%) voluntarily participated in the project.
The mean score was 70% correct matches between fundus photographs and fellow students (range 7 - 100%). The students’ course evaluations were overall positive. Conclusions: We recommend the use of peer fundus photographs in the context of a learning competition as a simple, inexpensive, and effective way to improve teaching of direct ophthalmoscopy.
It should be a priority for all ophthalmologists involved in university-based education to improve the ophthalmic knowledge and examination skills of medical students. With the tremendous growth in medical information and technology, however, the constraints of time have made it necessary to eliminate some of the subjects covered during medical school and residency.1 Despite the rising prevalence of age related eye diseases and diabetic retinopathy, medical schools throughout the world continue to reduce the time allocated for ophthalmic education, thus diminishing
13
vis omual m Jou rna lo
ORIGINAL ARTICLE
me u dic
the clinical skills of graduating physicians.1,2 Within the ophthalmology curricula, relatively less time for teaching and practising eye examination skills has also been reported.3,4 In particular, the task of teaching direct ophthalmoscopy has been made more difficult by the limited availability of suitable patients, due to shorter stays and increased morbidity of hospitalised patients, and the busy time schedule during ambulatory visits. Under the arguments that indirect ophthalmoscopy has largely replaced direct examination and that direct ophthalmoscopy, even in the hands of experienced ophthalmologists, has been found to be of limited diagnostic value,5,6 the objective of teaching direct ophthalmoscopy to medical students is a subject of controversy.7 Nevertheless, the ability to perform ophthalmoscopy remains important in general practice and other medical specialities. When compared to the equipment required for indirect examination, a standard direct ophthalmoscope offers several advantages such as being readily available and portable, inexpensive, and allowing high magnification of the fundus even through undilated pupils. Various methods, like the use of plastic canisters and simulation mannequins, have been developed to aid medical students to learn direct ophthalmoscopy.8–15 Although such simulation models complement clinical education and are useful for teaching the basic principles of ophthalmoscopy, they cannot by any means replace the challenges and experiences of examining a living person. There are a few previous reports on ophthalmoscopy teaching based on the recognition of peer fundus photographs within small groups of medical students.16,17 Likewise, the identification of peer optic nerve photographs has been used for an objective assessment of the students’ ophthalmoscopy skills.18,19 In this paper, we present a learning-by-doing approach for teaching direct ophthalmoscopy among fellow medical students by letting them compete in matching fundus photographs of the whole class during their entire ophthalmology course.
Materials and methods The project was initiated at the Section of Ophthalmology at the University of Bergen, where four consecutive classes of
14
fourth-year medical students (with approximately 30 students per class) each year complete a required 9-week ophthalmology course. During the first week of the course, all students received two hours of formal group instruction on the principles of ophthalmoscopy and how to use a direct ophthalmoscope. During this session, they had one eye dilated with 1% tropicamide to facilitate practising on each other. They were also informed about our project of using peer fundus photographs for further ophthalmoscopy training throughout the ophthalmology course. Although this would be run as a competition among the classmates, it was emphasised that participation was voluntary and that their performance would have no bearing on later evaluations or their final course grade. A single 40-degree colour fundus photograph, centred at the optic disc, was taken of one randomly selected eye of each participating student, using a Canon CF-60 Dsi fundus camera system equipped with a Canon EOS-1 mark II camera (Canon Inc., Tokyo, Japan). Within the next few days, the photographs were labelled with random identification numbers to maintain anonymity, printed on A4 high quality glossy photo paper at 300 dpi (Figure 1), and displayed together on the classroom wall (Figure 2). Each student was then given a pre-numbered form to fill in the fellow students’ names matching the number of the printed fundus photographs on the wall. They were strongly encouraged to train and practise direct ophthalmoscopy on their classmates during the entire ophthalmology course, both between the course sessions and outside the formal teaching hours in the afternoon and evening. As all the students had key access to the classroom with the wall-mounted fundus photographs and several ophthalmoscopes, they could easily practise direct ophthalmoscopy on each other, with or without the use of mydriatics, and fill in the pre-numbered forms also after regular teaching time (Figure 3). Because the project was designed as a competition and meant to enhance individual learning, the students were asked not to share their results. Close to the end of the 9-week ophthalmology course, they were requested to return the filled-in forms to the teacher for review and assessment. On the last day of the course, the three students with the highest scores (i.e. number of correct
vis omual m Jou rna lo
ORIGINAL ARTICLE
me u dic
Figure 1. Fundus photograph of one of the students labelled with a random identification number and printed on A4 high quality glossy photo paper.
matches between each fundus photograph and a specific fellow student) received diplomas and free cinema ticket vouchers as a recognition of their achievement. If more than three students made the same top score, the winners were selected among the top scorers by random draw. All the participating students were also allowed to keep their own fundus photographs. The project was performed in accordance with institutional guidelines and governmental ethics regulations.
Results Our project of using peer fundus photographs for ophthalmoscopy training was first introduced in the fall of 2011, and has since then been implemented in every academic semester (fall, winter, spring, and summer). Between August 2011 and June 2013, a total of 239 fourth-year medical students, belonging to 8 different classes, completed their ophthalmology course in our department. Of these, 220 students (92%; 142 women
Figure 2. A collage of the students’ fundus photographs mounted on the classroom wall.
15
vis omual m Jou rna lo
ORIGINAL ARTICLE
me u dic
Figure 3. Medical students practising direct ophthalmoscopy by matching the fundus photographs to the correct eye of their classmates. This unarranged picture was taken unexpectedly after regular teaching hours.
and 78 men) voluntarily participated in the project. The students were remarkably enthusiastic about the competition and very active in training and practising direct ophthalmoscopy on one another, both between and after the formal teaching sessions. Among the participating students, the mean score was 70% correct matches between fundus photographs and fellow students (median 74%; range 7 - 100%). Thirty percent of the students scored 100%, 19% scored between 100 and 75%, 23% scored in the range from 75 to 50%, and 28% of the students scored below 50%. In all the classes taking part in the project, the students’ course evaluations were overall positive, particularly regarding the use of peer fundus photographs in the context of a learning competition.
Discussion Ophthalmoscopy is essential for diagnosis and treatment of many eye diseases, as well as a number of other severe and sometimes life-threatening medical conditions. Although direct ophthalmoscopy is a relatively simple procedure, efficient and proper use of the ophthalmoscope requires instruction, training, and above all practice. Several studies have shown that medical students and residents do not trust their abilities and skills in performing direct ophthalmoscopy.20,21 Gupta et al20 also found that the majority of medical students are interested in additional training, and that self-confidence was significantly greater
16
among those practising outside formal teaching sessions. Our approach to help students develop and practise the skills of direct ophthalmoscopy offers several advantages to both faculty and students. As the students spend a considerable amount of time learning for themselves outside the context of formal classroom teaching, additional resources can be devoted to more traditional clinical education and lectures. Peer physical examination also has the benefit of protecting patients from the discomfort of being examined by inexperienced learners. In addition, the students can easily share information on how the ophthalmoscopic examination was performed and experienced, point out each other’s mistakes, and correct them. Such peer-assisted learning has been shown to improve the students’ clinical examination skills.22 For classes with few students, the competition can be made more challenging by including peer iris photographs for penlight examination of the anterior segment, or fundus photographs not belonging to the classmates to increase the total number of images to be considered. We were surprised by the enthusiasm with which the students engaged in the project. Despite the repetitive and rather tedious task of matching about 30 fundus photographs to the correct eye of their classmates, they were remarkably committed and excited about the project and very active in performing ophthalmoscopy throughout the 9-week ophthalmology course. We mainly attribute this to the competitive and interactive nature of the learning method.
vis omual m Jou rna lo
the present project. Based on our experiences over the last two years, we therefore recommend the use of peer fundus photographs in the context of a learning competition as a simple, inexpensive, and effective way to improve the teaching of direct ophthalmoscopy to medical students.
me u dic
ORIGINAL ARTICLE
Although competitions may create a level of anxiety and students are more motivated when they cooperate rather than compete with their peers,23 we believe that this kind of competition, run in an informal and friendly atmosphere, promotes the students’ learning process. It is, however, important to point out to the students that participation is completely voluntary and does not have any impact on their final course grade or other assessments. Another concern when students are examined during training of clinical skills, is the rare event of finding an unexpected abnormality or disease.24 The students should therefore be informed that all the fundus photographs are screened for possible eye diseases before display, and if something unusual is found, they will be notified and examined before they decide whether or not to proceed in the project. Among the 220 students who have participated so far, all had normal fundus photographs except for two students with small patches of myelinated retinal nerve fibres. The main disadvantage of the presented learning method is that the students examine healthy subjects without ocular pathology. On the other hand, to search for fundus abnormalities is obviously meaningless if the examiner is incapable to handle an ophthalmoscope. Our method enables the students to develop the necessary motor skills and to use the corrective lenses in the ophthalmoscope to get a clear view of the fundus in eyes with a wide range of refractive errors. Thereby, they learn to recognise the normal anatomic variations of the optic disc, retinal vessels, macula, and general background of the fundus, and thus to distinguish normal from abnormal. They also develop the skills to judge and memorise what they see during ophthalmoscopy, which are particularly valuable if they in future clinical practice should want to compare their ophthalmoscopic findings with images of specific eye fundus diseases. At the end of our ophthalmology course, all students undertake a mandatory written and oral examination, where the latter includes clinical examination of patients with various eye diseases. Although we have not objectively evaluated the effectiveness of our learning method, it is our clear impression that the students’ ability to perform ophthalmoscopy and reach a correct diagnosis during the examination of real patients has improved significantly after introduction of
Declaration of interest None.
References 1. Clarkson JG. Training in ophthalmology is critical for all physicians. Arch Ophthalmol 2003; 121: 1327. 2. Quillen DA, Cantore WA. Impact of a 1-day ophthalmology experience on medical students. Ophthalmology 2006; 113: 2307–2309. 3. Jacobs DS. Teaching doctors about the eye: trends in the education of medical students and primary care residents. Surv Ophthalmolol 1998; 42: 383–389. 4. Quillen DA, Harper RA, Haik BG. Medical student education in ophthalmology: crisis and opportunity. Ophthalmology 2005; 112: 1867–1868. 5. Harding SP, Broadbent DM, Neoh C, White MC, Vora J. Sensitivity and specificity of photography and direct ophthalmoscopy in screening for sight threatening eye disease: the Liverpool diabetic eye study. BMJ 1995; 311: 1131–1135. 6. Mowatt G, Burr JM, Cook JA, Siddiqui MA, Ramsay C, Fraser C et al. Screening tests for detecting open-angle glaucoma: systematic review and meta-analysis. Invest Ophthalmol Vis Sci 2008; 49: 5373–5385. 7. Benbassat J, Polak BC, Javitt JC. Objectives of teaching direct ophthalmoscopy to medical students. Acta Ophthalmol 2012; 90: 503–507. 8. Colenbrander A. Simulation device for ophthalmoscopy. Am J Ophthalmol 1972; 74: 738–740. 9. Dodaro NR, Maxwell DP. An eye for an eye. A simplified model for teaching. Arch Ophthalmol 1995; 113: 824–826. 10. Bradley P. A simple eye model to objectively assess ophthalmoscopic skills of medical students. Med Educ 1999; 33: 592–595. 11. Levy A, Churchill AJ. Training and testing competence in direct ophthalmoscopy. Med Educ 2003; 37: 483–484. 12. Chung KD, Watzke RC. A simple device for teaching direct ophthalmoscopy to primary care practitioners. Am J Ophthalmol 2004; 138: 501–502.
17
vis omual m Jou rna lo
ORIGINAL ARTICLE
me u dic
13. Hoeg TB, Sheth BP, Bragg DS, Kivlin JD. Evaluation of a tool to teach medical students direct ophthalmoscopy. WMJ 2009; 108: 24–26. 14. Swanson S, Ku T, Chou C. Assessment of direct ophthalmoscopy teaching using plastic canisters. Med Educ 2011; 45: 520–521. 15. McCarthy DM, Leonard HR, Vozenilek JA. A new tool for testing and training ophthalmoscopic skills. J Grad Med Educ 2012; 4: 92–96. 16. Cross HE, Miller JM, Brown L. An objective method of teaching fundoscopy. J Acad Ophthalmol 2011; 4: 52–56. 17. Milani BY, Majdi M, Green W, Mehralian A, Moarefi M, Oh FS et al. The use of peer optic nerve photographs for teaching direct ophthalmoscopy. Ophthalmology 2013; 120: 761–765. 18. Afshar AR, Oh FS, Birnbaum AD, Namavari A, Riddle JM, Djalilian AR. Assessing ophthalmoscopy skills. Ophthalmology 2010; 117: 1863.
Journal of Visual Communication in Medicine May 2014; 37, No. 1–2, pp. 13–18 ISSN 1745-3054 Print/ISSN 1745-3062 online © 2014 The Institute of Medical Illustrators DOI: 10.3109/17453054.2014.884551
18
19. Asman P, Lindén C. Internet-based assessment of medical students’ ophthalmoscopy skills. Acta Ophthalmol 2010; 88: 854–857. 20. Gupta RR, Lam WC. Medical students’ self-confidence in performing direct ophthalmoscopy in clinical training. Can J Ophthalmol 2006; 41: 169–174. 21. Wu EH, Fagan MJ, Reinert SE, Diaz JA. Self-confidence in and perceived utility of the physical examination: a comparison of medical students, residents, and faculty internists. J Gen Intern Med 2007; 22: 1725–1730. 22. Field M, Burke JM, McAllister D, Lloyd DM. Peer-assisted learning: a novel approach to clinical skills learning for medical students. Med Educ 2007; 41: 411–418. 23. Bligh DA. What’s the Use of Lectures? D. A. and B. Bligh: New Barnet, England; 1972. 24. Pols J, Boendermaker PM, Muntinghe H. Incidence of and sequels to medical problems discovered in medical students during study-related activities. Med Educ 2003; 37: 889–894.
Copyright of Journal of Visual Communication in Medicine is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
communication in medicine
Matching fundus photographs of classmates. An informal competition to promote learning and practice of direct ophthalmoscopy among medical students Jørgen Krohn1,2, Bård Kjersem2 and Gunnar Høvding1,2 1
Department of Clinical Medicine, Section of Ophthalmology, University of Bergen, Bergen, Norway 2 Department of Ophthalmology, Haukeland University Hospital, N-5021, Bergen, Norway Email: [email protected]
Purpose: To present a new approach for teaching direct ophthalmoscopy to medical students. Methods: At the University of Bergen, four consecutive classes of fourth-year medical students complete a required 9-week ophthalmology course every year. In the present project, one fundus photograph was taken of each student. The photographs were randomly numbered, printed on A4 glossy photo paper, and displayed on the classroom wall. Each student was given a form to fill in the fellow students’ names matching the number of the fundus photographs. They were encouraged to practise direct ophthalmoscopy on their classmates outside formal teaching hours. At the end of the course, they returned the filled-in forms, and those with the highest number of correct matches between the fundus photographs and fellow students received a reward. Results: Between 2011 and 2013, 239 students completed their ophthalmology course. Of these, 220 students (92%) voluntarily participated in the project.
The mean score was 70% correct matches between fundus photographs and fellow students (range 7 - 100%). The students’ course evaluations were overall positive. Conclusions: We recommend the use of peer fundus photographs in the context of a learning competition as a simple, inexpensive, and effective way to improve teaching of direct ophthalmoscopy.
It should be a priority for all ophthalmologists involved in university-based education to improve the ophthalmic knowledge and examination skills of medical students. With the tremendous growth in medical information and technology, however, the constraints of time have made it necessary to eliminate some of the subjects covered during medical school and residency.1 Despite the rising prevalence of age related eye diseases and diabetic retinopathy, medical schools throughout the world continue to reduce the time allocated for ophthalmic education, thus diminishing
13
vis omual m Jou rna lo
ORIGINAL ARTICLE
me u dic
the clinical skills of graduating physicians.1,2 Within the ophthalmology curricula, relatively less time for teaching and practising eye examination skills has also been reported.3,4 In particular, the task of teaching direct ophthalmoscopy has been made more difficult by the limited availability of suitable patients, due to shorter stays and increased morbidity of hospitalised patients, and the busy time schedule during ambulatory visits. Under the arguments that indirect ophthalmoscopy has largely replaced direct examination and that direct ophthalmoscopy, even in the hands of experienced ophthalmologists, has been found to be of limited diagnostic value,5,6 the objective of teaching direct ophthalmoscopy to medical students is a subject of controversy.7 Nevertheless, the ability to perform ophthalmoscopy remains important in general practice and other medical specialities. When compared to the equipment required for indirect examination, a standard direct ophthalmoscope offers several advantages such as being readily available and portable, inexpensive, and allowing high magnification of the fundus even through undilated pupils. Various methods, like the use of plastic canisters and simulation mannequins, have been developed to aid medical students to learn direct ophthalmoscopy.8–15 Although such simulation models complement clinical education and are useful for teaching the basic principles of ophthalmoscopy, they cannot by any means replace the challenges and experiences of examining a living person. There are a few previous reports on ophthalmoscopy teaching based on the recognition of peer fundus photographs within small groups of medical students.16,17 Likewise, the identification of peer optic nerve photographs has been used for an objective assessment of the students’ ophthalmoscopy skills.18,19 In this paper, we present a learning-by-doing approach for teaching direct ophthalmoscopy among fellow medical students by letting them compete in matching fundus photographs of the whole class during their entire ophthalmology course.
Materials and methods The project was initiated at the Section of Ophthalmology at the University of Bergen, where four consecutive classes of
14
fourth-year medical students (with approximately 30 students per class) each year complete a required 9-week ophthalmology course. During the first week of the course, all students received two hours of formal group instruction on the principles of ophthalmoscopy and how to use a direct ophthalmoscope. During this session, they had one eye dilated with 1% tropicamide to facilitate practising on each other. They were also informed about our project of using peer fundus photographs for further ophthalmoscopy training throughout the ophthalmology course. Although this would be run as a competition among the classmates, it was emphasised that participation was voluntary and that their performance would have no bearing on later evaluations or their final course grade. A single 40-degree colour fundus photograph, centred at the optic disc, was taken of one randomly selected eye of each participating student, using a Canon CF-60 Dsi fundus camera system equipped with a Canon EOS-1 mark II camera (Canon Inc., Tokyo, Japan). Within the next few days, the photographs were labelled with random identification numbers to maintain anonymity, printed on A4 high quality glossy photo paper at 300 dpi (Figure 1), and displayed together on the classroom wall (Figure 2). Each student was then given a pre-numbered form to fill in the fellow students’ names matching the number of the printed fundus photographs on the wall. They were strongly encouraged to train and practise direct ophthalmoscopy on their classmates during the entire ophthalmology course, both between the course sessions and outside the formal teaching hours in the afternoon and evening. As all the students had key access to the classroom with the wall-mounted fundus photographs and several ophthalmoscopes, they could easily practise direct ophthalmoscopy on each other, with or without the use of mydriatics, and fill in the pre-numbered forms also after regular teaching time (Figure 3). Because the project was designed as a competition and meant to enhance individual learning, the students were asked not to share their results. Close to the end of the 9-week ophthalmology course, they were requested to return the filled-in forms to the teacher for review and assessment. On the last day of the course, the three students with the highest scores (i.e. number of correct
vis omual m Jou rna lo
ORIGINAL ARTICLE
me u dic
Figure 1. Fundus photograph of one of the students labelled with a random identification number and printed on A4 high quality glossy photo paper.
matches between each fundus photograph and a specific fellow student) received diplomas and free cinema ticket vouchers as a recognition of their achievement. If more than three students made the same top score, the winners were selected among the top scorers by random draw. All the participating students were also allowed to keep their own fundus photographs. The project was performed in accordance with institutional guidelines and governmental ethics regulations.
Results Our project of using peer fundus photographs for ophthalmoscopy training was first introduced in the fall of 2011, and has since then been implemented in every academic semester (fall, winter, spring, and summer). Between August 2011 and June 2013, a total of 239 fourth-year medical students, belonging to 8 different classes, completed their ophthalmology course in our department. Of these, 220 students (92%; 142 women
Figure 2. A collage of the students’ fundus photographs mounted on the classroom wall.
15
vis omual m Jou rna lo
ORIGINAL ARTICLE
me u dic
Figure 3. Medical students practising direct ophthalmoscopy by matching the fundus photographs to the correct eye of their classmates. This unarranged picture was taken unexpectedly after regular teaching hours.
and 78 men) voluntarily participated in the project. The students were remarkably enthusiastic about the competition and very active in training and practising direct ophthalmoscopy on one another, both between and after the formal teaching sessions. Among the participating students, the mean score was 70% correct matches between fundus photographs and fellow students (median 74%; range 7 - 100%). Thirty percent of the students scored 100%, 19% scored between 100 and 75%, 23% scored in the range from 75 to 50%, and 28% of the students scored below 50%. In all the classes taking part in the project, the students’ course evaluations were overall positive, particularly regarding the use of peer fundus photographs in the context of a learning competition.
Discussion Ophthalmoscopy is essential for diagnosis and treatment of many eye diseases, as well as a number of other severe and sometimes life-threatening medical conditions. Although direct ophthalmoscopy is a relatively simple procedure, efficient and proper use of the ophthalmoscope requires instruction, training, and above all practice. Several studies have shown that medical students and residents do not trust their abilities and skills in performing direct ophthalmoscopy.20,21 Gupta et al20 also found that the majority of medical students are interested in additional training, and that self-confidence was significantly greater
16
among those practising outside formal teaching sessions. Our approach to help students develop and practise the skills of direct ophthalmoscopy offers several advantages to both faculty and students. As the students spend a considerable amount of time learning for themselves outside the context of formal classroom teaching, additional resources can be devoted to more traditional clinical education and lectures. Peer physical examination also has the benefit of protecting patients from the discomfort of being examined by inexperienced learners. In addition, the students can easily share information on how the ophthalmoscopic examination was performed and experienced, point out each other’s mistakes, and correct them. Such peer-assisted learning has been shown to improve the students’ clinical examination skills.22 For classes with few students, the competition can be made more challenging by including peer iris photographs for penlight examination of the anterior segment, or fundus photographs not belonging to the classmates to increase the total number of images to be considered. We were surprised by the enthusiasm with which the students engaged in the project. Despite the repetitive and rather tedious task of matching about 30 fundus photographs to the correct eye of their classmates, they were remarkably committed and excited about the project and very active in performing ophthalmoscopy throughout the 9-week ophthalmology course. We mainly attribute this to the competitive and interactive nature of the learning method.
vis omual m Jou rna lo
the present project. Based on our experiences over the last two years, we therefore recommend the use of peer fundus photographs in the context of a learning competition as a simple, inexpensive, and effective way to improve the teaching of direct ophthalmoscopy to medical students.
me u dic
ORIGINAL ARTICLE
Although competitions may create a level of anxiety and students are more motivated when they cooperate rather than compete with their peers,23 we believe that this kind of competition, run in an informal and friendly atmosphere, promotes the students’ learning process. It is, however, important to point out to the students that participation is completely voluntary and does not have any impact on their final course grade or other assessments. Another concern when students are examined during training of clinical skills, is the rare event of finding an unexpected abnormality or disease.24 The students should therefore be informed that all the fundus photographs are screened for possible eye diseases before display, and if something unusual is found, they will be notified and examined before they decide whether or not to proceed in the project. Among the 220 students who have participated so far, all had normal fundus photographs except for two students with small patches of myelinated retinal nerve fibres. The main disadvantage of the presented learning method is that the students examine healthy subjects without ocular pathology. On the other hand, to search for fundus abnormalities is obviously meaningless if the examiner is incapable to handle an ophthalmoscope. Our method enables the students to develop the necessary motor skills and to use the corrective lenses in the ophthalmoscope to get a clear view of the fundus in eyes with a wide range of refractive errors. Thereby, they learn to recognise the normal anatomic variations of the optic disc, retinal vessels, macula, and general background of the fundus, and thus to distinguish normal from abnormal. They also develop the skills to judge and memorise what they see during ophthalmoscopy, which are particularly valuable if they in future clinical practice should want to compare their ophthalmoscopic findings with images of specific eye fundus diseases. At the end of our ophthalmology course, all students undertake a mandatory written and oral examination, where the latter includes clinical examination of patients with various eye diseases. Although we have not objectively evaluated the effectiveness of our learning method, it is our clear impression that the students’ ability to perform ophthalmoscopy and reach a correct diagnosis during the examination of real patients has improved significantly after introduction of
Declaration of interest None.
References 1. Clarkson JG. Training in ophthalmology is critical for all physicians. Arch Ophthalmol 2003; 121: 1327. 2. Quillen DA, Cantore WA. Impact of a 1-day ophthalmology experience on medical students. Ophthalmology 2006; 113: 2307–2309. 3. Jacobs DS. Teaching doctors about the eye: trends in the education of medical students and primary care residents. Surv Ophthalmolol 1998; 42: 383–389. 4. Quillen DA, Harper RA, Haik BG. Medical student education in ophthalmology: crisis and opportunity. Ophthalmology 2005; 112: 1867–1868. 5. Harding SP, Broadbent DM, Neoh C, White MC, Vora J. Sensitivity and specificity of photography and direct ophthalmoscopy in screening for sight threatening eye disease: the Liverpool diabetic eye study. BMJ 1995; 311: 1131–1135. 6. Mowatt G, Burr JM, Cook JA, Siddiqui MA, Ramsay C, Fraser C et al. Screening tests for detecting open-angle glaucoma: systematic review and meta-analysis. Invest Ophthalmol Vis Sci 2008; 49: 5373–5385. 7. Benbassat J, Polak BC, Javitt JC. Objectives of teaching direct ophthalmoscopy to medical students. Acta Ophthalmol 2012; 90: 503–507. 8. Colenbrander A. Simulation device for ophthalmoscopy. Am J Ophthalmol 1972; 74: 738–740. 9. Dodaro NR, Maxwell DP. An eye for an eye. A simplified model for teaching. Arch Ophthalmol 1995; 113: 824–826. 10. Bradley P. A simple eye model to objectively assess ophthalmoscopic skills of medical students. Med Educ 1999; 33: 592–595. 11. Levy A, Churchill AJ. Training and testing competence in direct ophthalmoscopy. Med Educ 2003; 37: 483–484. 12. Chung KD, Watzke RC. A simple device for teaching direct ophthalmoscopy to primary care practitioners. Am J Ophthalmol 2004; 138: 501–502.
17
vis omual m Jou rna lo
ORIGINAL ARTICLE
me u dic
13. Hoeg TB, Sheth BP, Bragg DS, Kivlin JD. Evaluation of a tool to teach medical students direct ophthalmoscopy. WMJ 2009; 108: 24–26. 14. Swanson S, Ku T, Chou C. Assessment of direct ophthalmoscopy teaching using plastic canisters. Med Educ 2011; 45: 520–521. 15. McCarthy DM, Leonard HR, Vozenilek JA. A new tool for testing and training ophthalmoscopic skills. J Grad Med Educ 2012; 4: 92–96. 16. Cross HE, Miller JM, Brown L. An objective method of teaching fundoscopy. J Acad Ophthalmol 2011; 4: 52–56. 17. Milani BY, Majdi M, Green W, Mehralian A, Moarefi M, Oh FS et al. The use of peer optic nerve photographs for teaching direct ophthalmoscopy. Ophthalmology 2013; 120: 761–765. 18. Afshar AR, Oh FS, Birnbaum AD, Namavari A, Riddle JM, Djalilian AR. Assessing ophthalmoscopy skills. Ophthalmology 2010; 117: 1863.
Journal of Visual Communication in Medicine May 2014; 37, No. 1–2, pp. 13–18 ISSN 1745-3054 Print/ISSN 1745-3062 online © 2014 The Institute of Medical Illustrators DOI: 10.3109/17453054.2014.884551
18
19. Asman P, Lindén C. Internet-based assessment of medical students’ ophthalmoscopy skills. Acta Ophthalmol 2010; 88: 854–857. 20. Gupta RR, Lam WC. Medical students’ self-confidence in performing direct ophthalmoscopy in clinical training. Can J Ophthalmol 2006; 41: 169–174. 21. Wu EH, Fagan MJ, Reinert SE, Diaz JA. Self-confidence in and perceived utility of the physical examination: a comparison of medical students, residents, and faculty internists. J Gen Intern Med 2007; 22: 1725–1730. 22. Field M, Burke JM, McAllister D, Lloyd DM. Peer-assisted learning: a novel approach to clinical skills learning for medical students. Med Educ 2007; 41: 411–418. 23. Bligh DA. What’s the Use of Lectures? D. A. and B. Bligh: New Barnet, England; 1972. 24. Pols J, Boendermaker PM, Muntinghe H. Incidence of and sequels to medical problems discovered in medical students during study-related activities. Med Educ 2003; 37: 889–894.
Copyright of Journal of Visual Communication in Medicine is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
