Keywords
medical school - education - ophthalmology - curriculum
There is no national standard for ophthalmology curricula in U.S. and Canadian medical
schools, and over the past 15 years, fewer schools are requiring ophthalmology rotations.
In 2000, 68% of schools required a clinical rotation[1] and by 2012, only 18% of schools held the requirement.[2] In conjunction with this shift, studies show that the current state of ophthalmology
training in medical school is insufficient in preparing students for residency. For
example, first year family medicine residents have reported a lack of confidence performing
ophthalmic clinical skills,[3] fourth year medical students fail to pass ophthalmology proficiency assessments,[4] and eye examination skills taught only once during medical school erode without
reinforcement.[5]
Ophthalmology exposure varies significantly between medical schools. The most recent
comprehensive report on the state of ophthalmology education in the United States
and Canada was a 2012–2013 survey study by the Association of University Professors
of Ophthalmology (AUPO). Of the 109 schools surveyed, 84% reported training students
in ophthalmic examination skills during preclinical education.[2] Ophthalmology exposure during clinical training was more variable.[2] All surveyed schools offered an elective ophthalmology rotation, and 72% of schools
had a functional student interest group in ophthalmology, but a minority of the schools
had a required clinical ophthalmology rotation.[2]
Despite the lack of emphasis on ophthalmology in many medical school curricula, eye
examination and management skills are important for physicians to master because they
can reveal systemic pathology and require emergent treatment.[6]
[7]
[8]
[9] In addition, there is evidence that medical students are interested in learning
more ophthalmology during medical school.[10]
[11] In the context of rapidly evolving medical school curricula, and lack of national
ophthalmology standards, it is important to assess ophthalmology training adequacy.[12] There is strong precedent for using survey-based research as a tool for evaluating
the medical school curriculum.[13]
[14]
[15]
[16] In recent years, studies have demonstrated deficiencies in medical education in
several clinical subspecialties, including otolaryngology, dermatology, and musculoskeletal
medicine. This suggests a need for widespread evaluation of the medical school curriculum.[15]
[17]
[18]
We sought to assess medical students' perceptions of ophthalmology training at New
York University School of Medicine (NYUSOM), where there is no mandatory ophthalmology
clinical rotation. Similar to many other schools, NYUSOM currently trains students
in clinical ophthalmology skills during preclinical years, has a student interest
group, and offers an optional clinical rotation but does not require one. The purpose
of this study is to determine how comfortable students are with specific ophthalmology
clinical skills and types of training they would find most helpful. The results may
help target specific areas of the ophthalmology curriculum for improvement at NYUSOM
and other schools with similar curricula.
Methods
Investigators created a 30-question cross-sectional survey (see [Supplementary Material]) to characterize NYUSOM students' perceptions of ophthalmology exposure in preclinical
and clinical years. The survey was designed in consultation with NYUSOM ophthalmologists,
including the department chair, program director, medical student education director,
and other faculty with extensive background in teaching. Questions aimed to explore
students' satisfaction with the school's ophthalmology curriculum and extracurricular
opportunities, confidence in their own ophthalmology clinical skills, and preferred
teaching methods. Basic demographic information was also collected, including respondent's
medical school class, gender, age, and preference for a surgical versus nonsurgical
career. In March 2017, the survey was sent via email to all currently enrolled NYUSOM
students, including those pursuing dual degrees. Email reminders were sent weekly,
and the survey was closed in May 2017. Statistical analysis was performed using logistical
regression for binary outcome measurements, and adjacent-category logit modeling for
ordinal outcome measurements. Statistical significance was set at p-value <0.05. The study was approved by the Institutional Review Board and was HIPAA-compliant.
Informed consent was obtained from participants, and the described research adhered
to the tenets of the Declaration of Helsinki.
Results
Survey response rate was 27.5% (166 of 604) of NYUSOM students. Of the 166 respondents, there were 20 first years (12.0%), 35
second years (21.1%), 59 third years (35.5%), 44 fourth years (26.5%), and 8 students
currently completing dual degrees (4.8%). Thirty-seven percent of respondents were
male and 63% were female. The majority of respondents preferred to enter a career
with both medical and surgical aspects, while 11% preferred completely surgical and
28% preferred completely medical careers. Fifteen percent reported they were considering
careers in ophthalmology.
The majority of students reported they were not satisfied with their ophthalmology
training in medical school (83.7%) and thought that the current curriculum does not
provide adequate exposure to ophthalmology (91%). Many reported they were not comfortable
performing ophthalmology exam skills, including performing visual acuity testing (50%),
using a direct ophthalmoscope (71.1%), performing a dilated eye exam (79.5%), and
identifying ocular emergencies (64.4%). First-year medical students were more uncomfortable
than greater class years, with 90% of MS1 students reporting being “very uncomfortable.”
However, the majorities of other classes also reported being uncomfortable, with 68.2%
MS4 students reporting being “very uncomfortable” or “uncomfortable”; 77.7% of respondents
were “slightly confident” or “not at all confident” in their acquired ophthalmology
skills. Gender was not significantly associated with lower confidence in eye examination
skills. The majority of students reported that they thought ocular health is “important,”
“more important,” or “very important” (97.7%).
Several factors, including class year, taking the ophthalmology elective, and career
aspirations, were associated with perception of training and confidence with clinical
skills. Students who had not taken the optional ophthalmology elective were more likely
to perceive their skill training as inadequate (odds ratio (OR) = 1.8, p = 0.029). Students who had taken the elective were 3.85 times (p = 0.018) more likely to be satisfied with the curriculum's exposure to ophthalmology.
Without adjusting for covariates, students with 1 more hour of ophthalmology training
were 2.25 times more likely to be satisfied with the curriculum (p = 0.002). However, if we adjust for covariates, the association is no longer significant.
Five factors were associated with students' greater confidence in ophthalmology skills,
including having taken the elective (OR = 2.51, p = 0.001), having more hours of ophthalmology training (OR = 1.42, p = 0.006), considering ophthalmology as a career (OR = 2.03, p = 0.012), having no family history of ocular disease (OR = 1.93, p = 0.004), and having experience caring for eye disease (OR = 1.58, p = 0.039). Three factors were associated with greater comfort in identifying ocular
emergencies, including having more medical education (OR = 2.12, p = 0.032), considering a career in ophthalmology (OR = 1.97, p = 0.028), and having cared for eye disease (OR = 1.57, p = 0.028). Four factors were associated with perceiving ocular health as important,
including having taken the elective (OR = 2.27, p = 0.035), having more medical education (OR = 1.28, p = 0.047), wanting to pursue a more surgical career (OR = 1.19, p = 0.029), and having shadowed an ophthalmologist (OR = 1.77, p = 0.037).
In terms of preference for additional ophthalmology education, the majority of students
did not think there should be a required ophthalmology rotation (80.7%). Most students
reported they would find additional in-person ophthalmology training to be most helpful
(64.8%), followed by web-based didactic (15.2%), lecture-based (9.6%), video (6.8%),
and virtual ophthalmology training (2.5%; [Fig. 1]).
Fig. 1 Medical students ranked five ophthalmology training methods from most to least helpful.
Most respondents wanted additional ophthalmology training to be in-person (107), followed
by web-based didactic (25), lecture-based (16), video (11), and virtual ophthalmology
training. Response rate was 97% (161/166) for ranking training methods.
Discussion
Our survey results are largely consistent with previous studies' findings on ophthalmology
education; however, we also explore additional factors associated with confidence
in ophthalmology clinical skills. NYUSOM students reported greater comfort with visual
acuity testing than with dilated eye and direct ophthalmoscope examinations. Similarly,
in a previous study, University of Massachusetts' medical school students self-reported
more confidence with visual acuity testing than with dilated eye examination.[19] Almost all (97.5%) of U.S. medical schools surveyed in a previous study reported
they teach visual acuity assessment, but less than 60% teach dilated eye exam skills.[19]
Greater confidence in exam skills was associated with more hours of training and having
taken the optional ophthalmology elective. Previous studies have similarly shown electives
and more training time are associated with both students' and residents' improved
perceptions of their own skills and their objective performance on assessments of
ophthalmology knowledge.[3]
[10] While more training hours are associated with greater confidence in clinical skills,
the relationship between hours of education and skill proficiency may in fact be more
complicated. Previous studies have shown that different training methods vary in their
efficacy,[3]
[11]
[20] and our study showed that students prefer certain training methods, such as in-person
education, over others, including video didactics. Although previous studies have
shown varying success between training methods, there is no consensus as to what type
of education is most effective. In addition to training method, timing of education
is important, and training distributed across all 4 years of medical education may
be more effective than training isolated to 1 or 2 years of medical education.[4]
[5] A third factor important for education and assessing students' competence is feedback.
NYUSOM provides live feedback to students during the preclinical teaching session
to improve eye examination skills, and other forms of feedback may include written
assessments, objective structured clinical examinations, and simulations. Therefore,
the training method, timing, and feedback mechanism, in addition to total number of
hours, should be carefully considered when revising ophthalmology curricula.
Our study was unique in that it identified additional factors besides hours of training
and participation in an elective which were associated with clinical skills, confidence,
and curriculum satisfaction. Factors related to personal interest in ophthalmology,
including having shadowed an ophthalmologist and pursuing a career in ophthalmology,
correlated with students valuing ocular health or having more confidence in their
own clinical skills. In addition, having cared for someone with an eye disease was
associated with greater confidence in ophthalmology skills. Therefore, introducing
students to patients with ocular diseases and aiming to pique students' interest in
ophthalmology, rather than formal skill training, may be an important component of
an adequate education. Exposing students to ophthalmology early in the course of their
medical education may motivate them to pursue more training throughout their education,
leading to greater confidence and satisfaction with the curriculum.
Although NYUSOM students reported that additional in-person ophthalmology training
would be most helpful, the majority of students did not want a required ophthalmology
rotation. Therefore, changes to the curriculum should focus on integrating ophthalmology
education into other rotations and preclinical learning, with an emphasis on early
exposure, to demonstrate the importance of ocular health and inspire students to seek
out shadowing and elective opportunities themselves. Given students' lack of comfort
with direct ophthalmoscope and dilated eye exams in comparison with visual acuity
exam, additional training should focus on these two skill sets. Also, to satisfy students'
desire for in-person training and their low comfort with identifying ocular emergencies,
a simulation may be beneficial and could be incorporated at many different points
in the curriculum, including preclinical or clinical neurology, emergency medicine,
or medicine rotations. Although our study did not parse diagnostic versus management
knowledge, a previous cross-sectional study showed that students' diagnostic knowledge
significantly surpassed management knowledge.[4] With the aim of preparing students for residency, training should emphasize management
skills and knowing when to refer patients to ophthalmologists.
Our study was limited by the fact that we did not compare NYUSOM students' perceptions
to those of students at a school with a required ophthalmology rotation. Given this,
we could not isolate the impact a required rotation may have on students' confidence
and satisfaction. However, our results provide insight into ophthalmology exposure
in medical school and indicate that curriculum adjustments may improve students' comfort
with clinical skills. Future studies should explore the role of the required rotation,
compare the efficacies of different training methods for ophthalmology, and determine
whether there are crucial aspects of the curriculum that should be standardized. In
addition, submitting this survey to other medical schools could make these results
more generalizable.
