Does access to a portable ophthalmoscope improve skill acquisition in direct ophthalmoscopy? A method comparison study in undergraduate medical education

Abstract

Background Direct ophthalmoscopy (DO) is an essential skill for medical graduates but there are multiple barriers to learning this. Medical students and junior doctors typically lack confidence in DO. Most students do not own an ophthalmoscope and learn via ward devices that vary in design and usability. The Arclight ophthalmoscope (AO) is an easy to use, low-cost and portable device that could help address device access. This study aimed to assess the impact of personal ownership of an AO on DO skill acquisition and competency amongst medical students in the clinical environment. Methods Method comparison study with 42 medical students randomised to either traditional device ophthalmoscope (TDO) control or AO intervention group during an 18-week medical placement. Three objective assessments of DO competency were performed at the beginning and end of the placement: vertical cup to disc ratio (VCDR) measurement, fundus photo multiple-choice questions (F-MCQ) and model slide examination (MSE). DO examinations performed during the placement were recorded via an electronic logbook. Results Students in both groups recorded a median number of six examinations each during an eighteen-week placement. There was no statistically significant difference between the groups in any of the objective assessment measures (VCDR p = 0.561, MCQ p = 0.872, Model p = 0.772). Both groups demonstrated a minor improvement in VCDR measurement but a negative performance change in F-MCQ and MSE assessments. Conclusions Students do not practice ophthalmoscopy often, even with constant access to their own portable device. The lack of significant difference between the groups suggests that device access alone is not the major factor affecting frequency of DO performance and consequent skill acquisition. Improving student engagement with ophthalmoscopy will require a more wide-ranging approach.

Perceived usefulness and ease of use of fundoscopy by medical students: a randomised crossover trial of six technologies (eFOCUS 1)

“…The difficulty of using a TDO in our study is consistent with previous literature [ 18 , 41 , 42 ]. A study of 101 medical students conducted after our trial found TDO was harder to use than the smartphone-mounted D-Eye on an unvalidated Likert scale [ 43 ].…”

“…Moreover, previous educational interventions to improve fundoscopy use which ignored these factors have been largely unsuccessful. Access alone was insufficient, as ownership of a portable direct fundoscopy device did not improve frequency or accuracy of fundoscopy in a randomised controlled trial of 42 students [ 42 ]. Retraining students in fundoscopy skills improved diagnostic accuracy but failed to improve the rate of documented fundoscopy in a three-year prospective educational study [ 49 ].…”

“…Limited confidence with fundoscopy examination has been widely reported, and identified as a significant barrier to usage [ 42 , 47 , 54 ]. We found after brief training that medical students were significantly less confident viewing the fundus using the traditional ophthalmoscope ( p =0.001) or prototype ( p =0.019) than the Panoptic, despite additional instruction for TDO.…”

Smartphone ophthalmoscopy: a potential way forward for non-ophthalmology medics in the COVID-19 era

“…It is acknowledged that direct ophthalmoscopy is underutilised by non-ophthalmic specialists, a view which is frequently supported by research. [1][2][3][4] Omission of ophthalmoscopy is, of course, perilous as it is may lead to delayed diagnosis and treatment. Clinicians will miss the opportunity to undertake a non-invasive in vivo assessment of retinal integrity, vasculature, and the optic nerve head; thus, potentially limiting the examination of patients with suspected conditions such as malignant hypertension; raised intracranial pressure; secondary metastases; and more common ocular conditions such as diabetic retinopathy or macula degeneration.…”

“…2 5 However, such rationale is somewhat at odds with more recent work where constant provision to an ophthalmoscope failed to stimulate a significant increase in usage. 3 Other reasons for not undertaking ophthalmoscopy may include time constraints; an inability to see anything useful, 2 which could particularly be the case with elderly patients who may have smaller pupils and hospital wards are generally well-illuminated environments; a belief that the procedure was low priority 2 or a lack of confidence using the instrument, especially on undilated pupils. 6 The consensus appears to be that more training is required.…”