Teaching Ophthalmoscopy to Medical Students (the TOTeMS Study)

Abstract

Purpose To determine medical student preferences for learning the ocular fundus examination and to assess their accuracy using different examination modalities. Design Prospective, randomized study of medical student education approaches. Methods First-year medical students received training in direct ophthalmoscopy using simulators and human volunteers. Students were randomized to receive vs. not receive specific training on interpreting fundus photographs prior to accuracy assessments. Students’ preferences for each of the three methods (direct ophthalmoscopy on simulators or human volunteers, or use of fundus photographs) and recognition of normal and abnormal fundus features were assessed. Results Of 138 first year medical students, 119 (86%) completed all required elements. For learning ophthalmoscopy, 85 (71%) preferred humans to simulators. For learning relevant features of the ocular fundus, 92 (77%) preferred photographs to ophthalmoscopy on simulators or humans. Accuracy of answers was better when interpreting fundus photographs than when performing ophthalmoscopy on simulators (p<0.001). Performance improved after specific teaching about assessing fundus photographs before testing (p=0.02). Examination of the ocular fundus was found easier and less frustrating when using photographs than when using ophthalmoscopy on simulators or humans. Eighty-four students (70%) said they would prefer to have fundus photographs instead of using the ophthalmoscope during upcoming clinical rotations. Conclusions Students preferred fundus photographs for both learning and examining the ocular fundus. Identification of ocular fundus features was more accurate on photographs compared to examination by direct ophthalmoscopy. In the future, the increasing availability of non-mydriatic ocular fundus photography may allow replacement of direct ophthalmoscopy in many clinical settings for non-ophthalmologists.

A new model for teaching Opthalmoscopy to medical students

“…However, we found a higher percentage compared to that seen in the TOTeMS study, in which 49% of students indicated they would perform direct ophthalmoscopy as part of the general physical examination (Kelly et al, 2013).…”

“…Among the proposed models include: styrofoam head with a holder for photographs; table tennis ball with printed words in its inner rear face; and plastic containers with retinal photographs in the bottom (Chung & Watzke, 2004). The TOTeMS study ( Kelly et al,2013) used plastic containers with fundus photography adhered to the back of the container to evaluate the medical student direct ophthalmoscopy teaching. Their conclusion was not favorable to the use of simulators, because the students preferred learning by fundus photography.…”

“…Hence, the positive feelings of scores ranged from 5-25, in which higher scores represent higher levels of positive feelings, the same goes for negative feelings. All tests were questionnaires adaptations used in the study Teaching Ophthalmoscopy to Medical Students (totems study) (Kelly et al, 2013). The questionnaires were translated into Portuguese and then subjected to reverse translation.…”

The demise of direct ophthalmoscopy

“…Even when direct ophthalmoscopy is performed, students and physicians demonstrate a lack of confidence in their findings, further minimizing the ability of the ocular fundus examination to positively affect patient care. 7 Ophthalmoscopy has long been considered an essential part of the physical examination in patients with headache. Whereas most patients with headache who visit an emergency department have a primary headache syndrome, the detection of optic disc edema is indispensible in determining which patients have a more serious underlying cause.…”

Direct ophthalmoscopy should be taught to undergraduate medical students—No

“…The TOTeMS study 7 concluded that students preferred fundus photographs for both learning and examining the ocular fundus, with 70% saying they would prefer to have fundus photographs instead of using the ophthalmoscope during upcoming clinical rotations. When tested, students' answers were significantly more accurate when interpreting fundus photographs than when performing ophthalmoscopy.…”