• A General Approach to Teaching Medical Students Ophthalmology

    Written By:

    In recent years, medical students across the country have had a deficit of knowledge in ophthalmology. This has been due to many factors, but principally to a lack of formalized education and clinical exposure during medical school.

    Given the limited exposure that medical students have to ophthalmology in medical school, it is of critical importance that ophthalmologists capitalize on whatever exposure medical students do receive to enhance interest in the field.

    As a general statement, it is perhaps appropriate to categorize medical students as either having very limited knowledge of ophthalmology or, for those with some knowledge, a non-cohesive grasp of the subject. As such, it is important that every student be given a good general foundation, regardless of their previous exposure to the field, from which to build upon during their time spent with an ophthalmologist.

    As medical students ourselves, we wrote this article in order to help practicing physicians who will have exposure to medical students create this foundation, build upon it and seamlessly integrate teaching, even in the face of a busy practice.

    The following are three steps that we believe are important in teaching medical students. Within each section we have attempted to include useful tips and suggestions to accomplish the various steps.

    Step 1: Establish Educational Goals and Assessment

    Day 1:

    It is important to set aside enough time to perform the following:

    • Assess the level of interest of the student and prior exposure to ophthalmology.
    • Go over the student’s goals, and what he or she hopes to accomplish during the rotation.
    • Inform the student of any required expectations and tailor non-required expectations to meet the student’s goals.
    • Take the student on a tour of the clinic and explain how the clinic works, from when the patient checks in to when the patient checks out.
    • Talk to the student about what his or her role will be in the clinic.
    • We also believe it is important to go through an example chart to explain the information contained within and any common abbreviations (e.g. OD, OU, etc.).

    Days 1 to 3:

    Regardless of the student’s knowledge base, go over key fundamentals. This will give you the opportunity to assess them further and to fill in any knowledge gaps. Key fundamentals should at least include:

    • General anatomy of the eye.
    • Eight-step eye exam (the components of the exam and the tools involved). You will expand the students skill set in each of these steps throughout the rotation

    Step 2: Integrate the Student into the Clinical Encounter

    Before any clinical encounter:

    • Make sure to explain to students that you want them to ask questions, but be clear about which questions are acceptable to ask during the encounter and which should be asked after.
    • Develop a way of communicating with students that informs them as to whether or not they will be able to participate in the exam during the clinical encounter. For example: “If I don’t say that you are going to examine the patient, or do not offer you a chance to do it during the exam, you will not examine the patient during that encounter. So please do not ask to examine the patient if this occurs.”
    • Inform the student before a patient encounter if they should hold their questions during that encounter, or if they will not be allowed into that particular encounter.

    During the clinical encounter:

    • Introduce the student to the patient at the beginning of the encounter. This serves two purposes: 1) allows the patient to recognize the student as part of the care team, and 2) involves the student in the patient’s care.
    • If your clinic is running behind schedule, inform the student that you cannot let them perform the exam, or tell them they have limited time in their exam and that you will stop them if they are running over.
    • Verbalize things that may not otherwise be discussed, in order for the student to follow along (e.g., explaining the history of a well-established patient). If the patient is confused by this, inform him or her that this is to help the student understand what is going on, and that you will still explain everything at the end of the encounter.
    • Physical Exam
      • As a general rule, it is much easier to facilitate the exam for a student by asking the patient’s permission for the student to do the exam.
      • Inform the student of what physical exam you will want her or him to focus on (e.g. cup-to-disc ratio), and how much time is allowed to perform this (e.g. “Take a quick look at the cup-to-disc ratio”).
      • In the beginning, as the student may not have a good knowledge base regarding the physical exam, the following methods of teaching may be useful:
        • Verbalize the steps of the physical exam being performed (e.g. “In order to see X, I will do Y”), and then verbalize what the findings are (e.g. “The cup-to-disc ratio I see is 0.4.”).
        • Show the student the finding or view that would be seen with the physical exam (e.g. moving your head to the side so that a student can see through the slit lamp). This is also important even if the student becomes proficient, as it can save time.
        • Have the student perform the same physical exam maneuver and, if necessary, walk him or her through the various steps and have the student tell you what he or she sees.
      • When informing the student of key physical exam findings, explain the location of findings in reference to the student’s view (e.g. “To the upper left of your view”).
      • Have the student describe what he or she sees during or after an exam, allowing you to verify that the student is seeing the correct finding.

    Wrapping up the clinical encounter:

    • Ask the student if he or she has any general questions, had difficulty performing the exam or concerns. If time is limited, instruct the student to write questions down so you can address them later (see Step 3).

    Step 3: Integrate Clinical Knowledge and Reassessment of the Student

    Integrating clinical experiences with basic science knowledge is an important step in solidifying a student’s understanding of the fundamentals of ophthalmology.

    For instance, whenever possible, try to correlate findings with knowledge of systemic diseases the student is familiar with (e.g., diabetes, autoimmune disorders, etc.).

    Assign learning issues to students:

    • An important and often overlooked fact to consider when assigning learning issues to students is that information regarding ophthalmology may not be readily available to the student outside of dedicated resources (e.g., Basic Clinical Science Course books, Wills Eye Manual, etc.).
    • Learning issues should correlate with the student’s educational goals, be based on student questions during clinical encounters and be selected based on their level of importance in the student’s future field.
    • As a rule of thumb, the amount of learning issues assigned should not exceed the amount of time available to discuss these issues with the student and should take into consideration the student’s time (i.e., assign more difficult learning issues over a weekend).
    • Assigning learning issues to students and going over them serves multiple purposes: It increases students’ knowledge base, their confidence with the material and allows clarification of deficits and reassessment of their progress throughout the rotation.
    • Possible methods of discussing learning issues include: the student giving a brief presentation, having an informal conversation with the student, or briefly going over key points about the topic.

    Give lectures to the student:

    • Lectures should be on key topics for the student relevant to ophthalmology, can be specific to questions brought up by a student or address general-exam skill deficits.
    • Lectures can be as short as five minutes, but, regardless of the length, should be structured with learning points clearly established.

    Test student knowledge during and outside of clinical encounters:

    • It is very important to test and retest a student’s acquired knowledge on a rotation in order to increase confidence, emphasize importance, make teaching more interactive/dynamic and increase retention of material.
    • When it comes to assessing their knowledge during rotations, there are two things that can help maintain a good relationship with students and facilitate open communication:
      • Ask questions during a clinical encounter about topics that students have previously demonstrated knowledge. As an added benefit, this will help increase both the student’s and patient’s confidence when answered correctly.
      • If you suspect the student may not know the answer to a given question, it may be better to ask these questions outside a clinical encounter, or respond to them in a way that suggests that not knowing the answer was acceptable (i.e. “I’m glad that you did not know that, as I wanted to talk about that with you and the patient…”).
    • Another method of assessing students’ progression is to give students the chance to see patients on their own and present to you on what their findings and/or impressions were about a given patient.

    In order to continue fostering interest in ophthalmology as a field of interest for medical students, it is important to maximize the potential for education that students receive during any interaction with an ophthalmologist. We hope that you find this article useful and applicable in your own practice mentoring medical students, as you provide a much-needed service to benefit medical education in ophthalmology.

    * * *

    About the authors: Alexander S. Davis, PhD, is a graduating medical student from the University of New Mexico School of Medicine. He will be starting his ophthalmology residency at the University of Texas Medical Branch at Galveston in 2012. Kenneth M. Downes is a graduating medical student from the University of New Mexico School of Medicine. He begins his ophthalmology residency at California Pacific Medical Center in 2012. Amar J. Patel is a graduating medical student from the University of New Mexico School of Medicine. He will be applying for ophthalmology residency in 2011.