Assessing the knowledge and skills in clinical ophthalmology of medical interns: survey results from enugu, South-eastern Nigeria.

PURPOSE: To compare the skills and knowledge of clinical ophthalmology among medical interns in Enugu, Nigeria, to the recommendations of the International Council of Ophthalmology (ICO).
MATERIALS AND METHODS: A questionnaire-based cross-sectional survey was conducted of Medical Interns attending the University of Nigeria Teaching Hospital and Enugu State University Teaching Hospital, from April 2010 to June 2010. Data on cohort demographics, undergraduate ophthalmology exposure, clinical skills and diagnostic competencies were collected and analyzed. Statistical significance was indicated by P < 0.05.
RESULTS: The cohort comprised 81 males and 48 females (sex ratio = 1.7 : 1), aged 21-35 years (mean: 26.8 ± 2.4 years). The gender difference was significant (P < 0.05). The response rate was 88.7%. The duration of undergraduate ophthalmology exposure ranged from 1 to 4 weeks. Exposure was often adequate in cornea/external eye (95.3%), lens/cataract (95.3%) and glaucoma (92.2%); but not in vitreo-retinal disease (47.3%), neuro-ophthalmology (45.7%) and refractive surgery (0.0). The majority were competent at visual acuity testing (97.7%) and visual field examination (93.0%). There was lower competency at anterior chamber assessment (49.6%) and slit-lamp examination (39.5%). The majority could confidently diagnose conjunctivitis (96.1%) and cataract (90.7%), but not strabismus (42.6%) or macular degeneration (20.2%).
CONCLUSIONS: Medical interns in Enugu displayed gaps in their undergraduate ophthalmology exposure, clinical knowledge and skills. This has implications for stakeholders in medical education and eye care delivery. Review of the curriculum, provision of training resources and compliance with ICO guidelines could address the deficiencies.

INTRODUCTION

Medical internship is a fundamental component of undergraduate medical education1 and represents the critical transition period from strictly supervised undergraduate medical training to independent general medical practice. During internship training, trainees learn clinical skills, perform clinical procedures, develop good clinical judgment, and acquire communication skills relevant to patient care.2–6 There exists wide intra78 and inter9–12 specialty variations in interns’ clinical knowledge and skills base. The variation is attributable to disparities in undergraduate training emphasis and availability of training resources113 and differences in interns’ attitudes to learning.3 The acquisition of basic knowledge and skill in ophthalmology remains a fundamental training objective of undergraduate ophthalmic education.14 Worldwide, undergraduate ophthalmology training is anchored on the International Council of Ophthalmology (ICO) curriculum for ophthalmic education of medical students.14 However, inter-regional variations in availability of ophthalmic resources and prevalence of eye diseases have engendered regional adaptations of the ICO training blueprint involving curriculum content, structure and mode of delivery of ophthalmic education. These adaptations in turn underscore between-region differences in clinical ophthalmology knowledge and skills set of graduating medical students and medical interns. These have critical implications for the global realization of the objectives of VISION 2020 - ‘The right to sight’.

Previous surveys of the clinical knowledge and skills of medical interns have been dominated by assessments of their general medical skills;14–69–12 skills in non-ophthalmic specialties,278 with only few studies15–18 specifically evaluating ophthalmic knowledge and skills. The paucity of ophthalmology-specific surveys despite their established usefulness in generating critical feedback on undergraduate ophthalmic curriculum planning15 is disconcerting. Furthermore, the realization that all previous ophthalmology-specific surveys15–19 were conducted outside Africa highlights the urgent need for evidence-based data on this crucial issue especially in the resource-poor sub-Saharan African setting. To meet these research ends, the investigators embarked on a cross- sectional assessment of clinical ophthalmology knowledge and skills of medical interns in two tertiary centers in Enugu, south-eastern Nigeria. The findings will assist eye care trainers and those planning and implementing undergraduate medical curriculum. Additionally the data will serve as a baseline for inter-regional comparison of compliance with ICO's training guidelines14 and their effectiveness.

MATERIALS AND METHODS

Background

In Nigeria, the seven-year undergraduate medical training comprises three years each of pre-clinical (pre-clerkship) and clinical (clerkship) medical instructions and a mandatory one year post-graduation medical internship (Housemanship). The medical graduates are required by law to commence their internship training within 2 years of graduation from medical school. During internship, interns rotate through compulsory core clinical specialties of Surgery, Internal medicine, Pediatrics, and Obstetrics and Gynecology; and take elective postings of 2–4 weeks duration each in the minor specialties, ophthalmology included. On satisfactory completion of internship, the supervising consultant in each specialty signs off on the intern and finally the chief medical director of the training institution also signs off. This qualifies the intern for full registration as a general medical practitioner by the Nigerian Medical and Dental Council (NMDC). In Nigeria, it is a punishable offence for any medical graduate to practice medicine prior to completion of medical internship. Enugu is the administrative capital of Enugu state, one of the five component states of the south-east geopolitical zone of Nigeria. The University of Nigeria Teaching Hospital (UNTH) and Enugu State University Teaching Hospital (ESUTH), both located in Enugu, are the only accredited internship training centers in the Enugu state. However, other internship training centers exist in other states within the south-east geopolitical zone. At the University of Nigeria Teaching Hospital (UNTH) and Enugu State University Teaching Hospital (ESUTH) between April and June 2010, the investigators conducted a cross-sectional survey of currently serving medical interns to assess their clinical ophthalmology knowledge and skills.

Ethics

Prior to commencement of the study, ethics approval compliant with the 1964 declaration of Helsinki was sought and obtained from Ethical Committees (Institutional Review Boards) of the respective study centers.

Eligibility

All medical graduates who were actively doing the mandatory one-year internship at the study centers were enrolled. The survey instrument, formatted on ICO guidelines14 and further adapted from the survey by Noble et al,15 was an open-ended self-administered, structured questionnaire. To ascertain its psychometric reliability and construct validity, the questionnaire was pretested on a cohort of post-internship medical graduates waiting for their supervisor signatures at the study centers. Structural modifications to enhance flow and interpretation identified during the pre-test were performed before final deployment for data capture. The participants in the pre-test survey were excluded from the final survey. Of relevance to the study were data on the participants’ demographics, university where they received medical training, undergraduate ophthalmology training, duration since graduation and completed specialty rotations since commencement of internship. The participants’ self- assessment of adequacy of their undergraduate exposure to the 12 ICO core exposure areas was structured on a six-point Likert scale (0 - no exposure; 5 - excellent). Binary (Yes/No) responses were obtained on their self-rated competence in performance of 12 ICO core clinical skills and self-rated proficiency in the diagnosis of 15 ICO core clinical conditions. Likert scale-based responses were subsequently dichotomized and reduced to proportions by categorizing scores 0–2 as unsatisfactory and 3–5 as satisfactory. Data was entered into the Graph Pad Prism statistical software (GraphPad Software, La Jolla, CA, USA) and examined using descriptive and analytical statistics to yield frequencies, percentages and proportions. A significant between-class difference was indicated by P < 0.05, one degree of freedom.

RESULTS

Of the 145 potential subjects, 129 participated in the study. The survey response rate was 88.7% (129/145). The cohort comprised 81 (62.8%) males and 48 (37.2%) females (sex ratio = 1.7 : 1), aged 21–35 years, with a mean age of 23.7 ± 2.3 years [Table 1]. The gender difference was statistically significant (62.8% vs. 37.2%, P < 0.05). The demographic characteristics of the survey participants are shown in Table 1. All (100.0%) the participants were Nigerians who graduated from Nigerian Universities. Eighty five (65.9%) participants graduated from medical school less than one year prior to the survey while 44 (34.1%) graduated earlier than one year. Forty three (33.3%) participants had completed their two-weeks internship rotation in ophthalmology while 86 (66.7%) had not. The difference was statistically significant (33.3% vs. 66.7%, P < 0.05). The duration of undergraduate ophthalmology posting was 1–2 weeks in 48 (37.2%) participants and 3–4 weeks in 81 (62.8%) participants. Seventy three (56.6%) respondents judged the duration of their undergraduate posting as adequate while 56 (43.4%) did not. The main modes of undergraduate clinical ophthalmology exposure were clinic-based learning for 58 (45.0%) participants, didactic lectures for 34 (26.4%) participants, participation in eye theatre sessions for 14 (10.9%) participants, group discussions for 13 (10.1%) and self-directed learning for 10 (7.6%) participants. While 118 (91.5%) participants were satisfied with the quality of overall exposure, 11 (8.5%) expressed dissatisfaction with the adequacy of their exposure. The undergraduate clinical ophthalmology exposure to specific ICO-recommended core exposure areas was adequate in ocular anterior segment disease but less so in posterior segment disorders [Figure 1]. The majority of the respondents reported competency in the performance of all ICO-recommended core clinical tasks except anterior chamber assessment (49.6%) and slit lamp examination (39.5%). However, the participants tended to be more competent in performing visual acuity testing (97.7%) and confrontational visual field examination (93.0%) [Figure 2]. The assessment of the participants’ diagnostic skills with respect to the ICO-recommended core clinical conditions revealed diagnostic skills disparity biased in favor of ocular anterior segment diseases compared to posterior segment disorders [Figure 3].

Table 1

Demographic characteristics of 129 survey participants

Figure 1

Adequacy of undergraduate clinical ophthalmology exposure

Figure 2

Proficiency in performance of ICO-recommended core clinical tasks

Figure 3

Competency in diagnosis of ICO-recommended core clinical conditions. (*Hemianopic and bitemporal visual field defects)

DISCUSSION

The demographic profile of the cohort showed significantly more males than females, aged 21–35 years, with a mean age of 23.7 ± 2.3 SD years and a modal age group of 26–30 years. The observed male gender dominance is the inverse of the findings in Nepal;10 however, the respondents’ mean ages were similar. Although both surveys shared the same research objectives, the demographic data in the present report cannot be compared with a study from Canada15 because of between-survey differences in participants’ characteristics. While the age similarity with the report in Nepal10 could be explained by similarity in cohort characteristics, the differences in gender distribution could be attributed to the comparatively small sample size (n = 30) of the Nepalese survey, and probably between-region differences in gender representation in Medicine. These have implications for medical educators, healthcare planners and providers, and likely suggest the need for measures to restore gender equity in medicine.

The majority of the participants had 3–4 weeks of undergraduate exposure to ophthalmology and 91.8% considered the duration adequate. These observations varied sharply with the report in Canada by Noble et al,,15 wherein 78.2% of the survey respondents had less than two weeks of undergraduate ophthalmology training and only 32.0% felt the duration was adequate which was similar to other reports from Canada,1820 USA2122 and Australia/Asia.13

The difference in duration of exposure probably reflects the greater amount of curriculum time that was mandatory and allotted to undergraduate ophthalmology in Nigeria and this likely further explains the higher adequacy rating of the exposure duration by the respondents in the present survey. The results suggest the need for undergraduate medical training curriculum planners to make ophthalmology a core curriculum component and also increase the time for undergraduate exposure to ophthalmology.14

Consistent with the reports in Canada,15 the majority of respondents acquired their undergraduate ophthalmology exposure mainly through participation in eye clinic consultations. Although self-directed learning (SDL) ranked lowest in the present study, small group discussion was the least favored mode of exposure in Canada.15 Contrary to the scenario in developed countries, the restricted access to information and communication technology (ICT),23 an indispensable tool for SDL in the setting of the present survey probably explains the observed under-utilization of SDL. Although learning under real clinical settings remains the gold standard for establishing sound grounding in ophthalmology,14 the explosion of essential medical information to be taught to undergraduates15 and shrinking curriculum time allotted to non-core specialties142224 have necessitated the need for paradigm shift from traditional teaching methods to SDL and problem-based learning (PBL).1522 These have been established to be effective and time efficient.

Therefore, curriculum planners and those who implement, in collaboration with those responsible for funding the education system and other stakeholders, should factor in these developments during future curriculum reforms.

The adequacy of the interns’ undergraduate clinical ophthalmology exposure was biased in favor of clinical conditions affecting the ocular anterior segment to the detriment of posterior segment and neuro-ophthalmic disorders. This finding echoes the report by Noble et al15 and concurs with observations in Australia/Asia13 and New Zealand.20 The observed exposure pattern could be attributed to higher prevalence of ocular anterior segment disorders in the study environment, greater availability of resources for teaching these clinical conditions, or both. However, similar under-exposure to neuro-ophthalmology has been reported in developed countries131520 with different prevalence of eye diseases and unrestricted access to teaching resources. This suggests that trainer-dependent and or trainee-related factors probably account for the poor exposure. The resources needs for adequate exposure across all ICO core areas should include adequate ophthalmic manpower and material resources such as a direct ophthalmoscope, slit-lamp biomicroscope, automated perimeter and diagnostic dyes. The present data seems to re-emphasize the need, in view of curriculum time constraints, to integrate or embed clinical ophthalmology topics into core specialty teachings through the utilization of the horizontal and longitudinal integrative multidisciplinary clinical teaching model proposed by Mottow-Lippa,17 Mottow-Lippa et al25 and Jacobs.22 Appropriately adapted to suit the local learning environment, this model holds the potential to bridge the exposure gaps between ICO-recommended core exposure areas. Furthermore, there is the fundamental need to provide necessary resources to ensure adequate exposure across all the ICO's core exposure areas.

Although a majority of the interns were competent in performing each of the 12 ICO-recommended core clinical tasks, a higher number of interns reported competency in visual acuity, visual field and pupil examinations and ocular history taking. The skills proficiency profile of the participants in the present survey is similar to the report by Mottow-Lippa et al,25 on medical students but differed from the grossly skewed clinical skills pattern observed in a survey of residents by Noble et al.15 Erosion of skills acquired in medical school over time, and between-region differences in the extent of implementation of ICO training guidelines1320 likely explain the discrepancy between the findings of the present survey and that reported in Canada by Noble et al.15 The cohorts’ low skills proficiency scores for slit-lamp examination could be attributed to access barriers due to inadequate equipment and the trainer's unfavorable attitude to teaching slit-lamp examination to undergraduates. Paradoxically, respondents were more proficient in corneal foreign body removal than slit-lamp examination. The frequent use of head loupe for foreign body removal due to barriers to slit-lamp access likely explains this observation. Despite the participants’ modest skills rating across all the ICO's core skill areas, there is still the need to identify and overcome the underlying factors responsible for non-uniformity of interns’ ophthalmic clinical skill sets. The survey respondents were more frequently able to diagnose clinical ophthalmic disorders affecting the ocular anterior segment and less so for posterior segment conditions. The diagnostic skill profile of the participants could not be compared with similar studies reported elsewhere1516 as these surveys evaluated undergraduate ophthalmology exposure and performance of clinical tasks, but failed to assess participants’ competency in diagnosing ICO-recommended clinical conditions. The observed diagnostic skill profile reflects the pattern of respondents’ undergraduate ophthalmology exposure and both are likely influenced by the previously suggested determinants and share similar implications. The conclusions drawn from this study are limited by its two-centre design with the attendant restriction on data extrapolation and bias associated with self-rated efficacy surveys. Additional limitations include wide differences in respondents’ durations of ophthalmology exposure and the slim possibility of inaccurate recall of undergraduate ophthalmology experience. The rationale for the choice of the study population, medical interns and not medical students, has been elaborated on elsewhere.15 To overcome these limitations, the investigators suggest that similar studies in the future should be nationwide, observer-rated, and conducted early during internship training.

CONCLUSIONS

Medical interns in Enugu, south-eastern Nigeria, have crucial gaps in their undergraduate clinical ophthalmology exposure, skills and diagnostic competencies. The local pattern of eye diseases, the variable emphasis by trainers on subject areas and deficient training resources are the likely causes. These have implications for those planning the medical curriculum, undergraduate medical educators, eye care trainers and eye care providers. Curriculum review, provision of adequate training resources and strict compliance with ICO's training guidelines are recommended to reverse the trend.