Ophthalmic clinical skills teaching in the time of COVID-19: A crisis and opportunity.

WHAT PROBLEMS WERE ADDRESSED?

Despite advances in artificial intelligence‐based diagnostics, ophthalmic clinical skills remain an important acquisition during medical school. Simple ophthalmic examination techniques allow future non‐ophthalmic physicians to make timely referrals to ophthalmologists for sight‐threatening diseases. Currently, the coronavirus disease 2019 (COVID‐19) pandemic poses a serious public health crisis worldwide and an immediate challenge to traditional methods of medical education. With the present threat of disease transmission, face to face small group tutorials are not feasible, especially in the context of ophthalmic clinical skills, which requires close contact between the examiner and the patient.

Prior to the outbreak, we introduced ophthalmic clinical skills to second‐year pre‐clinical undergraduate medical students in the form of face to face demonstrations of techniques by a clinical tutor. A recent published study reported that, video‐based materials and written materials were synergistic in enhancing ophthalmic clinical skills and knowledge acquisition in an undergraduate medical programme. The objective of our adaption was to introduce video‐based and written materials to precede and complement Zoom™ (Zoom Video Communications Inc., San Jose, CA, USA) platform‐based small group tutorials. Our aim was to identify advantages and difficulties with this new approach as a necessary replacement for traditional face to face small group clinical demonstrations during the COVID‐19 pandemic.

WHAT WAS TRIED?

We taught ophthalmic clinical skills to second‐year undergraduate medical students, including the visual acuity assessment with near Snellen chart, pupil examination, confrontation test for visual field, extraocular movement examination and direct ophthalmoscope examination. In order to replace face to face 2‐hour group tutorials during the COVID‐19 outbreak, we devised a three‐pronged approach to provide an effective learning experience for our undergraduate medical students. First, for each examination technique, we included written information regarding: (a) technique; (b) physical signs demonstrated; (c) common mistakes by medical students, and (d) clinical relevance. Second, we recorded a video of a clinical teacher demonstrating the techniques on a surrogate patient. We uploaded both written material and videos on the e‐learning platform of our medical school. Third, after going through the online materials, the students were split into small groups of 30 students for a single 60‐minute tutorial with a clinical teacher on the Zoom cloud‐based video conference platform. During the tutorial, the teacher went through each key ophthalmic clinical skill and highlighted important points, pitfalls and clinical knowledge. The last 10 minutes were reserved for questions from students. Using the private message function, students were able to send live questions as they maintained anonymity. Assessment was conducted at the end of the block in the form of objective structured clinical examination (OSCE) stations.

WHAT LESSONS WERE LEARNED?

Our three‐pronged approach was designed to both enhance knowledge acquisition and increase competency attainment in ophthalmic clinical skills. By introducing an element of self‐directed learning (SDL) to precede our tutorials, the students took a proactive role in the learning experience. The tutorials themselves further served as an opportunity for critical reinforcement of self‐directed learning. We noted that the students were able to better follow the online clinical demonstration with the help of the pre‐tutorial materials.

One major revelation resulting from the introduction of Zoom tutorials was the ability for students to send live questions to the clinical tutor anonymously via private message. It allowed the tutor to read out loud and address questions for the entire group's benefit without the student having to reveal his or her identity. This is a unique advantage in Asian medical schools, where due to cultural upbringings, students are usually uncomfortable asking questions in public during tutorials and lectures fearing embarrassment. They prefer instead to email teachers later to address their questions. Furthermore, another significant advantage of our adaption was that recordings of the Zoom tutorials were made available to students to re‐watch later at their own pace. However, one important limitation we encountered in our tutorials was the difficulty in effectively teaching direct ophthalmoscopy online. To learn this technique, students first needed available simulated patients to practice on. Furthermore, much of the difficulty in this particular skill is in understanding the correct angle of approach and the necessary adjustments to be made when examining the fundus. Face to face tutorials are still a more effective means of teaching for this particular skill. In conclusion, the COVID‐19 outbreak is an opportunity for a re‐evaluation of our teaching methods. The lessons learned from the use of video and online‐based teaching provide feedback to clinical teachers on how undergraduate medical students acquire knowledge and express themselves best.

WEB SITE

http://hkuelcn.med.hku.hk/ophthalmology/ophthalmic-examination/