key: cord-024622-ez4ke2of
authors: Moxon, Nathaniel R.; Goyal, Anju; Giaconi, JoAnn A.; Rosenberg, Jamie B.; Graubart, Emily B.; Waxman, Evan L.; Knoch, Daniel; Forster, Susan H.; Sankar, Privthi S.; Mirza, Rukhsana G.
title: The state of ophthalmology medical student education in the United States: An update
date: 2020-05-11
journal: Ophthalmology
DOI: 10.1016/j.ophtha.2020.05.001
sha: 
doc_id: 24622
cord_uid: ez4ke2of

nan

The state of medical student education in ophthalmology 38 Eye disease and vision loss worsen quality of life, independence, mental health, social function, 39 and mortality. [1] [2] [3] Visual impairment affects 7.5% of the U.S. population and requires frontline 40 providers to diagnose and manage eye conditions. 4,5 However, the time dedicated to teaching 41 medical students about these conditions has been on the decline for half a century. 6 Ninety-five responses were collected on Google Forms (81% response rate). 65

Our results revealed four main themes. First, the decline of ophthalmology's role in 66 medical student curricula has slowed, if not plateaued. Second, ophthalmology teaching has 67 shifted to the preclinical years. Third, ophthalmology has compensated for its decline in the 68 traditional curriculum by teaching knowledge and skills outside the regular curriculum. Finally, 69 programs with DMSEs have higher rates of both required and extracurricular exposure, and 70 higher rates of faculty engagement with medical students. Each of these findings raises further 71 points of discussion regarding how to shape ophthalmology curriculum, within models of 72 medical education that are constantly changing. 73

The first trend seen in the new data demonstrates how the decreasing curricular time for 74 ophthalmology has slowed, if not plateaued, particularly since the last survey in 2014. We found 75 that required exposure to ophthalmology during medical school in 2018 was very similar to 76

where it was 4-5 years earlier, despite the rapid decline of the required clinical ophthalmology 77 clerkship noted in decades prior to the 2014 study. 8 In 2018, required clerkships existed at 16% 78 of responding institutions while required preclinical coursework existed at 93% of institutions 79 compared to 18% and 95% respectively in 2014. These statistics indicate a much slower decrease 80 compared to that over the decade prior. 81

Of note, this plateau has occurred after competence of graduating medical students was 82 already compromised. By the time medical students graduate, an estimated 70% are not able to 83

properly use an ophthalmoscope. Further, primary care residency program directors report that

The state of medical student education in ophthalmology most of their residents do not meet AUPO standards for ophthalmic skills. 9,12 While 80% of 85 schools did have some required ophthalmology training, medical students in 20% of medical 86 schools have no required exposure to ophthalmology training in skills or clinical ophthalmology 87 exposure unless it is sought by individual students. The question that remains is whether the 88 current number of ophthalmology hours and teaching methods during medical school are 89 sufficient to produce competence in graduating medical students. 90

The second theme we identified is that ophthalmology teaching has shifted to the 91 preclinical years. The vast majority (94.7%) of institutions included some form of required 92 exposure to ophthalmology during medical school. Most institutions (78.9%) required preclinical 93 coursework only, 13.7% required both preclinical and clinical exposure, and 7.4% had clinical 94 exposure only. Preclinical coursework was 12.5 hours on average (median=7; n=84) but varied 95 from 1.5 to 50, with one outlier at 120. Lecture was the most common way to teach 96 ophthalmology, followed by skills training and problem-based learning. In terms of clinical 97 exposure, only 16% of schools required clinical rotations, half of which were embedded within 98 another course. On the other hand, clinical electives, typically four weeks in length, were 99 ubiquitous, and 58% of institutions also offered ophthalmology as an option during the surgery 100 rotation (see table 2 online). 101

The third theme relates to non-traditional teaching, which has allowed schools to 102 maintain exposure to ophthalmology. 10 As an increasing number of institutions transition to 103 shorter preclinical time, ophthalmology will have to continue to creatively reinvent itself in new 104 curricula alongside all other specialties condensed into the same period. We have already seen 105 this occur, as ophthalmology has compensated for loss in the traditional curriculum by teaching 106 knowledge and skills in other ways. Many institutions report activities outside of the curriculum The state of medical student education in ophthalmology for medical students, such as interest groups (89%), medical student advisors (80%), career fairs 108 (77%), and outreach or community service experiences (75%). More recently, our experience 109 with COVID-19 shows that virtual electives can be developed to teach content to medical 110 students. Efforts creating shared resources such as those on the American Academy of 111

Ophthalmology medical student portal are essential, especially when circumstances demand 112 remote learning. 113

A final trend observed in the data highlights a novel discussion related to designated 114 medical student educators. Programs with DMSEs have higher rates of both required and 115 extracurricular exposure, and higher rates of faculty engagement. Most AUPO institutions had a 116 DMSE (83%), under half (43%) of whom had funding for such a position. Institutions with a 117 DMSE offered more preclinical coursework (11.9 versus 10.8 hours), had more students opting 118 into electives (28 versus 21), and had higher rates of faculty engagement and extracurricular 119 exposure. There was a significantly higher likelihood that institutions with a DMSE actively 120 engaged medical students outside of the curriculum (p=0.01), had an ophthalmology interest 121 group (p=0.01), or had a formal student advisor in the department (p=0.003) (See table 3 online) . 122

The DMSE designation may be a marker for preserved ophthalmology education efforts. 123

The pipeline of students entering ophthalmology is also germane to this discussion. 124

Research has uncovered that racial and ethnic disparities in eye care exist. 15 Underrepresented 125 minorities and women continue to make up a minority of the ophthalmology workforce despite 126 an increasingly diverse pool of medical students. 16 Medical student exposure to ophthalmology 127 during medical school are the first steps to integrating potentially interested students into this 128 subspecialty. 17 129

The state of medical student education in ophthalmology

The survey results showing that ophthalmology is still required at a large percentage of 130 schools are encouraging. Medical student exposure to inspiring ophthalmologists is the best way 131 to teach the vital ophthalmology skills required of most physicians. Medical education is 132 changing rapidly, and ophthalmology must be an active participant in this change. 

Eye Health Needs to Be a Population Health 152

Longitudinal relationships among visual acuity, daily 154 functional status, and mortality: the Salisbury Eye Evaluation Study

Committee on Public Health Approaches to Reduce 158

Making eye health a population health 159 imperative: vision for tomorrow

Age-related eye diseases and visual impairment 161 among U.S. adults

Ophthalmology teaching in medical schools

Medical student education in ophthalmology: crisis and 167 opportunity

The state of ophthalmology medical student education in the 169

United States and Canada

NY: Carnegie 171 Foundation for the Advancement of Teaching, 1910. The state of medical student education in ophthalmology

Assessing the status of ophthalmic education 100 years after the 173

Unpublished survey of US ophthalmology departments. Oral 175 presentation at: Association of University Professors of Ophthalmology annual meeting

Evaluating medical students' proficiency with a handheld 178 ophthalmoscope: a pilot study

Stern GA. Teaching ophthalmology to primary care physicians. The Association of

University Professors of Ophthalmology Education Committee

Nonmydriatic ocular fundus photography in the 183 emergency department

Vision health disparities in the United States by 185 race/ethnicity, education, and economic status: findings from two nationally 186 representative surveys

Current and future status of diversity in ophthalmologist 188 workforce

A proposal to improve ophthalmic education in medical schools

Ophthalmology and specialty education for medical students

Teaching doctors about the eye: trends in the education of medical students and 194 primary care residents

Is there more than one type of elective? How many weeks is it? How much time is spent in clinic? How much time is spent in the OR? How many students take it each year? Do you have a research elective?How long is it? How many students take it each year? Are there other opportunities for medical students to get involved in research? Do you have any equipment that aids in teaching? If so, what equipment? Do you use the AUPO guidelines in assisting the writing of your ophthalmology curriculum? Is anyone in the department a member of the schools curriculum, retention, or other committees?Is anyone on specifically the curriculum committee? Are you doing anything outside of the curriculum for medical students? Do you have a freecare/outreach/community service experience for students? Is there an ophthalmology interest group? Do you have career fairs? Do you have student advisers in the department? Are there additional opportunities (non-committee, non-curriculum) that can provide faculty opportunities to work with medical students (i.e. medical student mentoring programs, CV workshops, etc.)? If yes, please specify: