Ophthalmology Clinical Skills Fair

Stephanie Baxter, MD, FRCSC

Department of Ophthalmology

Queen’s University

Objectives

• Compare our previous teaching methodology with the new clinical skills fair

• Discuss the success of this teaching modality with students - evaluations

• Discuss its ability to transfer the intended examining clinical skills to students

• Discuss if this model could be applied to other departments

What we were doing before

• Similar to other clinical teaching sessions in other areas of medicine– 1 group/week for 10 weeks– 10 students/group– Variable teacher

• No set objectives• Variable learning experience

– All students in same examining room learning the various skills

What we were doing before

• Pros– Spread out the teaching

among teachers– Required only one

teacher/session– Minimal space requirement

• Cons– Time consuming for teachers

who did many sessions– If several teachers, students

potentially had an inconsistent experience

– Were we really transferring the appropriate skills?

• No set objectives

The clinical skills fair was born

• Martin ten Hove’s idea – Based on Halifax model - ophthalmology evening

• Involved me - new UG director for Department• Brain stormed

– Logistics • What we would teach - Clinical skills we wanted to transfer• Who would be taught - At what level of med school training• How - # of groups/group size, time allocated per skill • Where we would teach - Close clinic for half day• When would we do it - Week of lectures vs. later to reinforce• Who would teach - Would need all teaching staff to help

The Fair - What

• The International Council of Ophthalmology (ICO) consensus– All medical students should demonstrate competency in these

clinical skills:• Measurement of distance & near visual acuity with and without correction or pinhole

(VA)• Confrontation visual fields (VF)• Assessment of extraocular motility and ocular position (EOM)• Measurement and interpretation of pupillary size and reaction • Direct ophthalmoscopy• Penlight examination of anterior segment including upper lid eversion• Removal of superficial corneal or conjunctival foreign body

• The ICO Task Force strongly recommends– Ophthalmology be part of core medical curriculum

The Fair - What

• Stations– Station 1 - Vision & pupils– Station 2 - EOM, IOP, VF– Station 3 - Slit Lamp - anterior segment– Station 4 - Ophthalmoscope - posterior segment– Station 5 - Peds & strabismus– Station 6 - Trauma

• Handout provided– Reference for session and future

The Fair - How

• Format– [12:30 - Boxed lunch with intro lecture]– 1:00 - 1:15 - Arrive in clinic– 1:15 - 2:45 - 3x30 minute stations– 2:45 - 3:00 - Break/snacks– 3:00 - 4:30 - 3x30 minute stations– 4:30 - 4:45 - evaluation & extra help

The Fair - What

• Stations– 30 minutes each

• 2-3 objectives/station - clearly outlined in handout• 5-10 minutes of didactic/instruction

– How to perform skill

• 20-25 minutes to practice the skill– HANDS-ON

– Practice on each other and use various models

– Some exercises to highlight/demonstrate findings

» Prisms to demonstrate esotropia/exotropia

» Lens to blur vision/pinhole to sharpen

» Internet simulators

The Fair - Who

• Groups– Phase 2B expanded clinical skills– 12 groups of 8-9 students - to keep groups small

• 6 stations• 2 concurrent identical tracks

The Fair - When, Where, Who

• Friday afternoon, after ophtho lectures– Originally 3-4 weeks later– Now at the the end of the week

• Johnson 6 Eye Clinic– Closed to patient care– 18 examining rooms used for teaching

• All teaching faculty and residents, support staff– Need many teachers– Helps demonstrates a team approach to eye care

Resounding Success

• Student evaluationsStrongly StronglyDisagree Disagree Neutral Agree Agree

Objectives were met 5 31 63Objectives were clearly stated 1 33 56The clinical skills fair was well organized 9 91I enjoyed this format for learning clinical skills 11 89My knowledge of the ophthalmic exam has increased 1 7 92My ophthalmic examining skills have improved 16 84Station UsefulnessVA and pupils 1 46 53IOP, EOM, VF 2 1 50 47Slitlamp examination 49 51Direct ophthalmoscope 1 45 54Examining children 3 42 55Trauma and emergencies 2 48 49

The printed handout was useful to have 2 63 35It was useful to have the handbook in advance 2 7 44 49I expect I will use the handbook as a resource in future 1 3 46 50I could have used this handout in an online format 7 6 33 30 24I would be willing to pay $10 to have a copy 23 31 26 15 5of the printed handoutI reviewed the suggested websites in advance 37 9 35 19I found the suggested websites useful 3 59 17 21

The clinical skills fair should be repeated annuallyin this format 2 13 85

Resounding Success

• Student evaluations - comments– Liked

• Hands on, using equipment• Small groups, comfortable to ask questions• Focus on primary care• Rotating stations, reasonable amount of time• Helped enforce what had been learned• Snacks

Resounding Success

• Student evaluations - comments– Disliked

• Slit lamp and ophthalmoscope stations too short• Repetitive

– Reviewing online and again at session

• Friday afternoon

Is it working?

• Survey 2005 (first year)– Does Queen’s University’s Ophthalmology Clinical

Skills Session improve medical student self-confidence in performing Direct Ophthalmoscopy and Slit Lamp examination?

Is it working?

• Survey 2005 (first year)– Cross-sectional survey was conducted immediately

before and after ophthalmology clinical skills session (CSS)

– Students rated their self-confidence on specific direct ophthalmoscopy and slit-lamp examination clinical skills

– Students chose from 5 levels of confidence:1 = Not at all confident2 = A little confident3 = Somewhat confident4 = Quite confident5 = Extremely confident

Is it working?

Mean Age Years (SD) 24.9 (3.4) n = 86

Gender (%) Males

Females

48.3

51.7

n = 89

Participated in Phase 1 Clinical Skills (%)

Yes

No

98.9

1.1

n = 91

Additional Ophthalmology Electives/Clinics (%)

Yes

No

15.4

84.6

n = 91

Prior Use of Slit Lamp

Biomicroscope (%)

Yes

No

22.0

78.0

n = 91

Ophthalmoscope Ownership (%)

Yes

No

92.2

7.8

n = 90

Percentage of Medical Students that Reported to be “Somewhat/Quite/

Extremely” ConfidentModerate/High

Confidence Pre-CSS (%)

Optic Nerve Head 56.0

Vessels 59.3

Central Retina (Macula) 29.7

Optic Disc Swelling 4.4

Small Retinal Hemorrhages

14.3

Epithelial Defect 14.8

Corneal Thickness 6.2

Anterior Chamber Depth 6.2

Percentage of Medical Students that Reported to be “Somewhat/Quite/

Extremely” ConfidentModerate/High

Confidence Pre-CSS (%)

Moderate/High Confidence

Post-CSS (%)

Optic Nerve Head 56.0 87.2

Vessels 59.3 92.3

Central Retina (Macula) 29.7 62.8

Optic Disc Swelling 4.4 62.3

Small Retinal Hemorrhages

14.3 55.3

Epithelial Defect 14.8 75.6

Corneal Thickness 6.2 68.4

Anterior Chamber Depth 6.2 77.6

Percentage Increase in Medical Students’ Self-Confidence Before and

After Clinical Skills SessionMean

Pre-CSS

Mean Post-CSS

Mean differen

ce

%

Increase

p -value

Optic Nerve Head 2.7 3.5 0.8 30.0 <0.001

Vessels 2.8 3.5 0.7 25.0 <0.001

Central Retina (Macula) 2.1 2.7 0.6 28.6 <0.001

Optic Disc Swelling 1.4 2.7 1.3 92.9 <0.001

Small Retinal Hemorrhages

1.6 2.7 1.1 68.8 <0.001

Epithelial Defect 1.7 3.2 1.5 88.2 <0.001

Corneal Thickness 1.2 3.0 1.8 114.3 <0.001

Anterior Chamber Depth 1.2 3.2 2.0 166.6 <0.001

Paired t-Test

Is it working?

• Question of student confidence

• Question of skill transfer– Not really answered with this study– Sister study

• Ability to properly perform skill and detect findings pre-clinical skills fair

• Attend the clinical skills fair• ? Increase in ability to properly perform skill

and detect findings post-clinical skills fair

Critique

• Pros– All students/one session

• Time economical

– More consistent teaching– Contact with all faculty– Popular among students– Enjoyable for faculty

• Time economical• Interaction with students• “Wow’ factor - satisfying

• Cons– Resource intensive

• Teacher intensive~ 18-20 teachers

• Space intensive– Many rooms

– Clinic closed

• More pre/post prep

– Focused on N findings• F/U with Phase 2C

– 2-3 months later

Application to other specialties

• Absolutely

• Matter of– Defining

• How, who, what, when, where

– Having the resources• Teachers• Space - Clinical Teaching Centre

Conclusions

• Clinical skills fair in ophthalmology– Not much different than traditional clinical skills

sessions• Format

– More successful than could have been predicted• HANDS-ON• Skill transfer still needs to be fully assessed

– Offers certain advantages over traditional clinical skills• Set objectives, consistently taught, access to many staff

– Could be applied to other areas of medicine• Depending on resources (space/people) available