Teaching Ear Examination Skill to Undergraduate Students Using Check List

Abstract

For examination of ear, proper illumination is a pre requisite. Diseases related to ear may lead to altered sense of hearing and may affect normal balance system. If students are taught to examine ear using a check list, they may perform better. To teach ear examination to undergraduate students using a check list. Total 50 undergraduate students of M.B.B.S. attending E.N.T. clinic in Chirayu Medical College and Hospital were included in the study. They were given enrolment no. 1 to 50 and were divided into two groups. Group 1, enroll. no. 1 to 25 and group 2, enroll. no. 26 to 50. Group 1 was taught using check list and the Group 2 was taught without use of checklist. Both the groups were evaluated using check list. The group B students were again taught, using check list and were again evaluated using check list. Use of check list showed that there was statistically significant improvement in learning by students using check list in group 1 students compared to group 2 students who were taught without use of check list. The group 2 students also had improvement on evaluation, after they were taught using check list. Study suggests that use of check list for ear examination skill to undergraduate students has significant role and students learn better than when taught without use of checklist. Inclusion of checklist for teaching ear examination to undergraduate students may be considered.

Curriculum Innovation Project

Background

Curriculum changes often lead medical schools to implement skills training at the undergraduate level. One of the reasons for this implementation was the fact that limited undergraduate skills training often resulted in junior doctors being required to perform skills during full-time internships for which they have not been prepared [1–3]. This may result in junior doctors underperforming, which can be stressful for them and is a potential risk for their patients. However, this underperformance is not always visible as basic medical skills are only part of the entire internship experience [4, 5]. Undergraduate skills training is not intended to replace clinical experience as the key mode of learning, but as a preparation for learning of clinical skills in real practice [6, 7]. It is a medical educational reform which facilitates the learning of basic clinical skills in a setting other than clerkships and which is understandable in view of the changes of healthcare delivery and changes in healthcare education [8]. The undergraduate basic medical skills programme should be designed to support the intended learning outcomes and be integrated within the overall curriculum, including within the assessment strategy [8].

Otorhinolaryngology (E.N.T.—Ear, Nose and Throat) is a surgical branch dealing with management of diseases related to ear, nose and throat. Ear is one of five special sense organs which has dual function of hearing and balance. Diseases related to ear may lead to altered sense of hearing and may affect normal balance system. Proper examination of ear is of utmost importance. For examination of ear, proper illumination is a pre requisite. Various illuminating instruments are in use in E.N.T. departments, like Bulls eye lamp and head mirror, head light with fibre optic cable and cold light source, head light with inbuilt battery, Otoscope, Oto-endoscope and Needle otoscope [9]. Main aim of all these instruments is to illuminate the site to be examined. Students are trained to examine ear without use of check list. To appreciate correct findings in ear with otoscope and bulls eye lamp and head mirror, it needs lots of efforts and skill from students and they miss many findings. If they are trained to examine ear using a check list, they may perform better. Also they may appreciate findings more precisely and may correctly diagnose ear diseases in greater majority of patients.

Aim and Objectives

To teach ear examination to students using a check list.

Specific Objectives

1. To know whether there is difference in performance of undergraduate students who were taught by using check list and those who were taught WITHOUT using checklist.

2. To know if there is any improvement in performance of undergraduate students, before and after use of check list.

Methodology

Study was carried out in the department of Otorhinolaryngology (ENT), Chirayu Medical College and hospital, Bhopal (M.P.).

Study design

A cross sectional study

Sample size

50 undergraduate students posted in ENT clinics

Study group

Third year undergraduate students who had their regular clinical posting in department of ENT

Study area

Department of ENT, Chirayu Medical College & Hospital, Bhopal (M.P.)

Proposal for study was submitted to the institutional ethics committee and the study was done after permission from institutional ethics committee. 50 undergraduate Students were given enrollment numbers from 1 to 50. They were divided into two groups, group 1 and group 2, comprising of first 25 enrollments that is 1st to 25 and 2nd 25 enrolments that is from 26 to 50. Both the groups were briefed about the project. Informed consent was taken from the students of both the groups.

One faculty (observer) also was briefed about the project.

Check list was prepared for teaching students to examine ear.

For students of group 1, Check list was used to teach examination of ear.

Students of 2nd group were taught to examine ear, without use of check list.

Evaluation of both the groups was done by observer, using check list (OSCE) who did not know about method used to train the two groups.

After evaluation, students of 2nd group were taught using check list and they were evaluated again by the same observer using check list (OSCE).

This evaluation was done only to know about use of check list and it was not added to any form of assessment of the students.

Data was the marks obtained by them in the evaluation.

Statistical analysis was done by t test and P value.

Inclusion criteria:

1. Third year undergraduate students who had their regular clinical posting in department of ENT.

2. Willingness to participate in the study.

Exclusion criteria:

Not willing to participate in the study.

Observations and Results

Total 50 Third year undergraduate students who had their regular clinical posting in department of ENT took active part in the project. All the students were very enthusiastic to be part of the curriculum project and were highly cooperative.

After teaching both the groups, they were evaluated by the faculty (observer), who was briefed about the curriculum project (Tables 1, 2).

Table 1.

Evaluation of Group 1 (25 students) who were taught ear examination using check list

Enroll. no.	Check list step	No. of students did correctly	No. of students missed/did incorrectly
1.	Explains the procedure to the patient Explains that an instrument will be used, but it will not be painful	25	0
2	Prepares to examine
a.	Sits down close alongside or in front of the patient	25	0
b.	Positions the patient so that her/his ear faces the student squarely	25	0
c.	Selects the speculum which fits snugly into the patient’s external ear opening and fits it to the otoscope	23	2
d.	Takes up the otoscope and switches it on	25	0
e.	Retracts the pinna upwards and backwards, to bring the cartilaginous canal into line with the bony canal	25	0
f.	Places the speculum and otoscope into the external meatus (no deeper than 1 cm) and looks through it	25	0
3.	Examines the external ear canal and comments on:
a.	Its contents (wax, secretions, foreign bodies)	25	0
b.	Its walls	25	0
4.	Examines the eardrum and comments on
a.	Whether it is intact (normal: no perforations)	24	1
b.	Its colour (normal: pearly grey)	23	2
c.	Cone of light (normal: shiny—a cone, from the centre forwards and downwards)	23	2
d.	The handle of the malleus	22	3
5.	Checks hearing using whispered voice	25	0
6.	Occludes opposite ear and lips not visible	24	1
7.	Performs Weber test	25	0
8.	Rinne test	25	0
9.	Absolute Bone Conduction test	25	0
10.	Communicates the findings of the examination briefly to the patient	25	0

Table 2.

Evaluation of Group 2 (25 students) who were taught ear examination WITHOUT use of check list

Enroll. no.	Check list step	No. of students did correctly	No. of students missed/did incorrectly
1.	Explains the procedure to the patient Explains that an instrument will be used, but it will not be painful	25	0
2	Prepares to examine
a.	Sits down close alongside or in front of the patient	25	0
b.	Positions the patient so that her/his ear faces the student squarely	19	6
c.	Selects the speculum which fits snugly into the patient’s external ear opening and fits it to the otoscope	17	8
d.	Takes up the otoscope and switches it on	25	0
e.	Retracts the pinna upwards and backwards, to bring the cartilaginous canal into line with the bony canal	22	3
f.	Places the speculum and otoscope into the external meatus (no deeper than 1 cm) and looks through it	20	5
3.	Examines the external ear canal and comments on:
a.	Its contents (wax, secretions, foreign bodies)	18	7
b.	Its walls	18	7
4.	Examines the eardrum and comments on
a.	Whether it is intact (normal: no perforations)	15	10
b.	Its colour (normal: pearly grey)	16	9
c.	Cone of light (normal: shiny—a cone, from the centre forwards and downwards)	16	9
d.	The handle of the malleus	15	10
5.	Checks hearing using whispered voice	20	5
6.	Occludes opposite ear and lips not visible	20	5
7.	Performs Weber test	16	9
8.	Rinne test	16	9
9.	Absolute Bone Conduction test	15	10
10.	Communicates the findings of the examination briefly to the patient	25	0

Table 3 shows individual performance of each student of group 1. Average marks obtained by students of group 1 were 18.56, out of 19 marks.

Table 3.

Marks obtained by Group 1 students (taught WITH check list)

Enroll. no.	Marks obtained (19)
1	19
2	19
3	19
4	18
5	19
6	15
7	19
8	18
9	19
10	19
11	16
12	19
13	19
14	18
15	19
16	19
17	19
18	18
19	19
20	19
21	19
22	19
23	19
24	19
25	19

Table 4 shows individual performance of each student of group 2. Average marks obtained by students of group 2 were 14.52, out of 19 marks.

Table 4.

Marks obtained by Group 2 students (taught WITHOUT use of check list)

Enroll. no.	Marks obtained (19)
26	12
27	15
28	15
29	13
30	15
31	14
32	15
33	16
34	15
35	13
36	13
37	16
38	15
39	15
40	15
41	13
42	15
43	15
44	15
45	15
46	15
47	15
48	15
49	14
50	14

Table 5 shows individual performance of each student of group 2 after they were taught using Check list. Average marks obtained by students of group 2, after they were trained using check list were 18.36, out of 19.

Statistical analysis was done as following

Column A (Table 3)	Group 1 with checklist
Vs	Vs
Column B (Table 4)	Group 2 WITHOUT checklist
Unpaired t test
P value	< 0.0001
P value summary	***
Are means signif. different? (P < 0.05)	Yes
t, df	t = 14.22 df = 48
How big is the difference?
Mean ± SEM of column A	18.56 ± 0.2007 N = 25
Mean ± SEM of column B	14.52 ± 0.2010 N = 25

Table 5.

Marks obtained by Group 2 students (taught WITH use of check list)

Enroll. no.	Marks obtained (19)
26	18
27	18
28	17
29	19
30	19
31	18
32	18
33	19
34	19
35	18
36	19
37	19
38	18
39	17
40	17
41	18
42	19
43	18
44	17
45	19
46	19
47	19
48	19
49	19
50	19

Difference in the average score of two groups—Group 1 with checklist and Group 2 without checklist was found to be statistically significant when unpaired t test was applied.

Column B (Table 4)	Group 2 WITHOUT checklist
Vs	vs
Column C (Table 5)	Group 2 after WITH checklist
Paired t test
P value	< 0.0001
P value summary	***
Are means signif. different? (P < 0.05)	Yes
One- or two-tailed P value?	Two-tailed
t, df	t = 15.39 df = 24
Number of pairs	25
How big is the difference?
Mean of differences	− 3.840
95% confidence interval	− 4.355 to − 3.325

Difference in the average score of group 2 WITHOUT checklist and group 2 with checklist was also found to be statistically significant when paired t test was applied.

Discussion

Clinical skills acquisition is a major focus of education for health professionals extending from undergraduate to postgraduate and continuing to professional education. Clinical examination in ENT has a very vital role. Ear is one of five special sense organs which has dual function of hearing and balance. Students are taught ear examination in the clinics without use of check list. The group of students who were taught ear examination using check list, imbibed the skill of ear examination better than those students who were taught without use of check list. Also it was found that when students of group B were taught using check list, they had improvement in evaluation for ear examination. From the study it is evident that use of check list for teaching of ear examination helps in taking care of all the steps of examination and hence minimizes the chances of missing the findings in ear. Individual limitations of students can be taken care more efficiently using check list. This will contribute in achieving our goal of ideal Indian Medical Graduate. Also this will minimize the error of missing the important clinical findings thus correct diagnosis which will directly help in better management of patient thus helping us as a doctors, our patients and our society at large.

Outcomes: What This Study Adds

This study suggests that implementation of check list for ear examination may be considered.

Also study can be done for use of check list for examination of Nose and Throat.

Limitations: None.

My Reflections:

• What was good:

This was an opportunity to know how useful a check list is for teaching ear examination. The students were briefed about the project. Students were very very happy to know about the efforts which are being made by our regional centre to train the faculties. They also had expressed their eagerness to contribute for the noble cause and voluntaried to be the part of the research project. The student learnt in a different way and they enjoyed learning and retained what they were taught using checklist. Both the groups were taken care of that neither of the two groups were deprived of learning.

• What could have been differently:

This project has helped me to think beyond the existing methods of teaching in clinics.

• The road ahead:

The use of check list may be included for teaching examination of ear, nose and throat.

Conclusions

Our study shows that there is difference in performance of undergraduate students who were taught by using check list and those who were taught WITHOUT using checklist.

Also our study shows that there is improvement in performance of undergraduate students, before and after use of check list. Thus use of check list to teach ear examination skill to undergraduate students has significant role and students learns better than when taught WITHOUT use of checklist. Use of check list helps in teaching students and the students could retain and implement what they were taught. In check list all the steps of examination are taken care. Errors of missing the important clinical findings will be minimum thus correct diagnosis which will directly help in better management of patient thus helping us as a doctors, our patients and our society at large.

Implications

Teaching ear examination skill to undergraduate students using check list will help student in better learning. Long term retention and implication of what they learnt and thus will be able to diagnose the diseases related to ear correctly and manage the patients in a better way thus will help the patients and society at large.

Appendix 1: Ear Examination Check List

1. Explains the procedure to the patient

   Explains that an instrument will be used, but it will not be painful.

2. Prepares to examine:

3. Sits down close alongside or in front of the patient;

4. Positions the patient so that her/ his ear faces the student squarely.

5. Selects the speculum which fits snugly into the patient’s external ear opening and fits it to the otoscope.

6. Takes up the otoscope and switches it on—should use the right hand for the right ear examination and left hand for the left ear.

7. Retracts the pinna upwards and backwards, to bring the cartilaginous canal into line with the bony canal.

8. Places the speculum and otoscope into the external meatus (no deeper than 1 cm) and looks through it.

9. Examines the external ear canal and comments on:

10. Its contents (wax, secretions, foreign bodies).

11. Its walls (smooth, pinkish, dry).

12. Examines the eardrum and comments on:

13. Whether it is intact (normal: no perforations).

14. Its colour (normal: pearly grey).

15. Cone of light (normal: shiny—a cone, from the centre forwards and downwards).

16. The handle of the malleus.

17. Checks hearing using whispered voice.

18. Occludes opposite ear and lips not visible.

19. Performs Weber test.

20. Rinne test.

21. Absolute Bone Conduction test.

22. Communicates the findings of the examination briefly to the patient.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Consideration

None. No animal or Human Experimentation was done.