Is undergraduate ophthalmology teaching in the United Kingdom still fit for purpose?

Introduction

There is a growing crisis in ophthalmology education. An increasing number of junior doctors and general practitioners are losing confidence in their ophthalmic knowledge; this includes a declining use of the fundoscope [1], associated loss in confidence with recognising sight-threatening pathologies [2], and a consequential rise in inappropriate referrals to tertiary eye units [3]. Furthermore, modern medical curriculums in the UK are becoming increasingly ‘crowded’, resulting in many academic institutes prioritising subjects that align with the broader learning objectives of the General Medical Council (GMC). These include the colonisation of novel undergraduate topics and less time for the basic sciences [4]. Over the last two decades, ophthalmology has witnessed a decline in teaching from 2-week clinical rotations [5] to altogether non-compulsory in a modern curriculum [6]. Greater attention is required to the state of undergraduate ophthalmology training in the United Kingdom (UK).

These curriculum changes have meant that there is limited teaching for ophthalmology at an undergraduate level. Presently, in the UK, a clinical rotation in ophthalmology is non-compulsory in certain medical schools and the vast majority of teaching revolves around traditional methods, such as didactic lectures, workshops and textbooks [6]. These methods are not conducive to efficient knowledge transfer [7], or supporting the current digital era of learning. As a result, over half (52%) of senior medical students do not feel confident in their ophthalmic knowledge and three-quarters (75%) feel their respective medical school’s methodology of delivering ophthalmology education is inadequate [6]. Adjunctive educational methods need to be adopted in ophthalmology to combat the constraints of modern medical curriculums, improve student confidence in ophthalmology, and to future-proof undergraduate ophthalmology education.

Blended learning

Blended learning is the provision of supplementary resources that support education in the traditional, virtual and self-directed learning environments [8]. This approach is especially applicable to ophthalmology since the specialty has lost time in the undergraduate curriculum, resulting in less room for passive learning through didactic lectures and clinical observership [6]. Blended learning provides a unique solution to support self-directed, active learning techniques that foster an ethos of lifelong learning amongst undergraduate medical students [8]. Active learning can be facilitated using a ‘flipped classroom’ (FC) approach, which has been successfully integrated into a two-week ophthalmology rotation in the United States by Kivell and colleagues [9]. Prior to clinical placement, medical students were allowed to undertake self-directed 90-minute porcine eye dissection following short lectures. This method allowed students to grasp clinically-relevant complex eye and orbital anatomy using an active learning style. Alternatives are available to dissection, should a more cost-effective method be required as a pre-classroom activity [10, 11]. The FC approach has grown popular in multiple ophthalmology units as a method to improve both knowledge gain and student satisfaction [9, 12, 13].

A variety of pre-classroom resources are necessary for the FC approach to remain an attractive solution for individualised learning amongst students rotating through ophthalmology. Teaching resources can include three-dimensional ophthalmic models [10, 11], virtual ophthalmic software [14, 15], and multimedia modalities [13, 16]. Following pre-classroom activities, the remaining time can be spent supporting higher cognitive domains: applying clinical knowledge to patient cases and troubleshooting more challenging concepts with senior ophthalmology faculty. Finally, medical education is changing to account for the exponential rise in technology, greater accessibility to the internet, and falling costs of digital devices [17]. As a result, there is a growing emphasis on using technology to assist blended learning techniques as both students, pedagogues and academic institutes enter an era of ‘digital learning’ (Fig. 1) [14, 18–20].

Fig. 1. A new model for undergraduate ophthalmology teaching.

‘Technology-enhanced learning’ (TEL) has multiple elements, including digital ophthalmoscopy, virtual anatomy software and video-based multimedia to be integrated as part of traditional teaching in a ‘blended learning’ approach.

Technology-enhanced learning

Technology-enhanced learning (TEL) is an umbrella term for educational resources that employ digital devices, e-Learning material and virtual learning environments to enhance the student learning experience [18]. The benefits of employing TEL resources in undergraduate ophthalmology education are multi-faceted, providing interactivity, accessibility and flexibility for learners during shorter ophthalmology placements. Most importantly it appeals to ‘digital natives’, the label given to current medical student belonging to generation Y and Z. These student cohorts subconsciously seek to integrate TEL resources as part of their undergraduate ophthalmology learning. This includes the use of 3D virtual software to learn ocular anatomy [15], digital devices to support clinical skills [19–22], and virtual learning environments to support ophthalmology placements (Table 1) [14]. Our group at Sussex Eye Hospital (Brighton, UK) used BioDigital (NY, USA) to teach ocular anatomy to undergraduate students using a blended learning approach and 70% of students stated they would integrate the resource with future learning (unpublished).

Table 1.

Brief summary of technology-enhanced learning (TEL) resources available to teachers involved in undergraduate ophthalmology education that can be integrated into a traditional curriculum.

Author (Date)	Brief description of study and TEL methodology
Steedman (2012) [13]	Randomised control trial exploring the use of video-based multimedia versus textbook resources on topics of acute vision loss and cataracts.
Succar (2013) [14]	Randomised control trial exploring the use of virtual ophthalmology clinics versus traditional ophthalmology placement.
Allen (2015) [15]	Proof-of-concept study to design a virtual 3D anatomical software exploring the eye, orbit and oculomotor system.
Schulz (2016) [21]	Randomised control trial exploring the use of digital teaching ophthalmoscope compared to conventional ophthalmoscope on clinical exam performance.
Mamtora (2018) [19]	Cross-sectional study examining smartphone-assisted ophthalmoscopy (D-EYE) compared to conventional ophthalmoscope.
Shikino (2019) [20]	Randomised control trial exploring the use of smartphone-assisted ophthalmoscopy (iExaminer) compared to conventional ophthalmoscope on diagnostic accuracy and timing till diagnosis of students.
Lee (2019) [22]	Proof-of-concept study describing the use of digital camera attachment for slit-lamp examination to produce live high-quality images of an ophthalmic examination.

In addition, video-based TEL has exponentially grown in the last two decades. In some cases, ‘YouTube’—the largest online video repository—has been labelled as the first resort for learning new concepts in medicine or allied healthcare subjects [23]. The case is no different for ophthalmology education where there are numerous free, online and accessible educational videos produced by experienced pedagogues [24, 25]. Educational videos can be easily created by educationalists and guide students through purposeful narration to support self-directed learning, as well as reduce learning time with no compromise on knowledge retention [13].

Conclusions

Ophthalmology remains one of the most technologically up-to-date specialties in healthcare, yet this is not reflected in our educational methods. Undergraduate ophthalmology education is in dire need of reform as junior doctors are losing confidence in assessing ophthalmic complaints and undergraduate students are dissatisfied with traditional teaching methods. Our advice to educators is to avoid the temptation to fall back on traditional teaching methods, but rather embrace TEL as part of a blended learning approach. TEL has been shown to reduce learning time, improve knowledge retention and enhance student engagement, especially amongst digital learners. The limited time left in a clinical rotation needs to be prioritised for applying and evaluating ophthalmic theory to patient cases, and not encountering elementary knowledge for the first time. We hope educationalists remain brave in exploring this new era of digital learning to ensure the longevity of ophthalmic knowledge in our future healthcare workforce and to make ophthalmology an enjoyable topic to learn for students.

Author contributions

YSB finalised the paper. YSB, HN, NT, PG and SR all contributed equally to the ideation, writing and editing of this paper.

Competing interests

The authors declare no competing interests.