Original Article
Ophthalmology in the undergraduate curriculum A review in Queensland Denis Stark, FRACO, FRCS (Ed)* Andrew Beinssen, MB BS (Qld), BSc (Hon)? Chris Morreyt
Abstract Three hundred and sixty-nine postal questionnaires related to the content and teaching of the undergraduate medical course were sent to Queensland city and provincial ophthalmologists, general practitioners, physicians and surgeons. The return rate was 53%. The views of the four groups were similar in most respects. The majority of respondents thought that ophthalmology should be taught as a separate course. They stated visits to operating theatre and eye casualty unit should be included in the course. Ophthalmologists and general practitioners stated the course should be longer, physiciansthought it should remain the same length and surgeons felt less time should be dedicated to the teaching of ophthalmology.Topic areas regarded as essential were the acute care areas: trauma; glaucoma; infection; use of an ophthalmoscope; acute visual loss; and red eye. Squint was also regarded as an essential area by ophthalmologists. Key words: Course content, ophthalmology teaching, questionnaire, undergraduate medical course.
*Clinical Associate Professor, Department of OphthaimofoKv, Mater Hospita I, South B r i s bane, Queensla nd. ?Resident Medical Officer, General Hospital, Cairns, Queensland. $Sixth Year Medical Student, University of Queensland, St Lucia, Queensland.
Ophthalmology is an important clinical discipline, aspects of which are necessary to complete any full patient examination. It also has ever-increasing relevance to other specialty areas, such as endocrinology, neurology, paediatrics, cardiology and nephrology.' However, little time is given to the teaching of ophthalmology in most undergraduate curricula.'-s In Queensland three and a half weeks, just three per cent of clinical years, is spent training in this field. Five to nineteen per cent of all patients in primary health care have eye-related conditions, yet this area occupies less than five per cent of the undergraduate curriculum in any American medical ~ c h o o l . ~Even . ~ . less ~ time is spent in some schools in the United Kingdom',4 and in some there is pressure to reduce the time allocated to ophthalmology in the undergraduate One study states that 'currently assigned time for teaching ophthalmology is limited and gradually de~lining'.~ In maximising the effectiveness of a course, especially if teaching time is limited, there are two important aspects to consider. First, curriculum content must be carefully chosen, and second it must be taught efficiently.I0 It has been demonstrated that giving clear and concise goals to students at the start of a course facilitates learning. l o The development of clear goals has been an important aspect of improvements to undergraduate ophthalmology course^.^.^'-'^ Over the last 50 years the concept that a medical student can no longer learn all medical knowledge has been well accepted by medical s c h o o l ~ . ~This ~-'~
Reprint requests: Dr D J Stark, Department of Ophthalmology, Mater Hospital, Stanley Street, South Brisbane, Queensland 4010, Australia. Ophthalmology in the undergraduate curriculum
297
Course area 0 0 Trauma . .
m
mI
~~
/ 0 / 0 0 / 0 0 / / 0 0 0 0 / 0 / / ~ / 0 . . . . . . . . . . . . . . . . . . . . . . .
Cataract
0
I
/
I
::::::;:::: 0
0
/
/
I
I
0
/
/
0
/
0
i
0
Essential
1\\1
/
r)-TI
I
Desirable but not essential
......................
Glaucoma
. . . . . . . . . . . . . . . . . . . . . . .
Squint
Useful but not required
Infection Not mportant
Neuro-ophthalmology Tumours
I have no basis for comment
Retinal vascular Retinal degeneration I
Ophthalmoscope
.
0
.
. . . 0 0 0
I . 0
. 0
. /
I . . / 0
. 0
. 0
. /
. 0
I . 0
. /
. . . . . / / 8 0 0
I
I
I
I
I
I
I
I
. . . / 0 0
Optics \ \ \ \ \ \ \ . \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ / ~ / 0 0 / 0 1 0 0 0 0 0 0 0 0 / / 0 / IL l
Acute visual loss
I
Red eye
r
I
. . . . . . . . . . . . . . . . . . . . . . . . ,
0
20
1
,
,
,
40
,
,
,
\
,
,
, , # / / , , ,
,
60
\
80
100
Per cent
Figure 1 Responses of the groups as to which areas in the course should be given more emphasis.
change in thinking means that the curriculum content of any course must now be carefully chosen from the vast and expanding body of knowledge a~ailable.~. lo. l 6 'Traditional methods to determine curriculum content are based on the assumption that the specialised subject matter experts, particularly the full-time Faculty teachers of a subject, are the only persons capable of determining the appropriate content to be taught or learnt7.l7However, an undergraduate course should provide the basic knowledge in an area that is required by all graduates; for this reason the method described by Spivey in 1968,14where representatives from many different backgrounds are consulted during curriculum design, provides a more balanced course structure. His method has been used around the world in subsequent studies.1.4.17.'8 The responses to Spivey's original questionnaire show a very consistent three-group pattern emerging: all nonophthalmological specialists responded similarly and consistently despite differing backgrounds, and there was also consistency of individuals within the ophthalmologist and general practitioner groups. The general practitioners were universally more demanding than the other groups,'O confirming the 298
perceived practical need. Subsequent studies show a similar p a t t e ~ n . ' ~ . ' ~ In his original study Spivey carefully chose the content of the questionnaire in a design process that involved an initial 'brainstorming session' followed by consultation with 'content experts' in specialty and subspecialty areas.'O The major problem inherent in this method is that the selection of these forced answer detailed statements may introduce a design bias. This factor is not discussed in any of the previous literature. Vernon4 uses the principles of Spivey's broadbased consultation. However, he used a much simpler questionnaire, splitting the whole subject into just thirteen broad topics. This has the drawback that the curriculum designer must then decide what is to be specifically taught within these topics. Many lists of the 'important' areas for an undergraduate curriculum have been made;1.3-5.'1.12~'4,17,19.20 they range in length from six to 59 areas. S p i ~ e y , ~ . ' ~ in his original 'brainstorming session', created a seven-point list which was refined to six in 1976 by Crombie.' They are: applied anatomy and physiology of the eye; the red eye; visual failure; glaucoma; squint; and the eye in systemic disease.' Australian and New Zealand Journal of Ophthalmology 1992; 20(4)
Vernon expanded the list to 13: trauma; cataract; glaucoma; squint; infection; neuro-ophthalmology; tumours; retinal vascular disease; retinal degeneration; use of the ophthalmoscope; optics; acute visual loss; and the red eye.4 The current study is similar to that undertaken by Vernon4 in the United Kingdom and we compare the results and discuss their implications.
Materials and methods Population and sampling The target population of this study was doctors practising in Queensland. T o obtain a practical sample group, four specific subgroups were chosen: ophthalmologists; general practitioners; surgeons; and physicians. Questionnaires were sent to 87 ophthalmologists, 139 general practitioners, 7 I general surgeons, and 72 general physicians; a total of 369. T h e addresses were obtained from the Queensland medical registry. The specialists were taken from the separate specialist listing, and the general practitioners from the general list. They were selected using random numbers generated on the Department of Social and Preventive Medicine’s (University of Queensland) computer. If the address was unsuitable, e.g. because it was in another state, or in the case of general practitioner selection if a specialist was chosen, the next suitable name on the list was used. The selection method provides a representative sample of country and city based practices. This sample relies on the assumption that the opinions of those returning the questionnaire are similar to those who do not. Spivey3included a forced (100%) return component; his results showed no variation in views, making the assumption valid. Table 1.
7
8 8+ Mean (weeks)
Procedure The questionnaires were distributed by mail in September 1989. They were accompanied by a covering letter and a stamped, self-addressed envelope. Four weeks after the posting doctors who had not yet replied were followed up with a phone call requesting they return the questionnaire.
Results Over all, doctors returned 195 questionnaires (53% return rate). Of these, ophthalmologists returned 62 questionnaires (71Yo return rate), general practitioners 64 (46% return rate), general surgeons 30 (42% return rate) and general physicians 39 (54% return rate). Fifty-eight per cent of the ophthalmologists were from urban and 42% from rural areas, 48% of the general practitioners were from urban and 52% from rural areas, 73% of general surgeons were from urban and 2’7% from rural areas, and 69% of general physicians were from urban and 31% from rural areas. Sixty-two per cent of ophthalmologists, 66% of general practitioners and 54% of general physicians
Per cent of respondents and course duration advocated* Per cent of respondents
Course duration (weeks) 1 2 3 4 5 6
Study design The questionnaire asked if the undergraduate course should be taught as a separate course, and if so how long it should be and whether it should include visits to operating theatre, eye casualty, and the optician. Doctors were also asked to choose five from 13 topics (see Figure 1). The questionnaire used a totally forced answer format, so that the data received could be easily tabulated and statistically analysed. The questionnaire was designed as simply as possible to maximise the postal reply rate. All statistics used in this study were calculated using the Chi-square test.
Ophthalmologists
General practitioners
General surgeons
General physicians
4.8% 19.4% 9.7% 22.6% 1.6% 19.4% 0 12.9% 3.2% 4.2
0 18.7% 9.4% 32.8% 1.6% 9.4% 0 20.3% 6.2% 4.8
6.7% 23.3% 6.7% 23.3% 0 20.0% 0 10.0% 0 3.7
17.9% 20.5% 7.7% 30.8%
2.6%
5.1% 0 7.7% 5.1% 2.9
*Not all respondents answered this question.
Ophthalmology in the undergraduate curriculum
299
50 Ophthalmologists 40
General Practitioners
30 Surgeons
20 10
Physicians
%
Variance 0
- 10
- 20 - 30 - 40
I Trauma Cataract Glaucoma Squint
lnfeclioi
Neura- Tumours Retinal Vascular Iphthalmalogy
Figure 2 Course content
-
Ophthal-
eration
Oplics
Acute VwaI
Red
Eye
Lass
response as a percentage variance from random.
thought ophthalmology should be taught as a separate subject, but only 38% of general surgeons thought this to be the case. The distribution of the length of time of the ophthalmology course is shown in Table 1. A mean choice for each specialty group was calculated and it showed that ophthalmologists suggested a 4.2 week course, general practitioners a 4.8 week course, general surgeons a 3.7 week course and general physicians a 2.9 week course. (Table 1). Seventy-three per cent of ophthalmologists, 86% of general practitioners, 72% of general surgeons and 74% of general physicians thought visits to the operating theatre should be included in the course. All groups were 97% or greater in agreement that sessions in eye casualty would be of some benefit. However, only 20% of ophthalmologists considered sessions with an optician necessary whereas 83% of general practitioners, 69% of general surgeons and 79% of general physicians thought such sessions should be included in the course (P< 0.05). Figure 1 shows the percentage responses of the groups as a whole as to which areas in the course should receive more emphasis. The areas of trauma, glaucoma, squint, infection, use of an ophthalmoscope, acute loss of vision, and the red eye were considered to be essential, by more than 50% of respondents. 300
Retinal
Degen- moscope
In order to determine any differences between groups as to where they considered the emphasis should be placed, each course area was examined individually. At the P< 0.05 significance levd ophthalmologists considered infections not as essential as the other groups. General surgeons considered cataracts, retinal vascular disorders and acute visual loss to be not as essential as the other groups. General surgeons and general physicians also considered squint to be not as essential as did ophthalmologists and general practitioners. General physicians considered neuro-ophthalmology more essential than did the other groups. Finally, general practitioners and general physicians considered optics to be more essential than did ophthalmologists and general surgeons. To determine subject priorities, respondents were asked to choose five topics from the 13 listed. If the respondents’ choices had been random, Vernon4, states that 38.5% of respondents would have chosen each topic. Therefore, in order to compensate for random selection the results are presented as a percentage above or below that expected if the selections were at random (Figure 2). At the P < 0.05 significance level, the opinion of ophthalmologists differed from those of the general practitioners, general surgeons and general physicians on squints, while the opinions of the Australian and New Zealand Journal of Ophthalmology 1992; 20(4)
general practitioners and general surgeons differed from those of the ophthalmologists and general physicians on infections. The rankings provided six areas which were considered to be priorities: trauma; glaucoma; infection; use of an ophthalmoscope; acute loss of vision; and the red eye.
Discussion Currently in Queensland, only three and a half weeks of the medical course or 3% of the clinical years is devoted to teaching ophthalmology and within this three and half weeks the teaching is equally distributed amongst ophthalmology and otolaryngology, effectively reducing the ophthalmological content to less than 2% of the clinical years. In our study ophthalmologists, general practitioners and general physicians were all of the opinion that it should be taught as a separate subject; only the general surgeons felt it should remain as it does, a combined subject with otolaryngology taught within the discipline of surgery. Both ophthalmologists and general practitioners agreed that the amount of time allocated to ophthalmology solely in the current curriculum should be extended up to 4.2 and 4.8 weeks respectively. The fact that general surgeons did not consider that the time should be increased and that general physicians considered it should be reduced (Table l), highlights the problems faced by the minor specialties when they are under-represented on curriculum design board^.^ The results of this study can be used to support a case for increased allocation of time to ophthalmology teaching. However, the call for increased student knowledge, coupled with the fact that the undergraduate medical curriculum has a finite time limit makes a request for increased time allocation to ophthalmology unlikely to be successful. More efficient variation on traditional teaching methods may then be needed to compensate for the restricted time available. Discussion of this area is beyond the scope of this study. Waring et al." and Phillips et a l l 2 have considered this in respect of ophthalmology with encouraging results. All of the groups agreed that visits to the operating theatre and sessions in an eye casualty unit would be advantageous to the student. The former is not included in the present curriculum. It is apparent that all groups consulted felt it would be advantageous for medical graduates to have an overview of surgical techniques to enable them to Ophthalmology in the undergraduate curriculum
assist their patients preparing for such surgery. Evidence for the difference of opinions of the four groups as to whether optics should be included in the curriculum was highlighted by the opinions of the general practitioners and general physicians who considered optics to be more essential than the ophthalmologists and general surgeons. This may reflect the fact that ophthalmologists integrate optics as a subtopic of ophthalmological and systemic disease whereas the former two groups see a less distinct connection between optics and ophthalmological and systemic disease. Only 20% of ophthalmologists thought a session with an optometrist would be of some benefit; the other groups were strongly in favour of such a visit. Vernon4 obtained similar results and concluded that some ophthalmologists may not consider a session with an optometrist important as they teach students what they need to know about refractive errors and optics. The opinion of general practitioners, general surgeons, and general physicians would highlight the fact that this area of ophthalmology is not covered adequately at present and the role of the ophthalmologist is not fully understood by other medical disciplines. This suggests an increased emphasis on refractive errors, optics and visual aids should be included in the curriculum, together with appropriate instruction of the roles of the ophthalmologist and optometrists in the management of the related conditions. This should be beneficial in aiding future general practitioners, as the provider of primary health care, in determining appropriate management of their patients. Using Vernon's expanded list of 134 we found seven areas were considered to be an essential part of student training (Figure 1). These areas included: trauma; glaucoma; squint; infection; use of an ophthalmoscope; acute loss of vision; and the red eye. General surgeons considered cataracts, retinal vascular disorders and acute visual loss not to be essential knowledge, and along with the general physicians thought squint not to be important; in contrast to ophthalmologists and general practitioners. This situation could reflect the concern of ophthalmologists and general practitioners that certain conditions have a potential to be reversed and visual loss prevented. It is likely that if paediatric physicians had been included in the survey, the importance of strabismus would have been recognised by that group as it is an important condition in childhood. 301
The fact that the general physicians considered neuro- ophthalmology as more essential than the other groups may be attributed to their involvement with complex neurological problems, which may frequently have a neuro-ophthalmological component. In Figure 2 it can be seen that the areas requiring most emphasis in the course are: trauma; glaucoma; infection; use of an ophthalmoscope; acute visual loss; and the red eye - a pattern similar to that in Figure 1, except for the area of squint. Ophthalmologists differed from the other groups solely in the area of squint. This is identical to Vernon’s4 findings and he postulated that this reflects the ophthalmologist'^ concerns for pot en t iall y preventable visual loss. This major difference in opinion would suggest the need to further stress the importance of strabismus in the curriculum as a condition that can cause permanent loss of vision or be evidence of major pathology. General practitioners and general physicians also differed in opinion to other groups on infections and this may represent again an area in which they are involved in their daily practice. Five to 19 per cent of all primary health care patients have eye-related condition^.^ The results illustrated in Figures 1 and 2, coupled with support for sessions in an eye casualty unit, indicate the topics involving acute primary care and screening are preferred to those relating to more chronic or rarer conditions. These were also the findings of Vern~n.~ One of our aims was to compare this study with the one undertaken by Vernon in the United Kingdom in 198tL4As stated there is a very close correlation regarding sessions with an optician. Both studies support the teaching of ophthalmology as a separate subject, and that the course should be longer. However, in our study the mean lengths chosen by ophthalmologists and general practitioners, 4.2 and 4.8 weeks respectively, were lower than the 5.0 and 5.35 weeks recommended in Vernon’s study. Sessions in an eye casualty unit and the operating theatre are shown to be considered advantageous to the student in both studies. Differences were noted between the two studies only in the area of retinal vascular disorders. Our study considered this area not to be essential, whereas that of Vernon considered it to be so. The large degree of similarity between the two studies highlights the fact that doctors in various parts of the world and in various specialty groups consider the student should be well equipped to deal with those problems commonly seen by the 302
providers of primary health care in the area of ophthalmology.
Conclusion The study reveals that there is substantial agreement as to what should form the basis of the undergraduate medical curriculum in ophthalmology in Queensland. Previous studies in which the broad-based questionnaire was used show a similar situation in other areas throughout the WOrld~3.4.10.17.18 It is the opinion of many that the ophthalmology course in Queensland should be taught as a separate discipline and the time currently allocated to it lengthened. Given time constraints, the use of different and possibly more efficient teaching methods should be explored. It is a general consensus that the course should include visits to the operating theatre and eye casualty unit and knowledge of those core areas that are involved in acute primary care, namely trauma, glaucoma, infection, use of an ophthalmoscope, acute loss of vision and the red eye. Recommendations from the various individual groups also see the necessity for increased teaching of optics, refraction, visual aids, and squint. A study such as this creates much debate. The problem of whether to prepare the student for postgraduate training or independent practice will continue to arise. We must emphasise that ophthalmology plays a vital role in many acute primary health care situations. Sufficient time and quality teaching in the most important areas must be a priority in an undergraduate ophthalmological course to allow a medical graduate to practise at a competent level.
References 1. Crombie AL. Ophthalmology in the undergraduate curriculum. Trans Ophthalmol SOCUK 1976;96:33-4. 2. Dias PLR. An evaluation of the undergraduate teaching programme in ophthalmology in Sri Lanka and Malaysia. Med Educ 1987;21:334-9. 3. Spivey BE. Ophthalmology in medical student education: philosophy, content, and process. Ophthalmology 1978;85: 1299-311. 4. Vernon SA. Eye care and the medical student: where should the emphasis be placed in undergraduate ophthalmology? J Roy SOCMed 1988;81:335-7. 5. Moriarty BJ. Ophthalmology in Jamaica. Arch Ophthalmol 1988; 1061557-8. 6. Maumenee AE. The educational and political structure of ophthalmology in America. Arch Ophthalmol 1967;77:295-304. 7. Crombie AL. Minimum requirements for the undergraduate curriculum. Trans Ophthalmol SOCUK, 1980;100:311-12. Australian and New Zealand Journal of Ophthalmology 1992; 20(4)
8. Archer DB. The seed-corn. Trans Ophthalmol SOCUK 1985;105:211-17. 9. Kalina RE, Van Dyk HJ, Weinstein GW. Ophthalmology teaching in medical schools. J Med Educ 1981;56: 143-5. 10. Spivey BE. A technique to determine curriculum content. J Med Educ 1971;46:269-74. 11. Waring GO, Harris R, Walters RF, Berris C. Clinical ophthalmology instruction for medical students. Surv Ophthalmol 1977;22: 106-12. 12. Phillips CI, Bartholomew RS, MacMichael IM. Tapelslide course in ophthalmology for undergraduates. Br J Med Educ 1975;9:231-5. 13. Archer DB. Undergraduate ophthalmology: The practice of teaching. Trans Ophthalmol SOCUK 1980;100:313-14. 14. Spivey BE. Ophthalmology for medical students: content and comment. Arch Ophthalmol 1970;84:368-75.
15. Haining WM. Symposium on the teaching commitment in ophthalmology. T r a n s Ophthalmol SOC UK 1980; 100:309-10. 16. Education in ophthalmology in North America. Br J Med Educ 1967;l: 119-26. 17. McCarthy WH, Donaldson EJ, Hollows FG. What should we teach? A consensus method to determine curriculum content. Med Educ 1977;11:249-56. 18. Worthen DM. Ophthalmology for medical students: Objectives. Arch Ophthalmol 1972;88:314-20. 19. Spivey BE, Gamble L. Ophthalmology: What do we need to know? Am J Ophthalmol 1987;103(4):586-9. 20. Harvey JT, Chong JP, Neufeld VR, Slackett DL, Oates MJ. Ranking clinical problems and ocular diseases in ophthalmology: an innovative approach to curriculum design. Can J Ophthalmol 1988;23:255-8.
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Ophthalmology in the undergraduate curriculum
303
Ophthalmology in the undergraduate curriculum A review in Queensland Denis Stark, FRACO, FRCS (Ed)* Andrew Beinssen, MB BS (Qld), BSc (Hon)? Chris Morreyt
Abstract Three hundred and sixty-nine postal questionnaires related to the content and teaching of the undergraduate medical course were sent to Queensland city and provincial ophthalmologists, general practitioners, physicians and surgeons. The return rate was 53%. The views of the four groups were similar in most respects. The majority of respondents thought that ophthalmology should be taught as a separate course. They stated visits to operating theatre and eye casualty unit should be included in the course. Ophthalmologists and general practitioners stated the course should be longer, physiciansthought it should remain the same length and surgeons felt less time should be dedicated to the teaching of ophthalmology.Topic areas regarded as essential were the acute care areas: trauma; glaucoma; infection; use of an ophthalmoscope; acute visual loss; and red eye. Squint was also regarded as an essential area by ophthalmologists. Key words: Course content, ophthalmology teaching, questionnaire, undergraduate medical course.
*Clinical Associate Professor, Department of OphthaimofoKv, Mater Hospita I, South B r i s bane, Queensla nd. ?Resident Medical Officer, General Hospital, Cairns, Queensland. $Sixth Year Medical Student, University of Queensland, St Lucia, Queensland.
Ophthalmology is an important clinical discipline, aspects of which are necessary to complete any full patient examination. It also has ever-increasing relevance to other specialty areas, such as endocrinology, neurology, paediatrics, cardiology and nephrology.' However, little time is given to the teaching of ophthalmology in most undergraduate curricula.'-s In Queensland three and a half weeks, just three per cent of clinical years, is spent training in this field. Five to nineteen per cent of all patients in primary health care have eye-related conditions, yet this area occupies less than five per cent of the undergraduate curriculum in any American medical ~ c h o o l . ~Even . ~ . less ~ time is spent in some schools in the United Kingdom',4 and in some there is pressure to reduce the time allocated to ophthalmology in the undergraduate One study states that 'currently assigned time for teaching ophthalmology is limited and gradually de~lining'.~ In maximising the effectiveness of a course, especially if teaching time is limited, there are two important aspects to consider. First, curriculum content must be carefully chosen, and second it must be taught efficiently.I0 It has been demonstrated that giving clear and concise goals to students at the start of a course facilitates learning. l o The development of clear goals has been an important aspect of improvements to undergraduate ophthalmology course^.^.^'-'^ Over the last 50 years the concept that a medical student can no longer learn all medical knowledge has been well accepted by medical s c h o o l ~ . ~This ~-'~
Reprint requests: Dr D J Stark, Department of Ophthalmology, Mater Hospital, Stanley Street, South Brisbane, Queensland 4010, Australia. Ophthalmology in the undergraduate curriculum
297
Course area 0 0 Trauma . .
m
mI
~~
/ 0 / 0 0 / 0 0 / / 0 0 0 0 / 0 / / ~ / 0 . . . . . . . . . . . . . . . . . . . . . . .
Cataract
0
I
/
I
::::::;:::: 0
0
/
/
I
I
0
/
/
0
/
0
i
0
Essential
1\\1
/
r)-TI
I
Desirable but not essential
......................
Glaucoma
. . . . . . . . . . . . . . . . . . . . . . .
Squint
Useful but not required
Infection Not mportant
Neuro-ophthalmology Tumours
I have no basis for comment
Retinal vascular Retinal degeneration I
Ophthalmoscope
.
0
.
. . . 0 0 0
I . 0
. 0
. /
I . . / 0
. 0
. 0
. /
. 0
I . 0
. /
. . . . . / / 8 0 0
I
I
I
I
I
I
I
I
. . . / 0 0
Optics \ \ \ \ \ \ \ . \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ / ~ / 0 0 / 0 1 0 0 0 0 0 0 0 0 / / 0 / IL l
Acute visual loss
I
Red eye
r
I
. . . . . . . . . . . . . . . . . . . . . . . . ,
0
20
1
,
,
,
40
,
,
,
\
,
,
, , # / / , , ,
,
60
\
80
100
Per cent
Figure 1 Responses of the groups as to which areas in the course should be given more emphasis.
change in thinking means that the curriculum content of any course must now be carefully chosen from the vast and expanding body of knowledge a~ailable.~. lo. l 6 'Traditional methods to determine curriculum content are based on the assumption that the specialised subject matter experts, particularly the full-time Faculty teachers of a subject, are the only persons capable of determining the appropriate content to be taught or learnt7.l7However, an undergraduate course should provide the basic knowledge in an area that is required by all graduates; for this reason the method described by Spivey in 1968,14where representatives from many different backgrounds are consulted during curriculum design, provides a more balanced course structure. His method has been used around the world in subsequent studies.1.4.17.'8 The responses to Spivey's original questionnaire show a very consistent three-group pattern emerging: all nonophthalmological specialists responded similarly and consistently despite differing backgrounds, and there was also consistency of individuals within the ophthalmologist and general practitioner groups. The general practitioners were universally more demanding than the other groups,'O confirming the 298
perceived practical need. Subsequent studies show a similar p a t t e ~ n . ' ~ . ' ~ In his original study Spivey carefully chose the content of the questionnaire in a design process that involved an initial 'brainstorming session' followed by consultation with 'content experts' in specialty and subspecialty areas.'O The major problem inherent in this method is that the selection of these forced answer detailed statements may introduce a design bias. This factor is not discussed in any of the previous literature. Vernon4 uses the principles of Spivey's broadbased consultation. However, he used a much simpler questionnaire, splitting the whole subject into just thirteen broad topics. This has the drawback that the curriculum designer must then decide what is to be specifically taught within these topics. Many lists of the 'important' areas for an undergraduate curriculum have been made;1.3-5.'1.12~'4,17,19.20 they range in length from six to 59 areas. S p i ~ e y , ~ . ' ~ in his original 'brainstorming session', created a seven-point list which was refined to six in 1976 by Crombie.' They are: applied anatomy and physiology of the eye; the red eye; visual failure; glaucoma; squint; and the eye in systemic disease.' Australian and New Zealand Journal of Ophthalmology 1992; 20(4)
Vernon expanded the list to 13: trauma; cataract; glaucoma; squint; infection; neuro-ophthalmology; tumours; retinal vascular disease; retinal degeneration; use of the ophthalmoscope; optics; acute visual loss; and the red eye.4 The current study is similar to that undertaken by Vernon4 in the United Kingdom and we compare the results and discuss their implications.
Materials and methods Population and sampling The target population of this study was doctors practising in Queensland. T o obtain a practical sample group, four specific subgroups were chosen: ophthalmologists; general practitioners; surgeons; and physicians. Questionnaires were sent to 87 ophthalmologists, 139 general practitioners, 7 I general surgeons, and 72 general physicians; a total of 369. T h e addresses were obtained from the Queensland medical registry. The specialists were taken from the separate specialist listing, and the general practitioners from the general list. They were selected using random numbers generated on the Department of Social and Preventive Medicine’s (University of Queensland) computer. If the address was unsuitable, e.g. because it was in another state, or in the case of general practitioner selection if a specialist was chosen, the next suitable name on the list was used. The selection method provides a representative sample of country and city based practices. This sample relies on the assumption that the opinions of those returning the questionnaire are similar to those who do not. Spivey3included a forced (100%) return component; his results showed no variation in views, making the assumption valid. Table 1.
7
8 8+ Mean (weeks)
Procedure The questionnaires were distributed by mail in September 1989. They were accompanied by a covering letter and a stamped, self-addressed envelope. Four weeks after the posting doctors who had not yet replied were followed up with a phone call requesting they return the questionnaire.
Results Over all, doctors returned 195 questionnaires (53% return rate). Of these, ophthalmologists returned 62 questionnaires (71Yo return rate), general practitioners 64 (46% return rate), general surgeons 30 (42% return rate) and general physicians 39 (54% return rate). Fifty-eight per cent of the ophthalmologists were from urban and 42% from rural areas, 48% of the general practitioners were from urban and 52% from rural areas, 73% of general surgeons were from urban and 2’7% from rural areas, and 69% of general physicians were from urban and 31% from rural areas. Sixty-two per cent of ophthalmologists, 66% of general practitioners and 54% of general physicians
Per cent of respondents and course duration advocated* Per cent of respondents
Course duration (weeks) 1 2 3 4 5 6
Study design The questionnaire asked if the undergraduate course should be taught as a separate course, and if so how long it should be and whether it should include visits to operating theatre, eye casualty, and the optician. Doctors were also asked to choose five from 13 topics (see Figure 1). The questionnaire used a totally forced answer format, so that the data received could be easily tabulated and statistically analysed. The questionnaire was designed as simply as possible to maximise the postal reply rate. All statistics used in this study were calculated using the Chi-square test.
Ophthalmologists
General practitioners
General surgeons
General physicians
4.8% 19.4% 9.7% 22.6% 1.6% 19.4% 0 12.9% 3.2% 4.2
0 18.7% 9.4% 32.8% 1.6% 9.4% 0 20.3% 6.2% 4.8
6.7% 23.3% 6.7% 23.3% 0 20.0% 0 10.0% 0 3.7
17.9% 20.5% 7.7% 30.8%
2.6%
5.1% 0 7.7% 5.1% 2.9
*Not all respondents answered this question.
Ophthalmology in the undergraduate curriculum
299
50 Ophthalmologists 40
General Practitioners
30 Surgeons
20 10
Physicians
%
Variance 0
- 10
- 20 - 30 - 40
I Trauma Cataract Glaucoma Squint
lnfeclioi
Neura- Tumours Retinal Vascular Iphthalmalogy
Figure 2 Course content
-
Ophthal-
eration
Oplics
Acute VwaI
Red
Eye
Lass
response as a percentage variance from random.
thought ophthalmology should be taught as a separate subject, but only 38% of general surgeons thought this to be the case. The distribution of the length of time of the ophthalmology course is shown in Table 1. A mean choice for each specialty group was calculated and it showed that ophthalmologists suggested a 4.2 week course, general practitioners a 4.8 week course, general surgeons a 3.7 week course and general physicians a 2.9 week course. (Table 1). Seventy-three per cent of ophthalmologists, 86% of general practitioners, 72% of general surgeons and 74% of general physicians thought visits to the operating theatre should be included in the course. All groups were 97% or greater in agreement that sessions in eye casualty would be of some benefit. However, only 20% of ophthalmologists considered sessions with an optician necessary whereas 83% of general practitioners, 69% of general surgeons and 79% of general physicians thought such sessions should be included in the course (P< 0.05). Figure 1 shows the percentage responses of the groups as a whole as to which areas in the course should receive more emphasis. The areas of trauma, glaucoma, squint, infection, use of an ophthalmoscope, acute loss of vision, and the red eye were considered to be essential, by more than 50% of respondents. 300
Retinal
Degen- moscope
In order to determine any differences between groups as to where they considered the emphasis should be placed, each course area was examined individually. At the P< 0.05 significance levd ophthalmologists considered infections not as essential as the other groups. General surgeons considered cataracts, retinal vascular disorders and acute visual loss to be not as essential as the other groups. General surgeons and general physicians also considered squint to be not as essential as did ophthalmologists and general practitioners. General physicians considered neuro-ophthalmology more essential than did the other groups. Finally, general practitioners and general physicians considered optics to be more essential than did ophthalmologists and general surgeons. To determine subject priorities, respondents were asked to choose five topics from the 13 listed. If the respondents’ choices had been random, Vernon4, states that 38.5% of respondents would have chosen each topic. Therefore, in order to compensate for random selection the results are presented as a percentage above or below that expected if the selections were at random (Figure 2). At the P < 0.05 significance level, the opinion of ophthalmologists differed from those of the general practitioners, general surgeons and general physicians on squints, while the opinions of the Australian and New Zealand Journal of Ophthalmology 1992; 20(4)
general practitioners and general surgeons differed from those of the ophthalmologists and general physicians on infections. The rankings provided six areas which were considered to be priorities: trauma; glaucoma; infection; use of an ophthalmoscope; acute loss of vision; and the red eye.
Discussion Currently in Queensland, only three and a half weeks of the medical course or 3% of the clinical years is devoted to teaching ophthalmology and within this three and half weeks the teaching is equally distributed amongst ophthalmology and otolaryngology, effectively reducing the ophthalmological content to less than 2% of the clinical years. In our study ophthalmologists, general practitioners and general physicians were all of the opinion that it should be taught as a separate subject; only the general surgeons felt it should remain as it does, a combined subject with otolaryngology taught within the discipline of surgery. Both ophthalmologists and general practitioners agreed that the amount of time allocated to ophthalmology solely in the current curriculum should be extended up to 4.2 and 4.8 weeks respectively. The fact that general surgeons did not consider that the time should be increased and that general physicians considered it should be reduced (Table l), highlights the problems faced by the minor specialties when they are under-represented on curriculum design board^.^ The results of this study can be used to support a case for increased allocation of time to ophthalmology teaching. However, the call for increased student knowledge, coupled with the fact that the undergraduate medical curriculum has a finite time limit makes a request for increased time allocation to ophthalmology unlikely to be successful. More efficient variation on traditional teaching methods may then be needed to compensate for the restricted time available. Discussion of this area is beyond the scope of this study. Waring et al." and Phillips et a l l 2 have considered this in respect of ophthalmology with encouraging results. All of the groups agreed that visits to the operating theatre and sessions in an eye casualty unit would be advantageous to the student. The former is not included in the present curriculum. It is apparent that all groups consulted felt it would be advantageous for medical graduates to have an overview of surgical techniques to enable them to Ophthalmology in the undergraduate curriculum
assist their patients preparing for such surgery. Evidence for the difference of opinions of the four groups as to whether optics should be included in the curriculum was highlighted by the opinions of the general practitioners and general physicians who considered optics to be more essential than the ophthalmologists and general surgeons. This may reflect the fact that ophthalmologists integrate optics as a subtopic of ophthalmological and systemic disease whereas the former two groups see a less distinct connection between optics and ophthalmological and systemic disease. Only 20% of ophthalmologists thought a session with an optometrist would be of some benefit; the other groups were strongly in favour of such a visit. Vernon4 obtained similar results and concluded that some ophthalmologists may not consider a session with an optometrist important as they teach students what they need to know about refractive errors and optics. The opinion of general practitioners, general surgeons, and general physicians would highlight the fact that this area of ophthalmology is not covered adequately at present and the role of the ophthalmologist is not fully understood by other medical disciplines. This suggests an increased emphasis on refractive errors, optics and visual aids should be included in the curriculum, together with appropriate instruction of the roles of the ophthalmologist and optometrists in the management of the related conditions. This should be beneficial in aiding future general practitioners, as the provider of primary health care, in determining appropriate management of their patients. Using Vernon's expanded list of 134 we found seven areas were considered to be an essential part of student training (Figure 1). These areas included: trauma; glaucoma; squint; infection; use of an ophthalmoscope; acute loss of vision; and the red eye. General surgeons considered cataracts, retinal vascular disorders and acute visual loss not to be essential knowledge, and along with the general physicians thought squint not to be important; in contrast to ophthalmologists and general practitioners. This situation could reflect the concern of ophthalmologists and general practitioners that certain conditions have a potential to be reversed and visual loss prevented. It is likely that if paediatric physicians had been included in the survey, the importance of strabismus would have been recognised by that group as it is an important condition in childhood. 301
The fact that the general physicians considered neuro- ophthalmology as more essential than the other groups may be attributed to their involvement with complex neurological problems, which may frequently have a neuro-ophthalmological component. In Figure 2 it can be seen that the areas requiring most emphasis in the course are: trauma; glaucoma; infection; use of an ophthalmoscope; acute visual loss; and the red eye - a pattern similar to that in Figure 1, except for the area of squint. Ophthalmologists differed from the other groups solely in the area of squint. This is identical to Vernon’s4 findings and he postulated that this reflects the ophthalmologist'^ concerns for pot en t iall y preventable visual loss. This major difference in opinion would suggest the need to further stress the importance of strabismus in the curriculum as a condition that can cause permanent loss of vision or be evidence of major pathology. General practitioners and general physicians also differed in opinion to other groups on infections and this may represent again an area in which they are involved in their daily practice. Five to 19 per cent of all primary health care patients have eye-related condition^.^ The results illustrated in Figures 1 and 2, coupled with support for sessions in an eye casualty unit, indicate the topics involving acute primary care and screening are preferred to those relating to more chronic or rarer conditions. These were also the findings of Vern~n.~ One of our aims was to compare this study with the one undertaken by Vernon in the United Kingdom in 198tL4As stated there is a very close correlation regarding sessions with an optician. Both studies support the teaching of ophthalmology as a separate subject, and that the course should be longer. However, in our study the mean lengths chosen by ophthalmologists and general practitioners, 4.2 and 4.8 weeks respectively, were lower than the 5.0 and 5.35 weeks recommended in Vernon’s study. Sessions in an eye casualty unit and the operating theatre are shown to be considered advantageous to the student in both studies. Differences were noted between the two studies only in the area of retinal vascular disorders. Our study considered this area not to be essential, whereas that of Vernon considered it to be so. The large degree of similarity between the two studies highlights the fact that doctors in various parts of the world and in various specialty groups consider the student should be well equipped to deal with those problems commonly seen by the 302
providers of primary health care in the area of ophthalmology.
Conclusion The study reveals that there is substantial agreement as to what should form the basis of the undergraduate medical curriculum in ophthalmology in Queensland. Previous studies in which the broad-based questionnaire was used show a similar situation in other areas throughout the WOrld~3.4.10.17.18 It is the opinion of many that the ophthalmology course in Queensland should be taught as a separate discipline and the time currently allocated to it lengthened. Given time constraints, the use of different and possibly more efficient teaching methods should be explored. It is a general consensus that the course should include visits to the operating theatre and eye casualty unit and knowledge of those core areas that are involved in acute primary care, namely trauma, glaucoma, infection, use of an ophthalmoscope, acute loss of vision and the red eye. Recommendations from the various individual groups also see the necessity for increased teaching of optics, refraction, visual aids, and squint. A study such as this creates much debate. The problem of whether to prepare the student for postgraduate training or independent practice will continue to arise. We must emphasise that ophthalmology plays a vital role in many acute primary health care situations. Sufficient time and quality teaching in the most important areas must be a priority in an undergraduate ophthalmological course to allow a medical graduate to practise at a competent level.
References 1. Crombie AL. Ophthalmology in the undergraduate curriculum. Trans Ophthalmol SOCUK 1976;96:33-4. 2. Dias PLR. An evaluation of the undergraduate teaching programme in ophthalmology in Sri Lanka and Malaysia. Med Educ 1987;21:334-9. 3. Spivey BE. Ophthalmology in medical student education: philosophy, content, and process. Ophthalmology 1978;85: 1299-311. 4. Vernon SA. Eye care and the medical student: where should the emphasis be placed in undergraduate ophthalmology? J Roy SOCMed 1988;81:335-7. 5. Moriarty BJ. Ophthalmology in Jamaica. Arch Ophthalmol 1988; 1061557-8. 6. Maumenee AE. The educational and political structure of ophthalmology in America. Arch Ophthalmol 1967;77:295-304. 7. Crombie AL. Minimum requirements for the undergraduate curriculum. Trans Ophthalmol SOCUK, 1980;100:311-12. Australian and New Zealand Journal of Ophthalmology 1992; 20(4)
8. Archer DB. The seed-corn. Trans Ophthalmol SOCUK 1985;105:211-17. 9. Kalina RE, Van Dyk HJ, Weinstein GW. Ophthalmology teaching in medical schools. J Med Educ 1981;56: 143-5. 10. Spivey BE. A technique to determine curriculum content. J Med Educ 1971;46:269-74. 11. Waring GO, Harris R, Walters RF, Berris C. Clinical ophthalmology instruction for medical students. Surv Ophthalmol 1977;22: 106-12. 12. Phillips CI, Bartholomew RS, MacMichael IM. Tapelslide course in ophthalmology for undergraduates. Br J Med Educ 1975;9:231-5. 13. Archer DB. Undergraduate ophthalmology: The practice of teaching. Trans Ophthalmol SOCUK 1980;100:313-14. 14. Spivey BE. Ophthalmology for medical students: content and comment. Arch Ophthalmol 1970;84:368-75.
15. Haining WM. Symposium on the teaching commitment in ophthalmology. T r a n s Ophthalmol SOC UK 1980; 100:309-10. 16. Education in ophthalmology in North America. Br J Med Educ 1967;l: 119-26. 17. McCarthy WH, Donaldson EJ, Hollows FG. What should we teach? A consensus method to determine curriculum content. Med Educ 1977;11:249-56. 18. Worthen DM. Ophthalmology for medical students: Objectives. Arch Ophthalmol 1972;88:314-20. 19. Spivey BE, Gamble L. Ophthalmology: What do we need to know? Am J Ophthalmol 1987;103(4):586-9. 20. Harvey JT, Chong JP, Neufeld VR, Slackett DL, Oates MJ. Ranking clinical problems and ocular diseases in ophthalmology: an innovative approach to curriculum design. Can J Ophthalmol 1988;23:255-8.
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