Keywords
technology - curriculum - medical student education - surgical curriculum - surgical
teaching - ophthalmology rotation - surgical skills
Virtual medical education (VME) is a term that includes asynchronous instruction,
telemedicine, video libraries, and conference records, among other methods.[1] While VME approaches have steadily increased in medical schools across the United
States in the last two decades, the onset of the coronavirus disease 2019 (COVID-19)
pandemic catalyzed an even faster transition, as educators attempted to find ways
to minimize interruptions to medical education while maintaining or improving educational
goals. Many medical schools now utilize asynchronous instruction that allows students
to view and work at their own pace during didactic education, as well as employ surgery
libraries to allow exposure to surgical procedures and techniques.[2]
[3] Some schools have even developed remote methods for observing technical skills practiced
at home via GoPro video recordings.[4]
In fields such as surgery,[5] dermatology,[6] and rheumatology,[7] virtual consults through telemedicine have not only allowed safe, effective patient
care, but have also facilitated educational instruction during the time in which our
world has been affected by the COVID-19 pandemic.[8] These methods have also allowed students to contribute to the pandemic response.
For example, at some medical institutions, medical students have helped to relieve
clinical workloads by fielding virtual video-based triages for patients presenting
to the emergency department.[9] In addition to benefiting students and educators, patients report being particularly
receptive to the use of technology in their care in an academic setting.[6]
The American University Professors of Ophthalmology and American Academy of Ophthalmology
(AAO) recently published a white paper detailing medical student ophthalmic learning
objectives, which revolve around the basic understanding of different ophthalmic diseases.[10] The ability to meet those learning objectives was challenged in March of 2020, when
medical student clinical rotations were suspended following the recommendation of
the Association of American Medical Colleges in response to the COVID-19 pandemic.[11] Following this recommendation, most institutions highly discouraged or even prohibited
in-person away rotations due to public health concerns for a significant period of
time. This caused a reduction in direct medical student exposure to patients and posed
a challenge to ophthalmic education. Thus, with the understanding that the privilege
of in-person education can be interrupted by such adverse circumstances, it is now
more important than ever for innovations that increase student exposure to ophthalmology
and refine virtual teaching methods.
A review of virtual teaching resources for ophthalmology indicates that there is a
wide variety of methods available or in development.[12] These include online learning modules, video tutorials teaching clinical skills,[13] virtual reality tools,[14] and simulated eye conditions on virtual patients.[15] Although these methods are beneficial to student education, none can replicate the
interaction with real patients, observation of surgeries and physical exam techniques,
and support and mentorship that are integral to in-person ophthalmology rotations.
Many programs are adapting by creating virtual elective rotations to fill these gaps.[16]
[17]
[18] These virtual electives have allowed for medical student exposure to specialty care
during the COVID-19 pandemic, with the additional benefit of reducing personal protective
equipment use and exposure to the virus.[19]
Virtual rotations have the potential to benefit medical students and programs by improving
access to and reducing costs of medical education, even beyond the pandemic. One possible
realization of this potential would be the creation of virtual away rotations. Surveys
have found that 70 to 90% of ophthalmology residency applicants participate in at
least one away rotation, and the estimated cost of a single away rotation in ophthalmology
ranges from $990 to $1,700.[20]
[21]
[22] This cost can be prohibitive and likely disproportionately impacts students with
limited financial resources. Saving on housing, transportation, and cost of living
with virtual away rotations would reduce student debt as well as financial barriers
to entering ophthalmology.[21] Reducing these barriers may ultimately have an impact on the diversity of applicants
who choose to pursue this profession.
Another potential benefit of virtual electives is improved educational access. Although
there are over 180 allopathic and osteopathic medical schools in the United States,[11] there are less than 120 ophthalmology residency programs in the country. Students
at schools without a home ophthalmology program would benefit from a virtual rotation
elsewhere. In addition to facilitating away rotations, virtual rotations may also
increase the number of students that can rotate on a service at any given time, thus
allowing students at a home program to attend grand round conferences, participate
in telemedicine, or virtually attend clinic and surgical operations.[23] By increasing the number of students who can participate in an ophthalmology rotation,
virtual rotations could also increase exposure to ophthalmology among students who
do not pursue a career in the field. This would be beneficial because it has been
shown that limited ophthalmic education in medical school increases the likelihood
of future medical mismanagement and overreferral of simple eye disorders.[24]
[25]
Finally, ophthalmology as a specialty often struggles to recruit a diverse student
body to their residency classes.[26] The reasons for this are multifactorial but often have to do with limited exposure
to the specialty in the preclinical and clinical years of medical training. The use
of virtual rotations has the potential to introduce ophthalmology to a wider student
body at an earlier time in their clinical training.
In addition to the value provided to students, virtual rotations have the potential
to help academic ophthalmologists make informed decisions regarding the match process.
As in other surgical fields, over 50% of students matched at a program where they
completed an away rotation.[27] For instance, in the otolaryngology residency process, one of the three criteria
regarding candidate selection included rotation at that specific institution.[28] Similarly, in plastic surgery, interactions with residents and faculty was the single
most important activity to candidates.[19] A virtual curriculum in ophthalmology may allow increased time between students,
residents, and faculty, allowing all stakeholders in the match process to better determine
the fit for a particular program.
In this article, we detail the development of a virtual ophthalmology rotation piloted
at the University of Maryland School of Medicine. It is our hope that this virtual
rotation will not only serve a purpose during the COVID-19 pandemic and expand VME
in the field of ophthalmology, but introduce a strategy with long-lasting benefits,
and contribute to the body of teaching strategies for medical educators across disciplines.
Setting
A 4-week ophthalmology elective was designed at the University of Maryland School
of Medicine Department of Ophthalmology and Visual Sciences. Our unique curriculum
incorporates mobile-mounted tablets, allowing students to virtually participate in
inpatient consults, outpatient clinics, and ophthalmic surgery. An adaptable mounting
device attached to the slit lamp allows students to observe examinations in real time,
enhancing recognition of ocular pathologies. Students participate in a robust curriculum
that includes independent learning modules, video lectures, interactive modules, podcasts,
and surgical video rounds. Students engage with residents and faculty in interactive-guided
lectures and case-based discussions that focus on the AAO white paper teaching objectives.
Students are mailed surgical instruments and participate in prerecorded surgical modules
and faculty-led virtual wet laboratories.
Results
In the following sections, each component of the virtual curriculum will be described
individually. To see a sample full week schedule of a virtual student, please see
[Table 1]. Prior to the start of the elective, faculty were instructed via virtual preparation
sessions to teach students during clinical and surgical encounters as if they were
present in person. At this time, they were also briefed on expectations regarding
presentation of virtual teaching and wet laboratory sessions.
Table 1
Sample weekly schedule
|
Monday
|
Tuesday
|
Wednesday
|
Thursday
|
Friday
|
|
7–8 a.m.
resident lecture
|
7:30–8:30 a.m.
grand rounds
|
7–8 a.m.
resident lecture
|
7–8 a.m.
resident lecture
|
|
|
8:30–9 a.m. chair rounds
|
|
|
|
|
8 a.m.–12 p.m. independent learning
|
9 a.m.–12 p.m. independent learning
|
8 a.m.–12 p.m.
independent learning
|
8 a.m.–12 p.m.
independent learning
|
8 a.m.–12 p.m.
independent learning
|
|
|
12 p.m.–1 p.m.
resident led lecture
|
12 p.m.–1 p.m.
interactive faculty teaching session
|
12 p.m.–1 p.m.
interactive suture laboratory
|
|
1–4 p.m.
live virtual clinic
|
1–4 p.m.
live consult rounds
|
1–4 p.m.
live virtual clinic
|
1–4 p.m.
live consult rounds
|
1 p.m.
surgery observation
|
Mobile Virtual Rounding
The ophthalmology department works closely with the clinical mobility team to utilize
mobile iPad devices with secure Health Insurance Portability and Accountability Act
of 1996 compliant networking to allow virtual students to observe consults in the
hospital by logging into a Zoom session ([Fig. 1]). Zoom is a popular cloud-based teleconferencing app that allows users to connect
online for video and telephone communications. The students can see and hear the environment
projected to them from the iPad camera and speakers, and they are visible and audible
to faculty and patients via the video and audio transmitted from their computer or
mobile device. The mobile iPad devices are wheeled with the consult team around the
hospital in a variety of settings, including the pediatric and adult emergency department,
inpatient services, and the shock trauma center, allowing virtual students to accompany
faculty and residents. To simulate an in-person learning environment, students observe
as residents obtain a detailed history and differential diagnosis and verbalized physical
exam findings to allow medical students to come up with assessments and plans in real
time ([Fig. 2]). Students also participate in attending staffing of consults and actively contribute
to clinical discussions.
Fig. 1 Mobile iPads were allowed students to virtually attend consults throughout the hospital.
Fig. 2 Residents verbalized physical exam findings to allow virtual students to come up
with live-time assessment and plans for patient.
Virtual Clinic
Once again, mobile tablets (iPads) are utilized to allow students to participate in
clinical encounters at general ophthalmology and various subspecialty clinics by connecting
them via Zoom. Subspecialty clinics include glaucoma, retina, cornea, uveitis, neuro-ophthalmology,
pediatric, and oculoplastics. During both faculty and resident clinics, the mobile
iPads are wheeled to each patient room and virtual students are introduced to the
patients. The students can then take histories from patients and present to the attendings
or residents, thus actively participating in patient care. Additional learning opportunities
are facilitated by virtual students asking residents and attending faculty questions
throughout clinical encounters ([Fig. 3]), as well as faculty pointing out interesting exam findings which can be viewed
by slit lamp-mounted devices that share the image directly to the virtual video platform.
These devices allow in-person students ([Fig. 4]) and virtual students to observe physical exams simultaneously ([Fig. 5]).
Fig. 3 Virtual students were able to observe clinical encounters in the clinic.
Fig. 4 Both in-person and virtual students were able to watch slit lamp examinations simultaneously.
Fig. 5 Slit lamp images allowed students to visualize different eye pathologies. Cell phones
used Zoom “screening-sharing” feature so all virtual students were able to observe
through teaching scope.
Live Surgical Observation
In addition to watching surgical video libraries and participating in discussions
of challenging resident surgical cases during departmental chair rounds, virtual students
participate in remote surgical observation over the course of the rotation, typically
one-half session per week. The mobile tablet allows virtual students to view video
screens situated within the operating room throughout surgery and to engage with residents
and attendings in real time during surgery ([Fig. 6]).
Fig. 6 iPad devices were placed to allow students to view surgeries in real time in the
operating room. Devices were also placed close enough to allow engagement between
the virtual students, residents, and attending physicians.
Independent Learning
Throughout the course of the month, students are assigned both a combination of readings
on basic ophthalmology, as well as video lectures and interactive content.
Required readings are taken from the book “Basic Ophthalmology for Medical Students”
by Cynthia A. Bradford, and include topics such as eye examinations, acute and chronic
vision loss, neuro-ophthalmology, and eyelid, orbital, and lacrimal disease.[29] Other supplementary readings are also provided and are often interactive in nature
as discussed below.
Video lectures range from 8 to 35 minutes and are assigned throughout the rotation.
During the first few weeks of lectures, videos focus on eye anatomy, basic eye, and
slit lamp examinations and optics. As the course progresses, video lectures include
more in-depth pathophysiology, including pediatric ophthalmology, leukocoria, retinoblastoma,
diplopia, and cranial neuropathies.
Interactive content is also utilized throughout the rotation, and includes online
anatomy quizzes, AAO case studies,[30] and eye cases from the ophthalmology department at Indiana University.[31] Finally, students listen to the “Eyes for Ears” podcast throughout the rotation
and write up mock patient notes based on online cases.[32] Every month, feedback from students is elicited to help determine any updates to
the online content as necessary to maximize their online experience ([Fig. 7]).
Fig. 7 Example of curriculum portion for independent learning during virtual clinical elective.
Virtual Teaching Sessions with Faculty
Virtual students participate in interactive teaching sessions with faculty from various
subspecialists within the ophthalmology department. These teaching sessions are interactive
and allow students a more personalized experience with faculty. Topics include pediatric
ophthalmology, acute vision loss, chronic vision loss, oculoplastics, and neuro-ophthalmology.
Virtual Surgical Wet Laboratories with Faculty
Students are instructed on basic principles of ophthalmic surgery and suturing techniques
during faculty-led wet laboratories held on Zoom. Students participating in the virtual
rotation are mailed instrument sets which include single-use Westcott scissors, Castroviejo
needle holders, and 0.5 mm forceps purchased from Blink Medical along with materials
to practice suturing such as fabric with cut slits and foam packing peanuts ([Fig. 8]). Throughout the course of the rotation, students are assigned weekly wet laboratory
techniques to practice based on instructional videos, with the goal of gaining surgical
skills that students would develop in the operating room during an in-person rotation.
Students then receive suturing instruction from faculty members during the virtual
surgical wet laboratories to ensure proper technique and approach. Participants aim
the camera at their hands while suturing, while feedback and instruction is given
in real time.
Fig. 8 Wet laboratory kits were received by students and used for virtual suturing instruction.
Virtual Grand Rounds
Both the in-person and virtual students participate in weekly grand rounds. At the
conclusion of their rotations, all students perform a case presentation for faculty
and residents.
Conclusion
Virtual technologies can be utilized to enhance ophthalmology medical student education
in a safe and effective way during the COVID-19 pandemic and beyond. Independent study
materials allow students to learn at their own pace and build upon their foundation
of clinical knowledge, and mobile iPads allow them to apply this knowledge during
real patient encounters. The use of technology in the clinic, hospital consult service,
and the operating room greatly enhances the value of the rotation by allowing real-time
evaluation of patients, increased interactions with residents and faculty, and integration
of both an academic and clinical experience for the students. This technology can
be utilized in the future not only to help increase exposure to the field, but help
limit costs associated with traveling for rotations and create time-efficient opportunities
for students wishing to gain ophthalmologic clinical experiences.
The ability of this elective to expand the reach of ophthalmologic education is evidenced
by the fact that students applying into various specialties (Family Medicine, Pediatrics,
Internal Medicine, Obstetrics-Gynecology) and from all over the country (California,
Hawaii, and Puerto Rico) have successfully completed it since its inception. The rotation
has also been flexible enough to accommodate the various time zone differences these
students experienced. Additionally, this same technology and approach was used to
hold shadowing sessions with over 40 first- and second-year medical students interested
in ophthalmology, thus increasing early exposure to the field.
Upon completion of the rotation, students are encouraged to give feedback on their
experiences. Each month, the curriculum is updated to reflect feedback to improve
and strengthen the curriculum. In the future we plan to collect qualitative data on
the efficacy of this rotation on increasing interest and understanding of ophthalmologic
knowledge.
