Videotape versus live demonstration in enhancing the technique of DO 25

Videotape versus live demonstration in enhancing the technique and

confidence of direct ophthalmoscopy in undergraduate medical education: A
randomized controlled trial in a South Asian medical school
M. M. Dissanayake1, Y. Mathangasinghe2, D. N. Weerakoon2, W. D. D. Prasanni2

The Journal of the College of Ophthalmologists of Sri Lanka 2017; 23: 25-30

Abstract Introduction and objectives

Introduction and Objectives: Ophthalmoscopy is a core Ophthalmic evaluation is a core clinical skill that all
clinical skill. Our objective was to evaluate the effectiveness of the medical personnel should be competent in.
a videotape, a live demonstration and a combination of above, Prevalence of eye related conditions in primary care
in acquiring competence in Direct Ophthalmoscopy (DO) practice is very high with 5 to 19% of the patients
among medical undergraduates. presenting with an eye related complaint1. General
practitioners are the first line contacts of ophthalmic
Materials and Methods: A randomized controlled trial was emergencies. Thus they should be competent in
conducted among pre clinical medical students of University triaging and referring such emergencies to specialist
care efficiently2. Similarly, with an aging population,
of Colombo. Students were randomly allocated to three groups.
prevalence of conditions which lead to visual impair-
Group-V and Group-L were trained on DO for 20 minutes
ment such as cataract, glaucoma, diabetic retinopathy
using a videotape and by a live demonstration respectively. A
and age related macular degeneration are rising3.
third group (Group-VL) was trained with both methods for a
Impaired vision not only reduces the quality of life, but
total of 20 minutes. Videotapes were obtained while students
is a constant threat to life4. A prospective cohort study
performed DO on a simulated patient. Three blinded examiners concluded that the poor vision is an independent risk
assessed the recordings individually using the modified Queens factor for falls and hip fractures among geriatric
University Ophthalmoscopy OSCE checklist. Learning styles population5. Early detection of these conditions with a
were assessed using the VARK questionnaire. simple ophthalmic evaluation and timely referral in a
primary healthcare perspective has shown to improve
Results: A total of 106 students [37.7% (n=40) males] were patient outcomes6. Therefore it is quite reasonable to
assessed. The mean score of DO was (10.0±2.5)/14. Majority state that all the undergraduate students need an
were multimodal learners (61.3%, n=65). A two-way adequate training in Ophthalmology7.
ANOVA showed a statistically significant effect of teaching
method on performance score of DO [F(2,86)=7.024, p=.001, Unfortunately, over the last few decades, the time
partial η2=.140). Post-hoc comparisons indicated that mean allocated for ophthalmology teaching sessions in
scores for each group were significantly different: Group-V undergraduate curricula has reduced drastically3. A
(M=8.27, SD=2.07); Group-L (M=10.15,SD=2.32) and number of universities have completely cut-off
Group-VL (M=11.71, SD=1.47), p<.001. The interaction ophthalmology from the undergraduate syllabi8. This
effect for learning styles, F(4,86)=0.398, p=.810, did not reach has been mainly attributed to the time pressure in
teaching skills in a vastly evolving subject of
a statistically significant level.
Medicine9,10. Numerous studies have been carried out
worldwide to evaluate the outcome of this potentially
Conclusions: The live demonstration showed a better result
hazardous trend and the universal conclusion is that
than the video tape demonstration (p<.05). The combination the reduced ophthalmological exposure among
of video tape and live demonstration was significantly better undergraduates leads to low self confidence and poor
than the other two methods (p<.05). Their performance was knowledge in common ophthalmological conditions
not affected by learning styles. We recommend a combined among non-ophthalmological clinicians9, 11. Similarly,
approach as the preferred method of teaching DO to medical it has been shown that the patient outcomes have
undergraduates irrespective of their learning styles. worsened with poor undergraduate training in
ophthalmology3,9,12. Therefore it is essential to deliver
Key words: direct ophthalmoscopy, medical education, a focused training in Ophthalmology to medical
live demonstration, videotape students in a limited time frame.

Senior Lecturer, Specialist Ophthalmologist, 2Pre Intern Research Assistant, Department of Anatomy, Faculty of
1

Medicine, University of Colombo, Sri Lanka.

Vol. 23, No. 1, 2017

26

Over the last few years, experts in ophthalmology and approved by all the participating boards. The study was
medical education have initiated developing an conducted on the second year pre-clinical medical
integrated curriculum in Ophthalmology including the students. All the second year medical students were
core clinical concepts and minimum knowledge based invited for the study. None of them had received a
approaches to overcome the time constraints. Albeit the formal teaching on DO previously.
core knowledge expected from a graduate differs in few
aspects in these approaches, ophthalmoscopic The study instrument consisted of a self administered
examination is highly recommended virtually by all, questionnaire. This consisted of two parts. Part A
including the standards adopted by the Associations collected data on socio-demographic factors and
of University Professors in Ophthalmology and educational background of the students. Age, gender,
endorsed by the American Academy of Ophthalmology nationality, district of education, results of the end of
and International Council of Ophthalmology (13-15). first year medical school examination results and
handedness (right handed or left handed) were
A wide array of research has focused on various assessed in part A. Part B was used to assess the learning
techniques to teach Ophthalmoscopy to under- styles of the individual student which was a potential
graduates. Teaching Ophthalmoscopy to Medical confounder of the study. Visual Auditory Read/write
Students (TOTeMS) I & II trials have focused on fundal and Kinesthetic (VARK) questionnaire was used for this
photography and simulator based training to enhance purpose after obtaining the permission from the
these skills16. Simulators have been used widely in authors. VARK is a validated questionnaire which
research on ophthalmology teaching17-20. Despite recent assesses the predominant learning preferences based
advances in medical education field in Ophthal- on four sensory modalities: Visual, auditory, read/
moscopy, there is widespread evidence to suggest that write and kinesthetic. Visual learners prefer information
the medical students and junior doctors are not in maps, diagrams, charts or graphs etc. Aural or
confident and competent in this skill 11,21-23. Some auditory learners prefer information which is heard or
qualitative studies have shown that ‘not enough formal spoken. Read/write learners prefer information written
instructions’ is a major cause for the lack of Ophthal- as words. Kinesthetic learners prefer the use of
moscopy skills21,22. Conversely, medical students have experience and practice. [reference:web page]. There are
performed well after having given formal instructions24. also multimodal learners who have a mixture of
But after an extensive literature survey using web based preferences with no predominant learning style.
search engines like Google Scholar, Pubmed, MEDLINE
and a manual search at Postgraduate Institute of The study population was randomly allocated into
Medicine, Sri Lanka, we could not find research which three groups using simple random sampling method
addressed how the different approaches of delivering with computer generated random numbers. The three
formal instructions affect the individual’s performance groups were names Group V, Group L and Group VL.
at Ophthalmoscopy. Finding out simpler methods Group-V was trained on DO for 20 minutes using a
instead of high fidelity simulation methods to enhance videotape. The video is freely available on and
the undergraduate training of Ophthalmoscopy would reproduced with the permission from the authors. The
be highly cost effective for the students in developing duration of the video clip was 10 minutes. Therefore it
countries like Sri Lanka. was looped twice during the given 20 minutes. The
audio track was narrated by a doctor in English and
To our knowledge, this is the first randomized con- subtitles were displayed to facilitate the understanding
trolled prospective study investigating the effect of two among local students. Group-L was trained on DO for
different simple teaching approaches in undergraduate 20 minutes using a live demonstration. Three medical
medical education: a videotape versus a live demons- doctors conducted the live demonstration sessions.
tration. We intended to evaluate whether a videotape, They were trained under a consultant Ophthalmologist
a live demonstration or a combination of above two is and pretested on three different occasions to ensure
more effective in acquiring competence and confidence homogeneity of the training methods prior to the study.
in direct Ophthalmoscopy (DO). The content of the training session was similar to the
video demonstration. A third group (Group-VL) was
trained with both methods for a total of 20 minutes. An
Materials and methods
abridged version of live demonstration was used
This randomized controlled trial was conducted in the without reducing the essential content. The video clip
Faculty of Medicine, University of Colombo, Sri Lanka was displayed only once for this group. In none of the
in May 2016. The study confirmed to the provisions of instances students were given the opportunity to
Declaration of Helsinki. The ethical approval was practice DO on themselves before the assessment.
obtained from the Ethics Review Committee, Faculty Students of each group were given a short duration to
of Medicine, University of Colombo. The study was make necessary clarifications after training.

The Journal of the College of Ophthalmologists of Sri Lanka

Videotape versus live demonstration in enhancing the technique of DO 27

Students were asked to perform DO on simulated Results

patients. The simulated patients were briefed by an
A total of 106 students were assessed. Mean age was
investigator before the study. Each student had to
22.2 ± 0.9 years. Of them, 37.7% (n=40) were males and
perform the examination in an isolated examination
room with adequate lighting. Videotapes were obtained 62.3% (n=66) were females. Majority (94.3%, n=100)
from two different angles using high definition cameras were Sri Lankans while six students (5.7%) were
during the examination. Audiotapes were also obtained Bhutanese. None of them used English as their first
to assess the commands given by the students to the language.
patients. There was no time restriction for the exami-
nation. The video and audio tapes were coded and Five students had not filled the VARK questionnaire
digitally processed afterwards. Three blinded exami- properly and one student had not returned the
ners assessed the recordings individually using the questionnaire. Therefore the learning styles were
modified Queens University Ophthalmoscopy OSCE analyzed only among 100 students. Majority were
checklist (performance score). This was a validated multimodal learners (61.3%, n=65) followed by aural
checklist and the scores derived from the checklist (14.2%, n=15), kinesthetic (10.4%, n=11), read/write
directly correlated the ability of a candidate to correctly
(4.7%, n=5) and visual (3.8%, n=4). Sub group analysis
identify retinal pathology (reference). The original
of learning styles based on the affinity of the particular
checklist included 13 weighted items. The total marks
style (e.g. mild aural, moderate aural and severe aural)
allocated for the checklist was 24. But focusing on the
retina, optic disc and following the vessels from the disc was not performed due to small number of the
could not be assessed in our setting with the given population.
facilities. Similarly since the study population was pre-
clinical, they were not familiar with introducing self and The compositions of the three study groups (group-V,
gaining consent. The videotape also did not emphasize group-L and group-VL) are shown in Table 1. The
consent taking procedure. Thus four questions were distribution of different learning styles among three
withdrawn from the original Queens University study groups is further elaborated in Figure 1. The
Ophthalmoscopy OSCE checklist. Total mark (1 mark) mean score of DO was (10.0 ± 2.5) /14. Inter observer
allocated for focusing on the macula was given if the correlations of the performance scores were calculated
student asked the patient to look at the light source. using Kendall’s tau correlation coefficients. There were
The total marks allocated for the modified Queens strong positive correlations among all three examiners
University Ophthalmoscopy OSCE checklist was 14. (p<.01). The results of these correlations are sum-
The modified version of the Queens University
marized in Table 2. The mean scores were distributed
Ophthalmoscopy OSCE checklist was validated after
among the three groups as follows: The group which
pretesting by a consultant ophthalmologist, five doctors,
was trained only by the video (Group-V) scored the
five final year medical students and five third year
medical students. Three blinded examiners assessed lowest marks (M=8.27, SD=2.07). The group which
the video clips in order to validate the checklist. The underwent the training based on the live demonstration
internal consistency of the checklist (as measured by (Group-L) scored better than Group-V (M=10.15,
Cronbach’s alpha) was .87. SD=2.32). The highest score was seen among the group
which underwent both video and live demonstration
Same three blinded examiners assessed the videotapes (Group-VL) (M=11.71, SD=1.47). The results of the
of individual student and scored on the modified performance scores of DO are summarized in Figure 2.
Queens University Ophthalmoscopy OSCE checklist. A two-way between groups analysis of variance
If there was a discrepancy of more than three marks (ANOVA) was conducted to assess the effect of teaching
between two examiners, the video clips were method on performance score of DO. Preliminary
reassessed. The average mark of the three examiners studies were conducted to ensure the assumptions of
was calculated. normality (Shapiro-Wilk test) and homoscadasticity.
There was a statistically significant main effect of
Statistical analysis teaching method on performance score of DO [F(2,86)
=7.024, p=.001]. According to Cohen (1998) criterion,
Standard descriptive statistics were used to analyze and
describe socio-demographic data. A two-way ANOVA there was a large effect in our study (partial η2=.140).
was used to assess if there was a statistically significant Post-hoc comparisons using Turkey HSD indicated that
effect of teaching method on performance score of DO mean scores for each group were significantly different:
after controlling for the interaction effect for learning Group-V (M=8.27, SD=2.07); Group-L (M=10.15, SD
styles. All analyses were conducted on Statistical =2.32) and Group-VL (M=11.71, SD=1.47), p<.001. The
Package for Social Sciences (SPSS) version 22 with a interaction effect for learning styles, F(4,86)=0.398,
priori alpha of .05 p=.810, did not reach a statistically significant level.

Vol. 23, No. 1, 2017

28

Table 1. Composition of three study groups (Group V – Video only, Group L – Live demonstration only,
Group VL – Video and live demonstration). Please note that the learning styles of 6 students are missing

Group V Group L Group VL

Sample size 39 29 38
Mean age (SD) in years 22.1 ± 0.8 22.3 ± 0.7 22.0 ± 1.0
Gender Male 12 16 12
Female 27 13 26
Nationality Sri Lankan 37 28 35
Bhutanese 2 1 3
Learning Style Visual 1 1 2
Aural 3 5 7
Read/write 4 0 1
Kinesthetic 4 3 4
Multimodal 26 19 20

Figure 1. Distribution of different learning styles among three study groups.

(Group V– Video only, Group L – Live demonstration only, Group VL –Video and live demonstration).

Table 2. Kendall’s tau correlations between the performance scores of DO by each examiner

Scale Examiner 1 Examiner 2 Examiner 3

Examiner 1 - .775** .837**

Examiner 2 - - .778**
Examiner 3 - - -

**p<.01 (2-tailed)

The Journal of the College of Ophthalmologists of Sri Lanka

Videotape versus live demonstration in enhancing the technique of DO 29

Figure 2. Boxplot diagram of performance scores of Direct Ophthalmoscopy among three

different groups. (Group V – Video only, Group L – Live demonstration only, Group VL – Video
and live demonstration). The highest possible score is 14.

Annexures

Annexure 1: Queens University Ophthalmoscopy Objective Structured Clinical Examination checklist (the original
version). The stems which were not included in the modified version are shown in italic form.

Direct ophthalmoscopy technique checklist (point value in brackets) Done correctly ()

Introduces self, gains consent (1) ……….

Uses right eye/hand to examine patient’s right eye (and vice versa) (3) ……….
Turns ophthalmoscope on (1) ……….
Checks beam size and brightness (1) ……….
Begins ~40 cm from patient at 15° lateral to the patient’s line of vision (1) ……….
Advises patient to fixate on a spot on the wall (1) ……….
Keeps both eyes open while examining the patient (1) ……….
Finds the red reflex and follows it in (2) ……….
Appropriate proximity to the patient (3) ……….
Focuses the ophthalmoscope (3) ……….
Focuses on optic disc (3) ……….
Follows the vessels from disc (2) ……….
Focuses on macula (1) ……….

Vol. 23, No. 1, 2017

30

Discussion curriculum: reestablishing our value and effecting change.

Ophthalmology 2009; 116(7): 1235-6. e1.
In this randomized controlled trial, we compared two
methods, i.e. a videotape, a live demonstration and a 9. Clarkson JG. Training in ophthalmology is critical for all
combination of both to teach Direct Ophthalmoscopy physicians. Archives of Ophthalmology 2003; 121(9): 1327-
to medical undergraduates. We found that the group 10. Jacobs DS. Teaching doctors about the eye: trends in the
which underwent live demonstration showed a better education of medical students and primary care residents.
outcome than the group that underwent video tape Survey of Ophthalmology 1998; 42(4): 383-9.
demonstration (p<.05). The performance scores of the 11. Shuttleworth G, Marsh G. How effective is undergraduate
group that underwent the combination of video tape and postgraduate teaching in ophthalmology? Eye 1997;
and live demonstration was significantly better than the 11(5): 744-50.
other two groups (p<.05). Students' performance was
12. Stern GA. Teaching ophthalmology to primary care
not affected by their preferred learning styles
physicians. Archives of Ophthalmology 1995; 113(6): 722-4.
irrespective of the training method they underwent.
13. ICO. Principles and Guidelines of a Curriculum for
This randomized controlled trial was conducted in a Ophthalmic Education of Medical Students 2010 [updated
single centre. Multicentric studies among different 13 May, 2010; cited 2016 20 Feb]. Available from: http://
www.icoph.org/resources/15/Principles-and-Guidelines-
ethnicities may be necessary for global inferences. Here
of-a-Curriculum-for-Ophthalmic-Education-of-Medical-
we only assessed the technique of DO. Due to the lack
Students.html.
of resources we could not assess whether the students
directly visualized the retina. Since this is the first 14. Core Knowledge Skills White Paper | AUPO Medical
encounter of DO by the students, it was decided to Student Educators 2016 [cited 2016 20 Feb]. Available from:
http://www.aupomse.org/node/71.
concentrate only on the technique of DO.
15. The Royal College of Ophthalmologists. Undergraduate
We recommend a combined approach with videotapes Ophthalmology [cited 2016 20 Feb]. Available from: https:/
and live demonstrations to teach DO to medical /www.rcophth.ac.uk/training/undergraduate-
undergraduates irrespective of their learning styles. ophthalmology/#.
16. Kelly LP, Garza PS, Bruce BB, Graubart EB, Newman NJ,
Biousse V. Teaching ophthalmoscopy to medical students
References (the TOTeMS study). American Journal of Ophthalmology 2013;
156(5): 1056-61. e10.
1. Stark D, Beinssen A, Morrey C. Ophthalmology in the
undergraduate curriculum: A review in Queensland. 17. Benbassat J, Polak BC, Javitt JC. Objectives of teaching
Australian and New Zealand Journal of Ophthalmology 1992; direct ophthalmoscopy to medical students. Acta
20(4): 297-303. Ophthalmologica 2012; 90(6): 503-7.
2. Vernon S. Eye care and the medical student: where should 18. Dodaro NR, Maxwell Jr DP. An eye for an eye: a simplified
emphasis be placed in undergraduate ophthalmology? model for teaching. Archives of Ophthalmology 1995; 113(6):
Journal of the Royal Society of Medicine 1988; 81(6): 335-7. 824.
3. Succar T, Grigg J, Beaver HA, Lee AG. A systematic review 19. Hoeg TB, Sheth BP, Bragg DS, Kivlin JD. Evaluation of a
of best practices in teaching ophthalmology to medical tool to teach medical students direct ophthalmoscopy.
students. Survey of Ophthalmology 2016; 61(1): 83-94. Wisconsin Medical Journal (WMJ). 2009; 108(1): 24.
4. Freeman EE, Egleston BL, West SK, Bandeen-Roche K, 20. Miller D. A teaching eye model for ophthalmoscopy.
Rubin G. Visual acuity change and mortality in older adults. Academic Medicine 1981; 56(8): 671-2.
Investigative Ophthalmology & Visual Science 2005; 46(11):
21. Dalay S, Umar F, Saeed S. Fundoscopy: a reflection upon
4040-5.
medical training? The Clinical Teacher 2013; 10(2): 103-6.
5. Lord SR, Dayhew J. Visual risk factors for falls in older
22. Gupta R, Lam W-C. Medical students' self-confidence in
people. Journal of the American Geriatrics Society 2001; 49(5):
performing direct ophthalmoscopy in clinical training.
508-15.
Canadian Journal of Ophthalmology/Journal Canadien
6. Shah M, Knoch D, Waxman E. The state of ophthalmology d’Ophtalmologie 2006; 41(2): 169-74.
medical student education in the United States and
23. Noble J, Somal K, Gill HS, Lam W-C. An analysis of
Canada, 2012 through 2013. Ophthalmology 2014; 121(6):
undergraduate ophthalmology training in Canada.
1160-3.
Canadian Journal of Ophthalmology/Journal Canadien
7. Baylis O, Murray PI, Dayan M. Undergraduate d’Ophtalmologie 2009; 44(5): 513-8.
ophthalmology education-A survey of UK medical schools.
24. Cordeiro MF, Jolly BC, Dacre JE. The effect of formal
Medical Teacher 2011; 33(6): 468-71.
instruction in ophthalmoscopy on medical student
8. Mottow-Lippa L. Ophthalmology in the medical school performance. Medical Teacher 1993; 15(4): 321-5.

The Journal of the College of Ophthalmologists of Sri Lanka