Research Article

ISSN: 2574 -1241 DOI: 10.26717/BJSTR.2021.37.005968

Improving Undergraduate Ophthalmology Education

in the Time of COVID-19 Pandemic by Video-Assisted
Online Learning
Muhammad Syauqie* and Hendriati
Department of Ophthalmology, Faculty of Medicine, Andalas University, Indonesia
*Corresponding author: Muhammad Syauqie, Department of Ophthalmology, Faculty of Medicine, Andalas University,
West Sumatra, Indonesia

ARTICLE INFO ABSTRACT

Received: July 05, 2021 Introduction: The COVID-19 pandemic had forced many institutions to diminished
face-to-face teaching classes. We conduct an online teaching method through an
Published: July 15, 2021 e-learning platform during the pandemic to ensure that the students attain the basic
competencies. This study aimed to give an insight into the efficacy of online learning in
undergraduate ophthalmology education.
Citation: Muhammad Syauqie, Hendriati.
Improving Undergraduate Ophthalmology Methods: This was an interventional study in a university teaching hospital, and 64
Education in the Time of COVID-19 Pan- medical students participated in this study. The students were instructed to watch the
demic by Video-Assisted Online Learn- clinical skill video and make a case report through the e-learning platform. The students
ing. Biomed J Sci & Tech Res 37(2)-2021. completed the multiple-choice test and the student perception questionnaire during the
BJSTR. MS.ID.005968. online period. The students then continue to undergo two weeks of in-person clinical
clerkship, and at the end of the rotation, the students had an objective structured clinical
Keywords: Ophthalmology Education; examination test using simulated patients.
Video-Assisted Online Learning; Covid-19;
Blended Learning; I Learn Results: The mean score of multiple choice and clinical examination test was
72,50+12,54 and 89,80+6,66, respectively. There also improvement in knowledge and
skill about visual acuity and subject refractive examination at the end of the clinical
clerkship period. About 85.93% of students were satisfied with online learning
quality, but 95.31% of students stated that clinical skills were easier to understand if
demonstrated directly by the instructor.
Conclusions: This study results can encourage that video-assisted online learning
models can be useful as an adjunct for improving undergraduate students’ basic
ophthalmology skills before they entered clinical clerkship. Quality assurance of the
video resource should be done to ensure that students can achieve basic ophthalmology
competencies.

Introduction
to the misdiagnosis and mismanagement of ocular diseases and
The COVID-19 pandemic had given an immediate challenge
inappropriate referral to ophthalmologist [1,2]. This condition
to traditional undergraduate medical education methods, and
forced the need to develop virtual clinical learning. The online
in-person clinical clerkships, including ophthalmology rotation
learning method is not a substitute for traditional face-to-face
for medical students, had been suspended to prevent the threat
learning method and is not without its shortcoming, but it can help
of disease transmission. This rotation cancellation could lead
to ensure that the medical students would not lose their precious
to a lack of patient’s exposure and, eventually, inadequate
time and could continue with their academics in these uncertain
basic ophthalmology knowledge and clinical skills. The lack of
times [3,4].
ophthalmology case exposures in medical students will contribute

Copyright@ Muhammad Syauqie | Biomed J Sci & Tech Res | BJSTR. MS.ID.005968. 29232
Volume 37- Issue 2 DOI: 10.26717/BJSTR.2021.37.005968

Our university had developed an online learning platform university hospital wearing personal protective equipment,
named iLearn before the outbreak of COVID-19, but its use was which is mandatory. At the end of the ophthalmology rotation,
still limited. The COVID-19 pandemic then allows us to explore a the students undergo an objective structured clinical examination
new approach for teaching-learning techniques using this online (OSCE) test with the simulated patients, including visual acuity
learning platform. Adequate evidence-based research must be and subjective refractive examination. All data were collected and
provided to encourage the faculty to implement this alternative analyzed computerized using the descriptive statistic method. The
learning method during this pandemic period [5,6]. Therefore, authors then withdraw the conclusion from the result. This project
we conducted this study to evaluate the online learning method’s was deemed quality improvement and research ethics approval
effectiveness during the COVID-19 pandemic for undergraduate was waived.
medical students in ophthalmology clinical clerkships. This
Results
study will give an insight into the efficacy of online learning in
undergraduate ophthalmology education. The demographic data of the medical students are following.
Among 64 students, 52 were female (81,25%) and 12 were male
Methods (18,75%). The range of students ages was 19 years old to 28
This study was conducted from June to November 2020 at years old with a mean age was 22,66 years old. Assessment and
the Department of Ophthalmology of Faculty of Medicine Andalas evaluation of the online learning method are done by observing
University, Indonesia. This study design was an interventional the MCQ and OSCE test scores and the students’ perception
study. The online learning platform we used to conduct the online questionnaire results. By assigning this type of assessment, we
learning was the iLearn. This study enrolled 64 medical students can know the medical students’ level of basic knowledge and skills
who enter virtual clerkship in ophthalmology rotation during the in ophthalmology. Table 1 shows the mean score of the MCQ and
COVID-19 pandemic for about four weeks. The students had never OSCE tests Table 1. Mean score of multiple choice and objective
been undergone face-to-face clinical clerkship in the Department structured clinical examination test. From the test result, it can be
of Ophthalmology previously. Another inclusion criteria were seen that the students get good test scores both in MCQ and OSCE
clinical clerkship students who still registered as medical students tests. However, in the MCQ test, the knowledge about visual acuity
and clinical clerkship students who had iLearn platform personal and subjective refractive examination still poor, shown by the low
account. Exclusion criteria were clinical clerkship students who did mean score. Nevertheless, later in the OSCE test, the student’s skill
not complete the multiple-choice test and the student perception in visual acuity and subjective refractive examination had improved
questionnaire. a lot, shown by the increase of the mean score.

The students were instructed to enter the iLearn platform and Table 1: Mean score of multiple choice and objective structured
clinical examination test.
do several tasks, including watching the clinical skill video and
making a report about the case presented in the video, filling the Test Mean Score
multiple-choice question (MCQ) test and the student perception MCQ test 72,50 + 12,54
questionnaire through the iLearn platform. The clinical skill video Visual acuity and subjective refractive examination
55,55 + 22,20
topics include: score in MCQ test
OSCE test 89,80 + 6,66
a) Visual acuity examination and introduction of
Visual acuity and subjective refractive examination
ophthalmology examination tools. score in OSCE test
86,06 + 8,43

b) History taking and subjective refractive examination. Figure 1 shows the perception of the medical student about
c) Eyelid infection case presentation. online learning methods. From the questionnaire results, the
majority of the students agree that the videos were well-prepared,
d) Conjunctival infection case presentation.
and the contents were easily understood. The videos also help the
After watching the clinical skill videos, making the case students to achieve learning objectives in clinical ophthalmology
reports, and answering the multiple-choice test, the students fill a clerkship. However, some students prefer the face-to-face learning
questionnaire comprising ten questions about their perception of methods, especially in acquiring basic ophthalmology skills, with
online learning. After two weeks of online learning, the students the direct supervision of an ophthalmologist. A clinical skill directly
then undergo two weeks of in-person clinical clerkship in the demonstrated by the instructor will be easier to understand and
perform according to most students.

Copyright@ Muhammad Syauqie | Biomed J Sci & Tech Res | BJSTR. MS.ID.005968. 29233
Volume 37- Issue 2 DOI: 10.26717/BJSTR.2021.37.005968

Figure 1: Students’ perception about online learning.

Discussion Before the pandemic period, undergraduate ophthalmology

rotation took four weeks in our department. The learning-
The decline in undergraduate ophthalmology education
teaching process involves face-to-face case discussion and direct
level for medical students, which was further severed by the
observation of patient examination in the outpatient clinic. During
COVID-19 pandemic, could lead to a lack of essential basic skills in
the COVID-19 pandemic, the education process had shifted into
ophthalmology examination among medical students. The applied
half of online learning and half of in-person clerkship. This change
physical distancing and lockdown strategy had interfered with
is to reduce the number of students in our department where the
the learning-teaching process in most countries in the world. The
student’s group was split into halves so the physical distancing
medical students have been targeted to achieved some competencies
is still can be applied. This study result gives a promising result
in ophthalmology, but the current situation made it difficult because
about the implementation of online learning in undergraduate
there were diminished opportunities and times to encounter
ophthalmology education. Overall, both MCQ and OSCE tests show
real patients in the hospital. Modification of the ophthalmology
good mean scores of the students. A concern must be given to
teaching method must take place to accommodate this task within
basic ophthalmology skill which is more complicated for medical
a shorter period. The advancement of information technology had
students to master such as subjective refractive examination. In the
brought online learning as one of the best alternative teaching
online learning period, the students still difficult to comprehend
methods during this pandemic era to get sufficient competencies in
this issue, shown by a low mean score of the MCQ test (55,55 +
ophthalmic skills and knowledge [7-9].
22,20). However, after undergoing two weeks of in-person clinical

Copyright@ Muhammad Syauqie | Biomed J Sci & Tech Res | BJSTR. MS.ID.005968. 29234
Volume 37- Issue 2 DOI: 10.26717/BJSTR.2021.37.005968

clerkship in the university hospital, the skill of the students in provided by the instructor relative to student-selected materials
the subjective refractive examination had improved significantly. so the students can focus and concentrate on achieving the
Comprehensive management of simple refractive errors is one of learning objectives and clinical skills expected [15]. Computer-
the basic competencies in ophthalmic skill, which is mandatory assisted learning modules using virtual patients have been
to primary care physicians according to the National Standard of applied to enhance teaching and learning by allowing medical
Indonesian Medical Doctor Competencies [10]. Unfortunately, the students to sharpen their clinical reasoning skills by formulating
subjective refractive examination is quite difficult to master by the a diagnosis and treatment plan on virtual patients with simulated
medical students. This examination needs patience and repetitive eye conditions in a safe learning environment before practicing
practice in order to do it well and get an accurate refractive error on real patients. The application of virtual patients resulted in
measurement. Besides that, this examination needs a cooperative increased academic performance and sustained retention over
patient and does not enough by only watching an educational traditional teaching alone [16]. However, such particular skills,
video. In the in-person clinical clerkship period, the students such as refractive error correction and direct ophthalmoscopy,
had an opportunity to practiced it under the supervision of an still need real patients to practice in order to understand the
ophthalmologist and directly get feedback after the examination. correct angle of approach and the necessary adjustments to be
Feedback holds an important role in improving the student’s made during the examination. A hybrid learning model of virtual
clinical skill as it guides them to do the procedure according to didactics, simulation, telemedicine, self-directed learning, and
the standards. Therefore, face-to-face learning methods are still a in-person clinical encounters will provide students with various
more effective means of teaching for this particular ophthalmic skill experiences, including new opportunities in patient care and
[7,11]. technical skill development [1,17]. This study shows that despite
the excellent score of the overall multiple-choice test, the students
Overall, the student’s perception was good about online
still have inadequate knowledge about visual acuity and subjective
learning, where more than 85% of students were satisfied with
refractive examination topics during the online learning period.
the quality of online learning. About 85,94% of students also can
However, after their encounter real patients and practiced directly
comprehend the learning material in the video and achieved the
in the clinic during the in-person clinical clerkship period, their
learning objectives which were expected. More than 90% of the
knowledge and skill about visual acuity and subjective refractive
students agreed that the topic presented in online learning was an
examination topic have improved dramatically in the OSCE test at
essential topic to learned and very useful in clinical practice as a
the end of the period.
primary care physician. However, many of the students (93,75%)
stated that face-to-face learning methods were more effective than Before the pandemic, the learning process in medicine is still
online learning methods, especially in learning clinical skills such as commonly based on a conventional clerkship approach where
subjective refractive examination. About 95,31% of them considered learners observe clinical practice and learn from hands-on
that clinical skills that the instructor directly demonstrated will be activity when permitted by the clinical instructor. We are forced
easier to understand and can rehearse to perform under the direct to use online learning to teach clinical ophthalmology during the
supervision of an ophthalmologist. Few studies about perception pandemic to limit unnecessary face-to-face exposure. Nevertheless,
about online undergraduate ophthalmology teaching during the online learning cannot permanently replace in-person clinical
COVID-19 pandemic had shown positive feedback from students. clerkship. In-person ophthalmology clerkship enhances our
Majority of the students perceived that online learning was a ability to observe students and evaluate clinical performance,
favorable alternative to the conventional face-to-face learning including students’ integration into the healthcare team, skills
method with the ease of flexibility of the learning process to time in interacting with patients, professionalism, and clinical and
and place, repeatability of the learning material at own pace, and surgical skills. To overcome the shortcomings of online learning
the more courage to ask and interact with the instructor. The in clinical ophthalmology, we transformed our undergraduate
shortcomings of online learning were mainly the lack of clinical ophthalmology curriculum into blended learning, where online
training and patient encounter, the learning process was not as learning is combined with traditional face-to-face learning. In
interactive as traditional face-to-face learning, and limited facilities the online learning period, the students enrolled in the iLearn
include poor internet connectivity [2,12-14]. platform and were assigned to watch the clinical skill videos,
complete the multiple-choice test, and make a case report. In the
Provision of learning materials included clinical skill videos
clinical clerkship period, the students came to the teaching hospital
before undergraduate ophthalmology clinical clerkship had shown
wearing personal protective equipment, which is mandatory. The
to significantly improved subjective and objective measures of
students can observe the real patient examination directly in the
knowledge and skill performance. This effect is likely due to the
outpatient clinic. Afterward, the instructor gives an explanation
specified topics and the higher efficacy of selected materials

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Volume 37- Issue 2 DOI: 10.26717/BJSTR.2021.37.005968

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