Peter Awad, Mark Awad, John Awad

Background

Direct ophthalmoscopy is a core clinical skill expected of graduating UK medical students. The General Medical Council (GMC) within ‘Outcomes for graduates Practical skills and Procedures’ states that newly qualified doctors should be able to perform basic ophthalmoscopy and recognise common ophthalmic abnormalities (1). Despite this expectation, undergraduate exposure to practical ophthalmology is often limited, leaving many graduating medical students lacking confidence in performing fundoscopy and recognising sight-threatening pathology.

Failure to recognise important ophthalmic findings such as papilloedema or optic disc abnormalities may delay the diagnosis of serious neurological or systemic disease. It is therefore of paramount importance that newly qualified foundation doctors should possess sufficient confidence and competence to perform basic ophthalmoscopy and identify obvious abnormal findings requiring urgent escalation.

Informal feedback from final year medical students on placement suggested that many felt unprepared to perform direct ophthalmoscopy in clinical practice and lacked confidence in identifying clinically significant fundus abnormalities. This quality improvement project was therefore undertaken to evaluate current confidence and competence, implement a structured educational intervention and assess whether targeted teaching could improve these outcomes.

Aim

The primary aim of this quality improvement project was to determine whether a structured ophthalmology teaching programme could improve final year medical students’ confidence and competence in performing direct ophthalmoscopy and recognising common sight-threatening ophthalmic pathology.

Secondary aims were to improve preparedness for the UK MLA and foundation training whilst evaluating whether the teaching programme should become an ongoing component of undergraduate ophthalmology teaching.

Audit Standard

This project was conducted against the educational standards outlined within the GMC ‘Outcome for Graduates Practical Skills and Procedures’ (1), which states that graduating medical students should be able to:

‘Perform basic ophthalmoscopy and recognise common ophthalmic abnormalities’.

The project therefore assessed whether current undergraduate teaching adequately prepared final year medical students to achieve this expected competency.

Methodology

A multi-cycle educational quality improvement methodology using the plan, do, study, act (PDSA) framework was undertaken (2).

Baseline questionnaires were distributed to the medical students before commencement of the teaching programme. Students were asked to assess;

• Confidence in performing direct ophthalmoscopy
• Confidence in recognising papilloedema using an ophthalmoscope
• Perceived ability to identify the optic disc and retinal vessels
• Overall confidence in recognising common ophthalmic pathology

Following review of the baseline findings, a structured ophthalmology teaching programme was developed to address the educational deficiencies identified.

Formal teaching sessions covered;

• Direct ophthalmoscopy
• Oculoplastics
• Glaucoma
• Neuro ophthalmology
• Paediatric ophthalmology
• Interpretation of ophthalmic investigations
• Recognition and initial management of sight-threatening ophthalmic pathology

During project planning, consideration was given to allowing students to perform ophthalmoscopy through pharmacologically dilated pupils in a controlled teaching environment. Following discussion of governance and patient safety considerations, this approach was not implemented, and all practical teaching was subsequently delivered using undilated pupils.

Following each teaching cycle, students completed repeat questionnaires evaluating perceived confidence and overall educational value. Feedback was reviewed following each cycle to refine the content and delivery of subsequent teaching sessions in keeping with continuous quality improvement methodology.

Results

Baseline Assessment

The initial audit demonstrated that many final-year medical students lacked confidence in performing direct ophthalmoscopy despite approaching graduation.

Confidence in recognising papilloedema and other clinically significant retinal pathology was particularly limited, highlighting an important educational gap relative to the GMC outcomes expected of graduating doctors.

Students consistently reported limited opportunities to practice ophthalmoscopy during undergraduate training and identified fundoscopy as an area in which further practical teaching would be beneficial.

Post Intervention Assessment

Following completion of the teaching intervention, improvements were demonstrated across all assessed domains.

Among responding students:

• 100% reported feeling either extremely confident or somewhat confident in performing direct ophthalmoscopy
• 83% reported feeling confident identifying papilloedema using an ophthalmoscope
• All students successfully visualised the optic disc and retinal vessels, with 66.7% rating this 4/5 for ease and 33.3% rating it 5/5

Students also reported substantially reduced time required to identify the optic disc, with several participants commenting that they were able to visualise the optic nerve within only a few seconds.

Qualitative feedback was overwhelmingly positive;

• ‘Very helpful!! We don’t get much hands-on teaching otherwise’
• ‘Great – Feel way more confident doing it on real patients’
• ‘Very useful’
• ‘Really helpful’
• ‘Very informative’

Discussion

This project demonstrated that a structured ophthalmology teaching programme can substantially improve final year medical students’ confidence and perceived competence in performing direct ophthalmoscopy and recognising clinically significant ophthalmic pathology.

The greatest improvements were observed in students’ confidence performing fundoscopy following supervised practical teaching. This finding aligns with recent evidence demonstrating that undergraduate ophthalmology education benefits from structured teaching and increased opportunities for practical skills training (3).

Importantly, this project extends beyond the implementation of a single educational intervention. Feedback and outcome data were reviewed following each teaching cycle, enabling refinement of subsequent teaching sessions. This reflects the principle of continuous quality improvement using repeated PDSA cycles (2).

Although the original proposal explored pharmacological pupil dilation as a potential educational aid, practical teaching ultimately proceeded using undilated pupils. Despite this modification, substantial improvements in confidence and competence were still demonstrated.

Outcomes and Change Implemented

Following the overwhelmingly positive feedback received during this quality improvement project, students requested that this be repeated for future cohorts; as a result of this, the teaching programme is planned to continue for future cohorts, allowing ongoing evaluation through repeated audit cycles and continued refinement based on participant feedback.

This represents a sustained educational improvement arising directly from implementation of this quality improvement project.

Reflection

This project demonstrated the importance of structured practical ophthalmology teaching in preparing graduating medical students for foundation practice.

Future work should include continued delivery of the teaching programme alongside repeated evaluation using the same assessment methodology. Incorporation of additional simulated retinal pathology and objective assessment of practical ophthalmoscopy skills may provide further opportunities to enhance educational outcomes.

Conclusion

This multi-cycle educational quality improvement project identified deficiencies in undergraduate students’ confidence and competence in performing direct ophthalmoscopy and in recognising sight-threatening ophthalmic pathology.

Implementation of a structured teaching programme resulted in substantial improvements in student confidence and perceived competence. Repeated evaluation enabled progressive refinement of the intervention and supported ongoing delivery of the teaching programme for future cohorts.

This project demonstrates how targeted educational interventions can improve undergraduate preparedness for foundation training, while supporting final year medical students in meeting the General Medical Council’s practical skills standard for performing direct ophthalmoscopy and recognising common ophthalmic abnormalities.

References

1. General Medical Council. (2023).Practical Skills and Procedures. London: GMC.
2. NHS England. (2022). A Guide to Quality Improvement Methods. NHS England.
3. Liao, J., Wright, R. R., & Vora, G. K. (2024). The Decline of Basic Ophthalmology in General Medical Education: A Scoping Review and Recommended Potential Solutions. Journal of medical education and curricular development, 11, 23821205241245635. https://doi.org/10.1177/23821205241245635