GMC no: 7490478
Which elements of ophthalmology would you embed in the Foundation Curriculum?
Abstract
Constraints in training time and limited exposure to ophthalmology present challenges to a Foundation Programme that aims to engender safe and experienced doctors. A national teaching programme that covers key topics and a shift to online learning would complement learning in the clinical environment.
Introduction
The last decade has seen reforms to junior doctors’ career and working hours with Modernising Medical Careers (MMC)1 and the European Working Time Directive2, resulting in:
1. A standardised two-year postgraduate Foundation Programme (FP) during which trainees are expected to achieve generic clinical and non-clinical competences set by a national Foundation Curriculum.
2. Trainees will likely spend less time in training because of the weekly 48 hour cap, highlighting the importance in ensuring timely acquisition of key competences3.
The curriculum
The FP curriculum4 aims to:
1. Consolidate undergraduate education with professionalism and patient welfare;
2. Provide generic training to enhance essential interpersonal and clinical skills;
3. Develop leadership, team working and supervisory skills;
4. Provide a platform for workplace experience to inform career choice.
Postgraduate learning accompanies clinical duties and is thus difficult to approach in a structured, centrally-organised manner5. Furthermore, each trainee harbours different skills, experience, learning needs and career ambition. This necessitates a fine balance between bestowing basic, essential qualities that will guarantee safe practice amongst progressing trainees, and avoiding a curriculum that is simply prescriptive (which may limit development of many trainees).
Generic outcomes
Within the curriculum for ophthalmology specialty training6, some domains (clinical assessment, communication and role in health service) and specific learning outcomes (e.g. emergencies, resuscitation, leadership, teaching, good medical practice, ethics, team working) are important for all Foundation Doctors, regardless of career choice. Interpersonal and communication skills ranked highest amongst skill sets judged to be important by trainee ophthalmologists practising in the US Pacific Northwest7. The FP curriculum already incorporates most of these outcomes- additionally, an understanding of screening to ensure appropriate follow-up (e.g. for diabetic retinopathy) is advisable. Familiarity with these concepts allows for further development with continued training. By encouraging trainees to reflect on clinical experience and link learning events to these aspects of the curriculum using e-portfolio8, the FP curriculum caters well for variation in both individual doctors and the learning experiences they encounter.
Common and important ophthalmological conditions
Ophthalmic complaints are common, and often require proficiency in emergency eye care. Past estimates suggest that 6% of casualty attendances and 1.5% of GP consultations were ophthalmic9,10. Of GP consultations, 16% were referred for further management; 39% of referrals were for urgent assessment. It may be difficult for FP trainees to achieve adequate clinical exposure to ophthalmological diseases, especially for those without a placement in GP, A+E or ophthalmology. Indeed, most A+E SHOs (pre-MMC) were not confident in dealing with eye emergencies (68.8% in 1993, 63.9% in 2003), nor was there universal training (74.0% in 1993 and 77.4% in 2003)11,12. Only 22% of GPs felt that their undergraduate training had been adequate, and only 61% felt confident using dilating agents and performing ophthalmoscopy13. Ophthalmology teaching can be variable or absent from FP teaching programmes that are currently organised by local trusts, without a specific ophthalmology curriculum. I have constructed a concise table (Table 1), aimed to be realistic with FP time constraints, of key skills and common and important ophthalmological diseases for junior doctors. Some are particularly common (e.g. conjunctivitis, cataract) or are associated with impending sight-threatening complications (e.g. giant cell arteritis, angle closure glaucoma) and therefore warrant greater attention. Acute and chronic ophthalmological diseases can present in most specialties; early diagnosis of eye pathology in systemic disease (e.g. diabetes, thyroid, polymyalgia rheumatica) allows prompt systemic and ophthalmological management.
Awareness of globally significant diseases such as trachoma, onchocerciasis and vitamin A deficiency is desirable but in-depth knowledge is difficult to justify in a curriculum for busy junior doctors. These conditions are rare in the UK, and bear a reducing global burden14,15.
Arguments exist for Basic Surgical Skill training (including suturing, scrubbing, knot tying, instrument handling) prior to specialty training16. This would be useful to those with a career interest in surgical specialties, emergency medicine, special interest GP, interventional radiology and some medical specialties (chest drains for respiratory medicine, skin biopsy for dermatology etc.). A four-week programme for Foundation doctors improved confidence in numerous surgical techniques after 8 months’ follow-up17. Unfortunately, this would be cost- and time- intensive in a FP intended to maximise clinical experience. Moreover, these skills are important but not essential and many trainees may never use them. Trainees interested in such specialties can attend relevant courses using FP study leave and budget; attendance is deemed favourable in specialty applications.
GMC no: 7490478
Red eye (excluding trauma / Trauma / Gradual painless visual loss / Sudden onset visual loss / Change in eye appearance / SkillsAngle closure glaucoma^ / Corneal abrasion* / Refractive error, presbyopia* / Retinal detachment^ / Dilated pupil^ / History taking*
Conjunctivitis* / Corneal/tarsal*/ intraocular foreign body / Cataract* / Retinal vascular occlusion (arterial/venous/giant cell arteritis^) / Chalazion, hordeolum* / Examination (visual acuity, fields, pupils, movements)*
Blepharitis* / Hyphaema^ / Age related macular disease* / Vitreous haemorrhage / Thyroid eye disease / Dilation, ophthalmoscopy*
Keratitis* / Blunt/penetrating trauma^ / Primary open angle glaucoma* / Optic neuritis/ anterior ischaemic optic neuropathy / Strabismus / Differential diagnosis formulation*
Subconjunctival haemorrhage* / Chemical injury^ / Diabetic retinopathy* / Ptosis / Selection + interpretation of investigations*
Episcleritis / Hypertensive retinopathy* / Management plan formulation*
Anterior uveitis / Optic nerve normal/atrophy/ compression/ swelling* / Appreciation of when to refer*
Endophthalmitis / Amblyopia
Orbital cellulitis
Table 1. Junior doctors should be proficient in diagnosing, investigating and immediately managing common and important diseases, and in performing key skills.
Particularly common (*) and important (^) diseases/skills.
GMC no: 7490478
Pupil dilation and ophthalmoscopy may diagnose important sight-, and possibly life-, threatening ophthalmological and neurological diseases. These could be considered core skills that need “signing off” prior to progression.
Foundation Trainees in A+E and GP- many of whom may later pursue these specialties- could spend a few days during their rotation in eye casualty to gain clinical exposure to common and emergency ophthalmology. It is unclear how well this would fit with rotas that are already busy; ideally the experience would be universal, although this is unrealistic with clerking, ward cover and teaching responsibilities in other rotations.
Delivery
Clinical experience is ideal in developing key skills such as history taking, examination and ophthalmoscopy; simulation sessions involving clinical scenarios, have also proven effective18,19,20. With limited clinical exposure to ophthalmology, I believe that an e-learning module covering the core topics in Table 1 would be the most effective, time efficient way to deliver teaching, particularly as considerable content involves images of pathological eyes and retinae. Design and delivery may be time-consuming21, but there are already numerous successful platforms across specialties22,23,24,25 (including ophthalmology26) and these will likely become commonplace. Design will become simpler with experience. A single national e-learning module would save time and money of delivering individual trust lectures, and ensure that all trainees receive standardised, high quality teaching. E-learning may be perceived as less interactive, but live, recordable interactive webcasting27 is feasible and studies have shown that e-learning is at least as effective as traditional teaching28,29. Importantly, it provides flexibility for junior doctors- dedicated teaching time is difficult to achieve alongside busy wards and emergencies. Assessments, self-assessments and integration with e-portfolios would also be simpler23.
Assessment
In the FP, trainees improve through senior feedback on everyday performance and assessment through “supervised learning events”. “Signing off” trainees as competent without further reinforcement of the skill or demonstrating understanding may be unreliable. Trainees’ performances are case specific30, not all assessors are equally stringent, and trainees can choose their assessor- which may affect validity31,32. Formalised assessments may be more reliable, but would be difficult to organise and would represent a significant shift from a curriculum that aims to build on undergraduate education in the context of clinical practice. Research shows that more reliable results are achieved when trainers must judge several performance criteria, rather than just one33. An adequate “sign off” for a competency, such as ophthalmoscopy, should therefore include several competences- for example understanding the red reflex, dials, aperture and adjustment for refractive error; examination technique, and appreciating the significance of possible pathology. While unlikely to differentiate good from average trainees, this brief assessment, easy to perform in the clinical context, would identify trainees needing further training and guidance. Additionally, in place of routine senior feedback (which is difficult as ophthalmological cases are uncommon in FP rotations), a quick online test following e-learning modules could also ensure and reinforce trainees’ understanding.
Conclusion
The FP curriculum provides structure and guidance to trainees, trainers and assessors. Exposure to key ophthalmological conditions during the programme is limited. Medical education is constantly evolving, and the use of national e-learning modules would deliver standardised teaching that covers core specialty topics. A well-defined curriculum would confer greater confidence to future ophthalmology specialist trainees. GP and clinician expertise in diagnosing and managing treatable diseases, and more accurate, appropriate and comprehensive referrals, would permit greater ophthalmology resource allocation towards urgent and more complex cases. Regular curriculum review is desirable given continual advancement of clinical practice with population dynamics, diseases, and medical/surgical/teaching innovations.
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