Keywords
emergency medicine - educational interventions - ophthalmology
Despite literature suggesting that the number of patients with eye-related ocular
complaints who present to the emergency department (ED) has increased by 30% between
2001 and 2014,[1] there is still a lack of comfort amongst ED practitioners in dealing with eye-related
chief complaints. In a cross-sectional survey of emergency physicians in the U.K.,
26.0% received “no training” in the management of eye emergencies and 68.8% had “little
or no confidence” in dealing with eye complaints. In the U.S. literature, the slit
lamp exam has been identified among emergency medicine (EM) residents as one examination
skill for which they are significantly under-prepared.[2]
This is concerning as most EDs do not have eye care professionals on site to triage
or examine patients, which puts the responsibility of triaging and often treating
patients to ED physicians.[1]
[3] Furthermore, the availability of ophthalmologists on-call for EDs is not uniform
and many hospitals lack access to subspecialty ophthalmology services.[1]
[3] Given this, there is a strong need and desire for ED physicians to learn ophthalmic
skills. In a national survey amongst emergency physicians in Australia, more than
90% of the respondents desired further education in “ophthalmic emergencies.”[4]
Our objective was to conduct a needs assessment of the comfort level of EM residents
in diagnosing and managing patients who present with an ophthalmic chief complaint,
with the goal of targeting future educational interventions toward these needs.
Methods
This was a cross-sectional study conducted at Stanford University Hospital and Clinics
between June 2016 and August 2016. Prior to study initiation, this study was determined
to be IRB (Institutional Review Board)-exempt by the Stanford IRB on the basis of
being a quality improvement project. The EM residents in the Stanford/Kaiser EM program
cover two Level 1 trauma centers with consultation ophthalmology services continuously
available (Stanford University Hospital and Santa Clara Valley Medical Center). Additionally,
residents also rotate through Kaiser Permanente Northern California (Santa Clara),
where ophthalmology consultation is also available. At the time of this study, the
residency program was a 3-year program, and core content training related to eye emergencies
was based upon the Model of the Clinical Practice of Emergency Medicine.[5] This training was provided at the bedside, during case-based didactics, and through
dedicated hands-on skills laboratories. The skills laboratories were performed in
collaboration with the ophthalmology department and consisted of a 2-hour basic eye
skills laboratory for 1st year residents and another 2-hour advanced skills laboratory
for 3rd year residents. Bedside instruction took place when patients presented with
eye concerns to the ED and was provided by either EM faculty or by on-call ophthalmology
consulting house-staff if indicated. Third-year residents additionally were offered
the opportunity for a 1- or 2-week ophthalmology elective.
Between June 2016 and August 2016, surveys were administered online to the entire
EM residency, comprising 16 1st year residents, 14 2nd year residents, and 13 3rd
year residents (R1, R2, and R3, respectively). Survey questions targeted experience
and comfort level with common ophthalmic conditions or symptoms that patients present
with to the ED. These survey questions were based upon review of prior literature.[3]
[6]
[7] Survey completion was voluntary and anonymous. Questions were administered using
the Stanford Medicine Qualtrics platform, a HIPAA (Health Insurance Portability and
Accountability Act) compliant online survey platform. Survey questions are shown in
[Table 1]. Additionally, residents were also qualitatively queried as to their opinions on
ideal methods of learning ophthalmologic diagnostic and management skills.
Table 1
Survey questions administered to ED (emergency department) residents
|
1) Wherever you work after graduation, do you anticipate having ophthalmology consultation
services easily available?
|
A) Yes, similar to the current availability
B) Available, but less so
C) No
D) Not sure
|
|
2) I believe that knowing how to examine and manage patients with eye complaints will
be important to my future career
|
Scale of 1 (not at all important) through 10 (very important)
|
|
3) I feel comfortable with the basic slit lamp exam
|
Scale of 1 (not at all comfortable) through 10 (very comfortable)
|
|
4) Diagnosis and exam skills: If a patient were to present with the following condition
or complaint, I would feel:
A) Confident about my diagnosis and exam skills, to the extent that an ED provider
is able to perform (i.e., an ED provider would not be able to do a full dilated exam
for a patient with floaters, but would be able to do an ultrasound)
B) Semicomfortable with my diagnosis and exam skills, but would appreciate more experience
C) Not comfortable with my diagnosis or examination abilities, would definitely need
review
5) Management skills: If a patient were to present with the following condition or
complaint, I would feel:
A) Confident about my management skills, to the extent that an ED provider is able
to perform: I know when patients with this issue would need an ophthalmology consult
and know the appropriate history and physical to take, as well as medications, procedures
and imaging necessary to order prior to a consultation (if applicable)
B) Semicomfortable with my management: I may or may not know when patient with this
condition would need a consult or I feel comfortable performing only some but not
all of the management steps
C) Not comfortable with my management: I would not know when a patient with this condition
would need a consult or I do not know most of the management steps to take
|
Orbital cellulitis
Orbital fracture
Retrobulbar hemorrhage
Corneal abrasion
Corneal ulcer
Chemical burn
Corneal foreign body
Iritis
Hyphema
Ocular herpetic conditions
Ruptured globe
Patient who presents with “floaters”
Patient who presents with high eye pressure
Patient who presents with “double vision”
Patient who presents with abnormal pupils
|
|
6) If applicable, what do you feel has limited your comfort level or experience with
eye patients? Check all that apply.
|
A) Not enough patients
B) There are enough patients, but I do not have enough time to spend thinking about/examining
them amongst the other patients that I have to manage
C) There are enough patients, but I do not have enough didactics/lectures to know
how to manage them
D) There are enough patients, but I do not have enough experience with physical exam
skills to examine them
E) Not applicable, I feel very comfortable with most eye problems
|
Results
A total of 69.2% (9/13) of R3s, 57.1% (8/14) of R2s, and 75% (12/16) of R1s participated
in the survey. This resulted in a total response rate of 67.4% (29/43).
Most EM residents, when anticipating their careers postgraduation, did not expect
to have equivalent availability of ophthalmology consultation services available.
Only 24.1% (7/29) of residents expected equivalent levels of ophthalmology consultation
services ([Fig. 1]).
Fig. 1 Wherever you work after graduation, do you anticipate having ophthalmology consultation
services easily available?
EM residents overall believed ophthalmology examination and management skills would
be important to their future career ([Fig. 2]). On average when including all residents, importance was marked as 9.0 (standard
deviation [SD] = 1.3) on a 1 to 10 scale, with “1” being least important and “10”
being most important. R1s rated the mean importance as 8.8 (SD = 1.5), R2s as 8.9
(SD = 1.0), and R3s as 9.2 (SD = 1.1). These differences, although trending toward
increased importance for each increasing year of residency, did not reach significance
on one-way ANOVA testing (p = 0.77).
Fig. 2 I believe that knowing how to examine and manage patients with eye complaints will
be important to my future career. (1 = not at all important through 10 = very important).
Residents were also asked their average comfort with the slit lamp exam on a scale
of 1 to 10 ([Fig. 3]). In assessing level of comfort, R1s had a mean of 4.0 (SD = 2.5), R2s had a mean
of 5.4 (SD = 1.9), R3s had a mean of 6.9 (SD = 2.6), and all residents combined had
a mean of 5.3 (SD = 2.6). One-way ANOVA testing reached significance (p = 0.03) when comparing these three groups. Post hoc analysis using two-tailed t-tests assuming unequal variances revealed that the R1 and R3 comparison was the driver
of this significance (p = 0.02).
Fig. 3 I feel comfortable with the basic slit lamp exam (1 = not at all comfortable through
10 = very comfortable).
[Figures 2] and [3] present the above data in box-and-whisker plot format, with whiskers representing
minimum and maximum responses, and stacked boxes representing 25% percentile, median,
and 75% percentile of responses.
For questions 4 and 5 of the survey, residents were asked to mark whether they were
not comfortable, semicomfortable, or confident with diagnostic/exam or management
skills regarding specific topics (such as orbital cellulitis, orbital fracture, retrobulbar
hemorrhage, etc.). [Table 2] presents the responses from question 4 in aggregate and shows that, in total, after
answering the survey questions, R1s marked a total of 149 responses, R2s 104 responses,
and R3s 113 responses, making a total of 366 responses. [Table 3] presents the data from question 5 in aggregate, and shows that, in total, R1s marked
a total of 180 responses, R2s 90 responses, and R3s 119 responses, making a total
of 389 responses.
Table 2
Diagnosis and exam skill comfort level
|
R1 responses
|
R2 responses
|
R3 responses
|
R1–R3 responses
|
|
Not comfortable (%)
|
33/149 (22.1)
|
32/104 (30.8)
|
5/113 (4.4)
|
70/366 (19.1)
|
|
Semicomfortable (%)
|
107/149 (71.8)
|
60/104 (57.7)
|
60/113 (53.1)
|
227/366 (62.0)
|
|
Confident (%)
|
9/149 (6.0)
|
12/104 (11.5)
|
48/113 (42.5)
|
69/366 (18.9)
|
|
Total
|
149
|
104
|
113
|
366
|
Abbreviations: R1, 1st year resident; R2, 2nd year resident; R3, 3rd year resident.
Note: Difference in proportions of R1s, R2s, and R3s marking whether they were not
comfortable, semicomfortable, or confident is significant (p < 0.001).
Table 3
Management comfort level
|
R1 responses
|
R2 responses
|
R3 responses
|
R1–R3 responses
|
|
Not comfortable (%)
|
48/180 (26.7)
|
16/90 (17.8)
|
2/119 (1.7)
|
66/389 (17.0)
|
|
Semicomfortable (%)
|
131/180 (72.8)
|
51/90 (56.7)
|
74/119 (62.2)
|
256/389 (65.8)
|
|
Confident (%)
|
1/180 (0.6)
|
23/90 (25.6)
|
43/119 (36.1)
|
67/389 (17.2)
|
|
Total
|
180
|
90
|
119
|
389
|
Abbreviations: R1, 1st year resident; R2, 2nd year resident; R3, 3rd year resident.
Note: Difference in proportions of R1s, R2s, and R3s marking whether they were not
comfortable, semicomfortable, or confident is significant (p < 0.001).
Out of these 366 responses for question 4, only in 18.9% (69/366) of responses did
a resident mark that they were “confident” about their diagnostic or exam skills.
In responses to question 5, this decreased to 17.2% (67/289) for management skills
in question 5. There was an overall increase in confidence each year of residency.
However, even among the R3s, only 42.5% (48/113) of responses indicated confidence
in diagnostic or exam skills, and even fewer 36.1% (43/119) of responses indicated
confidence in management skills. Chi-square testing revealed that the difference in
proportions of R1s, R2s, and R3s marking whether they were not comfortable, semicomfortable,
or confident was significant (p < 0.001) for both questions 4 and 5.
[Figures 4] and [5] illustrate the responses to questions 4 and 5 in graphical format, and categorize
by condition and residency levels the comfort level of residents in their diagnostic,
exam, and management skills.
Fig. 4 If a patient were to present with the following condition or complaint, I would feel
________ about my Diagnosis and Exam Skills. (A = confident, B = semicomfortable,
or C = not comfortable).
Fig. 5 If a patient were to present with the following condition or complaint, I would feel
________ about my Management Skills. (A = confident, B = semicomfortable, or C = not
comfortable).
In [Fig. 6], residents revealed that there were a variety of reasons why their comfort level
with eye patients was limited. Importantly, only one R3 marked that they were “very
comfortable” with the eye exam.
Fig. 6 If applicable, what do you feel has limited your comfort level or experience with
eye patients? Check all that apply.
Discussion
Given the increase in patients presenting to EDs with eye related complaints,[1] it is essential that the comfort level of ED physicians with ophthalmologic patients
increases. As prior authors have noted, EDs, except at level 1 trauma centers, are
not routinely staffed by ophthalmology consultants.[1]
[3] Indeed, in our survey of ED residents, the majority indicated that they do not anticipate
having similar availability of ophthalmology consultation services postgraduation
([Fig. 1]).
ED providers desire increased ophthalmology knowledge and skills. In a survey of Denver
Health Emergency Medicine graduates (a 4-year EM program), slit lamp usage was identified
as an exam skill in which respondents felt significantly under-prepared.[2] As a reference, respondents felt that they were significantly over-prepared in ultrasound
usage and arterial line placement. In another survey among ED physicians in Australia,
more than 92% of the respondents desired further education in “ophthalmic emergencies.”[4] This ranked only second to neonatology emergencies and was desired above otolaryngology,
pediatric, obstetrics and gynecology, toxicology, envenomation, behavioral disturbance,
altered conscious state, and triage-related topics.[4] Our study corroborates this desire for ophthalmic education, with participants overall
believing ophthalmic exam and management skills to be important ([Fig. 2]).
Unfortunately, despite this increased interest, there is insufficient training of
ED physicians. In a survey administered in 1993 to ED physicians in the United Kingdom,
26.0% of respondents received no training in eye emergencies, 68.8% had little to
no confidence in these situations, and 42.2% worked in a department without slit lamps.[8] A repeat survey conducted in 2003 showed that, although the proportion of ED physicians
working in departments with usable slit lamps increased, 63.9% still felt little to
no confidence in dealing with eye emergencies.[9]
The above trends are corroborated in our study. We demonstrate that EM residents,
on average, do improve each year in terms of comfort level with the slit lamp exam,
but unfortunately even as R3s many are not fully comfortable ([Fig. 3]). The comfort level in diagnosing and managing various common eye complaints also
increases with each residency year ([Figs. 4] and [5] and [Tables 2] and [3]). However, overall, out of 3rd year residents, less than half indicated “confidence”
in ophthalmologic diagnostic, exam, and management skills.
Interestingly, [Figs. 4] and [5] illustrate that different ophthalmology conditions elicit different comfort levels.
For example, no R3s indicated “not comfortable” for diagnosing or managing orbital
cellulitis, orbital fractures, retrobulbar hemorrhages, corneal abrasions, corneal
foreign bodies, ocular herpetic conditions, ruptured globes, or a patient who presents
with floaters, elevated intraocular pressure, double vision, or abnormal pupils. However,
at least some R3s did indicate “not comfortable” for other conditions such as corneal
ulcer, chemical burn, iritis, and hyphema.
Lack of comfort with eye emergencies continues to be an issue, both in the U.S. and
abroad, and amongst U.S. EM residents in both 3-year and 4-year training programs.
This highlights the need for a fresh approach. There were a variety of reasons indicated
by residents in our study for their lack of comfort ([Fig. 6]). These included not enough patients, time, didactics, and/or hands-on examination
experience related to eye emergencies.
This suggests that there could be a multimodal educational approach towards addressing
this issue. For example, it has been shown that the amount of ophthalmic education
in medical school has progressively decreased,[10]
[11] and perhaps this could be a starting point for increased education amongst EM residents.
Other studies have shown a lack of easy-to-navigate, illustrated, and useful texts
for ED providers regarding common ophthalmologic emergencies, and this could also
be a method to increase ophthalmology education during EM residency.[12]
Another potential solution is incorporating “residents-as-educators” in the ED. Ophthalmology
and EM residents often interact during their training on call during real-time ED
consultations. Ophthalmology resident educators have been well received in prior educational
interventions,[13] and this method of education has been enthusiastically endorsed by other authors.[10] Specifically, it was previously demonstrated that ophthalmology residents who completed
a teaching module were as effective as faculty members in leading medical student
teaching sessions.[13] In our study, qualitatively, EM residents were enthusiastic about “in-the-moment”
teaching from ophthalmology residents. Examples of responses included “… have had
(ophthalmology) residents teach me in the ED and it is very educational,” and “… great
when (ophthalmology) resident grabs ED resident in ED to show findings/exam on patient,
even when busy.” However, most acknowledged time constraints, for example, “only challenge
is time constraint, for both ED and ophthalmology residents.” Perhaps targeted in
the moment teaching, acknowledging time constraints, could be focused toward the specific
high yield items identified in [Figs. 4] and [5] that residents felt the least comfortable diagnosing and managing.
There are limitations to this study. The specific conditions or symptoms posed in
questions 4 and 5 were based upon review of past literature, but were by no means
comprehensive, and expanding the survey to include other conditions could be performed
in the future.[3]
[6]
[7] Another limitation is the small sample size, and the uni-institutional nature of
the study. However, we do believe that results are generalizable given that they concur
very well with prior research. It should also be noted that there is a difference
between competence and confidence, and that our survey questions targeted confidence
levels. However, without a validated method for gauging ophthalmic skills amongst
ED providers, we rely on our survey results at the present time to serve as a proxy
for competency in ophthalmic skills. This does, however, suggest an interesting avenue
for future research evaluating the competency of ED providers on ophthalmic examination
skills. We also note that these surveys were anonymous and thus participants were
not influenced by concern regarding peer perceptions.
Conclusions
In conclusion, there is both need and desire for increased ophthalmic skills training
for emergency department residents. Possible solutions will need to be innovative
and multifactorial to target this goal.
