International Council of Ophthalmology

Ophthalmic Education:

Principles and Guidelines of a Curriculum for Ophthalmic Education of Medical Students: Chapter 1: Preamble

The Need To Educate Medical Students

In the International Ophthalmology Strategic Plan to Preserve and Restore Vision (1999), an International Task Force on Ophthalmic Medical Student Education was established.

The leadership of the International Council of Ophthalmology (ICO) agrees that ophthalmic education of medical students should include the basic knowledge and skills to provide appropriate levels of primary eye care, and medical students should learn the indications and need for referral to ophthalmologists for management of specialty cases.

Evidence-based ophthalmic curriculum for medical students should be incorporated as core curriculum for all medical schools.

It is recognized that in different geographic regions of the world, medical graduates may be required to provide primary eye care, while others may have easy access to referral of ophthalmic specialists.

Ophthalmic manifestations of systemic diseases are common, and an understanding of these eye manifestations is a necessary part of the comprehensive education for modern physicians.

History of Task Force on Ophthalmic Education of Medical Students

The International Council of Ophthalmology passed a resolution to call on all medical schools worldwide to establish a curriculum for ophthalmic education of medical students as part of their core curriculum for medical education, rather than as an elective in the course of medical education.

Dr. Yasuo Tano (Japan) and Dr. Gerhard K. Lang (Germany) were asked to Co-Chair the Task Force.

The Task Force took initiatives to begin developing a curriculum, and noted that:

1. In the 21^st Century, eye care has become increasingly important in the general practice of medicine.

2. Vision is one of the vital factors influencing quality of life.

3. As ophthalmic manifestations of systemic diseases are commonly associated with medical, neurological, and metabolic diseases, primary eye care (including recognizing eye diseases) should be the responsibility of family physicians.

4. A solid education in ophthalmology should be part of the comprehensive education of the modern physician. The Task Force recommended that the educational programs of all medical students include a basic understanding of eye diseases and eye manifestations of systemic diseases. Ideally, the family physician should recognize the eye diseases which would require a referral to an eye care specialist.

5. Historically, teaching methods of ophthalmology for medical students have consisted of: 1) traditional didactic lectures and clinical demonstrations; 2) illustrative case studies to highlight particular eye diseases; and 3) evidence-based medical teaching, pairing ophthalmic teaching with neuro-science, neurology, endocrinology, pediatrics, and other relevant subjects. The Task Force emphasizes the importance of clinical exposure to patients. Patient contact and bedside teaching in ophthalmology are critical in providing clinical experience.

6. Ophthalmology is mostly a surgical specialty, so medical students should be given an opportunity to observe procedures in the operating room. By allowing students to be exposed to the surgical procedures, they will acquire a more realistic understanding of ophthalmic practice.

7. The time allotment for teaching students in ophthalmology is important. It is recognized that different medical subspecialties compete vigorously for time in the medical education curriculum. However, an adequate period of time must also be allotted for learning eye care.

Principles

In January 2002, Dr. Richard K. Parrish II, took over the Chairmanship of the International Task Force and started working on a detailed curriculum for ophthalmic education of medical students.

The Task Force considered the importance of local diseases in different countries, especially in areas where eye diseases such as onchocerciasis or cataract are endemic. It is strongly believed that medical students in those regions should have a more in-depth understanding of these conditions. The final report consists not only of subjects in the curricula, but also covers sources of illustrative materials for use in teaching.

Under the leadership of Dr. Parrish, a series of principles were determined and guided the committee in the preparation of this curriculum.

1. The reduction in time allotted for ophthalmic education in medical school threatens to diminish the clinical skills of graduating physicians throughout the world. This will adversely affect the quality of eye care knowledge worldwide.

2. An ophthalmic cognitive and clinical skill set should be defined for international medical educators.

3. Basic ophthalmic knowledge and clinical skills should be recognized internationally and included as part of the medical student’s general curriculum.

4. Recommendations of the Task Force should reflect the consensus of a broad-based international ophthalmic educational community.

5. The Task Force should define minimum standards for medical student education which are not intended to replace existing curricula, such as Blueprint 2001: Training of Doctors in the Netherlands, or the Swiss Catalogue of Learning Goals in Ophthalmology.

6. Teaching materials, including clinical photographs, selected readings from existing textbooks, and publications should be made available through the ICO website for international medical students who do not have ready access to printed material.

Minimum Knowledge and Clinical Skills

The Task Force Chairman queried members of the International Federation of Ophthalmological Societies in January and April 2003 to determine the minimum ophthalmic knowledge and clinical skills that graduating medical students should demonstrate.

It was determined that all medical students should demonstrate competency in these areas:

1. Measurement of near visual acuity with and without correction.

2. Determination of visual fields by confrontation technique.

3. Examination of extraocular motility in the six cardinal positions of gaze and primary position.

4. Measurement and interpretation of pupillary size and reaction to light.

5. Penlight examination of the anterior segment, including upper lid eversion.

6. Examination of the optic nerve and posterior pole with direct ophthalmoscopy.

7. Removal of superficial corneal or conjunctival foreign body.

With these skills, the graduating medical student should be able to make the following diagnoses and initiate an appropriate treatment or referral plan for the following conditions: 1) conjunctivitis; 2) cataract; 3) corneal ulcer; 4) corneal foreign body; 5) macular degeneration; 6) diabetic retinopathy; 7) hypertensive retinopathy; 8) glaucoma; 9) uncorrected refractive error; 10) ocular trauma; 11) papilledema; 12) hemianopic and bi-temporal visual field defects; 13) acute onset of cranial nerve palsies III, IV, VI; 14) acute onset strabismus; 15) leukocoria.

The medical student curriculum designed by the ICO Task Force is divided into 12 parts. The first section, Fundamentals and Principles of Ophthalmology, outlines essential skills and serves as a basis for understanding the information provided in the 11 subspecialty sections.

Just as other widely circulated consensus documents reflect educational priorities, such as Blueprint 2001: Training of Doctors in The Netherlands (see References: Additional Source of Teaching Material), the curriculum of the Task Force is intended to complement, not replace, these existing standards.

The Task Force members understand that large regional variations in disease prevalence preclude the development of an inclusive curriculum for all medical students. This document is intended to serve as a resource that will provide access to a wide range of important educational topics.

Educational Priorities

* Basic Level: Information designated with a single asterisk (*) is necessary in the education of medical students worldwide.

** Standard Level: Information designated with two asterisks (**) reflects a higher level of ophthalmic understanding. Although not basic, many medical schools may already include this material in their curriculum. While important to ophthalmic care, the Task Force does not regard the cognitive or skill set designated under Standard Level as falling within the basic curriculum of most international medical students. This material may form the basis for an ophthalmology elective in medical school.

*** Advanced Level: Information designated with three asterisks (***) marks areas of advanced cognitive and clinical skills that are more appropriate for students who seek further training in ophthalmology. While important to ophthalmic care, the Task Force does not regard the cognitive or skill set designated as Advanced Level as falling within the basic curriculum of most international medical students. This material may form the basis for an ophthalmology elective in medical school.

Hours in Curriculum

The Task Force strongly recommends that all medical schools include ophthalmology as a part of the essential curriculum and not exclusively as an elective. The increasing age of the world population, high prevalence of common problems such as eye injury and red eye, and importance of vision in the information age support the need for the expansion of ophthalmic education.

To achieve this goal, the exact allotment of curriculum hours will depend on existing specific medical school infrastructure and general curriculum. The Task Force strongly recommends that sufficient time in the classroom and clinical setting be dedicated to mastering the learning objectives and clinical skills labeled as “Basic.”

The Task Force also strongly recommends that ophthalmic education should not be limited to the formal classroom setting, but also takes place in the clinic and operating room. Each student should be given an opportunity to observe common ophthalmic procedures, such as treatment of chalazion, removal of corneal foreign body, or cataract operation, and to examine the anterior segment with slit lamp biomicroscopy.

The Task Force estimates that the total educational commitment throughout medical school will require approximately 40-60 hours (or 5 to 8 days) exposure.

Specific Teaching Methods

Three teaching methods have traditionally been described to achieve ophthalmic educational goals: didactic lectures and clinical demonstration; illustrative case method study; and evidence–based medicine teaching (where ophthalmic education is paired with neuroscience, neurology, endocrinology, and geriatric medicine).

The Task Force recommends that international medical schools employ all methods to achieve these broad educational goals. The Task Force judges these teaching techniques to be complimentary and not competitive in nature. As the body of new information acquired through randomized clinical trials expands rapidly, the Task Force believes that the importance of evidence-based medicine will continue to grow.

Resources

Specific educational information is available through several existing publications of the American Academy of Ophthalmology and are referenced and identified to facilitate access.

Complete lectures on many important topics have been prepared by Professor Susan Lightman, Department of Clinical Ophthalmology at Moorfields Hospital, London, UK, and have been used as a part of the Curriculum for Undergraduate Medical Education. These self-contained educational units are presented in their entirety and may be accessed as identified.

To facilitate access, references (ref.) to images, figures, and charts from publications of the American Academy of Ophthalmology and others are listed within the curriculum. This may be of particular value for those students who do not have ready access to printed reference texts.

The Task Force recommends that this information be made available without charge to all students and teachers for educational purposes.

Additionally, the Task Force recommends that the Basic and Clinical Science Course manual teaching materials provided by the American Academy of Ophthalmology and the Undergraduate Medical Lecture Series provided by Professor Susan Lightman, Department of Clinical Ophthalmology, Moorfields Eye Hospital, London, UK, shall be made available to teachers and students all over the world though the ICO website: www.icoph.org/med/resources.html.

Next: II. Fundamentals and Principles of Ophthalmology

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