Response to: 'Direct ophthalmoscopy should be taught to undergraduate medical students'

Sir,

We would like to respond to the recent controversy regarding the relative merits of teaching direct ophthalmoscopy to undergraduate students.^{1, 2}

At the University of Nottingham, direct ophthalmoscopy is considered to be a life-saving examination that all medical students must acquire competency in. It is a widely held view that, direct ophthalmoscopy is an essential skill in the undergraduate ophthalmology curriculum.³ This is reflected in the universal teaching of this skill at an undergraduate level in the UK.³ Indeed, ophthalmoscopy is considered a fundamental competency of the Foundation Programme.⁴

Although it is true that physicians lack confidence in performing direct ophthalmoscopy, the reasons for this are multifactorial. The brevity of undergraduate ophthalmology rotations combined with the lack of practice of ophthalmic examinations by peers (GPs, hospital doctors and so on) may discourage trainees from using an ophthalmoscope when the need arises. The scenario of GPs sending patients with eye complaints to the friendly high street optometrist for evaluation and guidance is also familiar. As ophthalmologists we must strive to reverse the trend of self-reported low levels of confidence and address these concern head-on.

The suggestion that ophthalmic photography could negate the need to learn how to perform ophthalmoscopy fails to recognise the acute settings in which this skill is required. A junior doctor on-call overnight in the medical assessment unit assessing a patient with headache is not likely to have access to such photographic equipment, just as a junior doctor examining a patient with breathlessness would not have immediate access to a chest radiograph.

Implementation of simulation training and electronic resources in many medical schools has helped to deliver a more engaging and encompassing curriculum. Support for the validity of fundus simulators is gathering momentum. This is an under utilised teaching tool with the potential to maximise clinical confidence and competence when clinical opportunities may be scarce.⁵

As ophthalmic educators we need to tackle this on-going educational need at a postgraduate level in addition to undergraduate training so that the next generation of students and physicians are equipped with the skills they need to improve patient outcomes.