Current Scope of Online Ophthalmology Education and Curriculum Impact Due to COVID-19

Objective Abrupt changes in ophthalmology education caused by the COVID-19 pandemic have resulted in novel online curriculum development. The aims of this study were to identify (1) the scope of online curricula implemented both prior to and during the COVID-19 pandemic; (2) perception of educators on these online modalities; and (3) early lessons from online implementation that may guide future curricular planning. Methods Implementation of online curricula was evaluated by using a national online survey of Ophthalmology Directors of Medical Student Education (DMSE) via Qualtrics software. Participants Medical Student Educators of the Association of University Professors of Ophthalmology (AUPO) were surveyed. Results Fifty responses were collected, representing a 64.9% response rate. Prior to the COVID-19 pandemic, 44% of institutions had no online components in their courses, but 78.3% of institutions reported increasing online components in response to the pandemic. Required courses were significantly associated both with having implemented online components before the pandemic and implementing online-only versions of these courses in response to the pandemic. The three most popular modalities used for online teaching were lectures, interactive cases, and problem-based learning, with a median satisfaction of 4.0, 4.32, and 4.35, (out of five) respectively. The least popular modalities used were online teaching of physical exam skills and telemedicine, both with a median satisfaction of 2.5. Median overall educator satisfaction with online teaching was four (out of five). The most common weakness related to online teaching was the lack of effective physical exam skills training. Conclusion Our data demonstrate that most institutions successfully shifted their ophthalmology curriculum to a virtual and online version in response to the COVID-19 pandemic. DMSEs adapted quickly, transitioning in-person clinical courses, and extracurricular activities to online formats. Overall, educator satisfaction with online curricula was high. Integration of online curricula provides the opportunity to enrich institutional curriculums and overcome limitations imposed by decreasing curriculum time. This study reveals an early window into the utilization, strengths, and weaknesses of online ophthalmology education, which can serve as a guiding point to enhance ophthalmology curriculum development.

Self-Reported Social Media Use among Ophthalmology Residents

Objective To assess ophthalmology trainees' self-reported use of and attitudes toward social media. Methods An online survey was distributed by email to ophthalmology residency applicants of the Bascom Palmer Eye Institute between September 2016 and January 2020. Results Of the 1,688 email recipients, the survey was filled by 208 ophthalmology trainees (12.3%). Nearly all trainees reported using social media for personal purposes (92.3%), while less than half used social media for professional purposes (43.4%). There were mixed sentiments regarding the impact of social media on the patient–physician relationship, with the majority feeling that it challenges a physician's authority (55.2%) but also empowers the patient (57.5%) and encourages shared care (92.8%). Twenty-five percent of trainees had reviewed professional social media guidelines, and most rated the quality of medical information on social media as “poor” (60.9%). There were low rates of trainees looking up patients (13.8%), providing their account information to patients (1.5%), responding to patients' messages (2.6%), following patients' accounts (2.6%), and being followed by patients (2.6%). Conclusion The majority of ophthalmology trainees are active on social media. As these trainees enter practice, ophthalmology will likely see a rise in social media use. Training programs should consider a formal social media policy that is shared with all trainees as part of their education.

Impact of Video Describing Cataract Surgical Simulator Training on Patients' Perceptions of Resident Involvement in Cataract Surgery

Purpose The aim of this article is to investigate the impact of a 1-minute video describing resident training with a cataract surgical simulator on patients' perceptions regarding resident involvement in cataract surgery and to identify factors associated with patient willingness to have cataract surgery performed by a resident. Design Cross-sectional survey. Methods An anonymous Likert-style survey was conducted among 430 consecutive adult patients who presented for eye examination at the Penn State Health Eye Center. The survey included questions regarding demographics, understanding of the medical training hierarchy, and patient willingness to have a resident perform their cataract surgery. There were six questions regarding patient willingness to have residents perform their cataract surgery and the second question in this set informs the patient that residents are supervised by an experienced cataract surgeon. Patients were randomly assigned to one of two groups: patients in Group 1 completed the survey only, while patients in Group 2 watched a 1-minute video describing resident training with a cataract surgical simulator prior to completing the survey. Results Four hundred fourteen of the 430 patients (96.3%) completed the survey. Overall, 24.7% (n = 102) of respondents expressed willingness to allow an ophthalmology resident to perform their cataract surgery, and that proportion increased to 54.0% (n = 223) if the patient was informed that the resident would be supervised by an experienced cataract surgeon. Patients in Group 2 were twice as likely compared with patients in Group 1 to express willingness to allow an ophthalmology resident to perform their cataract surgery (odds ratio 1.92 [1.18–3.11], p = 0.009). Conclusions A thorough informed consent process including information regarding attending supervision and a brief video detailing resident training with a cataract surgery simulator may increase patient willingness to allow resident participation in cataract surgery.

Sex Disparities in Productivity among Oculoplastic Surgeons

Purpose The aim of the study is to investigate sex differences in academic rank, publication productivity, and National Institute of Health (NIH) funding among oculoplastic surgeons and whether there is an association between American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) membership and scholarly output. Methods Sex, residency graduation year, and academic rank were obtained from institutional websites of 113 U.S. ophthalmology programs. H-indices and m-quotients were obtained from the Scopus database. NIH funding information was obtained from the NIH Research Portfolio Online Reporting Tool. Results Of the 272 surgeons, 74 (30.2%) were females. When adjusted for career duration, differences in female to male proportions were only significant at the rank of assistant professor (assistant: 74.3 vs. 48.5%, p = 0.047; associate: 18.9 vs. 24.6%, p = 0.243; full professor: 13.0 vs. 37.2%, p = 0.114). Women had a shorter career duration than men [10.0 (interquartile range or IQR 12.0) vs. 21.0 (IQR 20.0) years; p < 0.001] and a lower h-index [4.0 (IQR 5.0) vs. 7.0 (IQR 10.0); p < 0.001], but similar m-quotients [0.4 (IQR 0.4) vs. 0.4 (IQR 0.4); p = 0.9890]. Among ASOPRS members, females had a lower h-index than males [5.0 (IQR 6.0) vs. 9.0 (IQR 10.0); p < 0.001] due to career length differences. No difference in productivity between sexes was found among non-ASOPRS members. ASOPRS members from both sexes had higher scholarly output than their non-ASOPRS counterparts. Just 2.7% (2/74) of females compared with 5.3% (9/171) of males received NIH funding (p = 0.681). Conclusion Sex differences in academic ranks and h-indices are likely due to the smaller proportion of females with long career durations. ASOPRS membership may confer opportunities for increased scholarly output.

Evolution of a Glaucoma Fellow's Surgical Training: Improvements in Tube Shunt Case Times during the Academic Year

Purpose The aim of the study is to report changes in tube shunt placement surgical case times for glaucoma fellows during the course of the academic year. Patients and Methods Electronic health records were retrospectively reviewed to determine patient demographics, surgical case times (defined as procedure start time to procedure end time), and glaucoma fellow involvement. Only cases with a glaucoma fellow as the primary surgeon were included. Operative case times were compared by first and second halves of the academic year (beginning in July and ending in June) using a two-tailed t-test. Results Five hundred and seventy-three individual tube shunt surgeries (385 Ahmed, 188 Baerveldt) performed by 28 glaucoma fellows (17 females, 11 males) at Duke University Eye Center and University of North Carolina Medical Center were included. Overall, case times were significantly shorter in the second half of the academic year as compared with the first (55.3 ± 17.1 minutes vs. 61.0 ± 17.4 minutes, p <0.001). Both male (57.3 ± 16.8 minutes vs. 63.2 ± 18.6 minutes, p = 0.008) and female (53.5 ± 17.3 minutes vs. 59.3 ± 16.4 minutes, p = 0.003) fellows demonstrated shorter case times over the academic year; additionally, female fellows trended toward shorter case times than male fellows in both the first half (p = 0.072) and second half (p = 0.053) of the academic year. Fellows also exhibited shorter case times with both Ahmed implants (54.1 ± 16.2 minutes vs. 59.3 ± 15.8 minutes, p = 0.002) and Baerveldt implants (57.8 ± 18.9 minutes vs. 64.2 ± 20.0 minutes, p = 0.025) cases over the academic year. Baerveldt case times were significantly longer than Ahmed cases in the first half (p = 0.028) and trended toward being longer than Ahmed cases in the second half (p = 0.070). Conclusion Across 5 years at two academic institutions, glaucoma fellows had shorter primary tube shunt surgical case times in the second half of the academic year. These findings reflect improvement in surgical efficiency throughout glaucoma fellowship. These findings should be taken into consideration when scheduling trainee surgeries at academic medical centers at different points in the academic year.

Correlation of Ophthalmology Residency Application Characteristics with Subsequent Performance in Residency

Purpose Only from reviewing applications, it is difficult to identify which applicants will be successful ophthalmology residents. The change of the USMLE Step 1 scoring to “Pass/Fail” removes another quantitative metric. We aimed to identify application attributes correlated with successful residency performance. This study also used artificial intelligence (AI) to evaluate letters of recommendation (LOR), the Dean's letter (MSPE), and personal statement (PS). Design Retrospective analysis of application characteristics versus residency performance was conducted. Participants Residents who graduated from the Dean McGee Eye Institute/University of Oklahoma Ophthalmology residency from 2004 to 2019 were included in this study. Methods Thirty-four attributes were recorded from each application. Residents were subjectively ranked into tertiles and top and bottom deciles based on residency performance by faculty present during their training. The Ophthalmic Knowledge Assessment Program (OKAP) examination scores were used as an objective performance metric. Analysis was performed to identify associations between application attributes and tertile/decile ranking. Additional analysis used AI and natural language processing to evaluate applicant LORs, MSPE, and PS. Main Outcome Measures Characteristics from residency applications that correlate with resident performance were the primary outcome of this study. Results Fifty-five residents and 21 faculty members were included. A grade of “A” or “Honors” in the obstetrics/gynecology (OB/GYN) clerkship and the presence of a home ophthalmology department were associated with ranking in the top tertile but not the top decile. Mean core clerkship grades, medical school ranking in the top 25 U.S. News and World Report (USNWR) primary care rankings, and postgraduate year (PGY)-2 and PGY-3 OKAP scores were predictive of being ranked in both the top tertile and the top decile. USMLE scores, alpha-omega-alpha (AOA) status, and number of publications did not correlate with subjective resident performance. AI analysis of LORs, MSPE, and PS did not identify any text features that correlated with resident performance. Conclusions Many metrics traditionally felt to be predictive of residency success (USMLE scores, AOA status, and research) did not predict resident success in our study. We did confirm the importance of core clerkship grades and medical school ranking. Objective measures of success such as PGY-2 and PGY-3 OKAP scores were associated with high subjective ranking.

Survey of Microinvasive Glaucoma Surgery and Other Glaucoma Surgical Experience among United States Ophthalmology Residency Programs

Purpose The aim of the study is to assess the state of glaucoma surgical training in United States ophthalmology residency programs, including experience with microinvasive glaucoma surgery (MIGS). Design The design of the study is anonymous, internet-based national survey. Participants Current United States ophthalmology residents of residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME). Methods An anonymous survey link was emailed to all 120 accredited United States ophthalmology residency programs inviting residents to participate in an assessment of residency glaucoma surgical experience. Survey responses were collected between January 21, 2019 and March 4, 2019 and analyzed using descriptive statistics. Main Outcome Measures The main outcomes of the study are demographic information, practice intentions, and anticipated primary surgical experience with ACGME-required glaucoma procedures and MIGS procedures, as self-reported by U.S. ophthalmology residents. Results Of the estimated 1,479 U.S. ophthalmology residents, 161 residents participated (10.9%). A total of 118 residents (73.2%) reported any degree of anticipated MIGS primary surgical experience during residency, with the iStent being the most familiar technique. The likelihood of any anticipated MIGS experience during residency was not significantly different by geographic region (p = 0.16), however, anticipated volume varied significantly (p = 0.037). Of the 113 respondents who reported an intention to manage glaucoma surgically in their eventual practice, 25 (22.1%) reported no anticipated primary MIGS experience during residency. 73.3% of residents anticipating MIGS experience anticipated 0 to 10 cases, with 42.9% anticipating less than 5 cases as primary surgeon. Conclusion MIGs are not a required component of the glaucoma surgical curriculum for U.S. ophthalmology residents. Although the majority of ophthalmology residents surveyed intend to manage glaucoma surgically in eventual practice, most receive minimal experience with these novel techniques during residency. Surgical training is variable by geographic region.

Factors Influencing Choice of Medical Specialty among Ophthalmology and Non-Ophthalmology Residency Applicants

Objective The study aimed to investigate factors influencing choice of specialty among ophthalmology and non-ophthalmology residency applicants. Patients and Methods Anonymous, web-based surveys were distributed through REDCap to the 2019 to 2020 residency applicants to the Penn State Department of Ophthalmology and, as a control group, Penn State medical students applying to non-ophthalmology residencies for the 2019 to 2020 cycle. The primary outcome was factors that influenced specialty choice among ophthalmology versus non-ophthalmology applicants. Secondary outcomes include hours of exposure to applicants' selected specialty in the medical school preclinical curriculum, and proportion of ophthalmology versus non-ophthalmology applicants who decided on, or developed a strong interest in, their specialty prior to clinical rotations. Results Surveys were completed by 203/441 (46.0%) ophthalmology and 85/139 (61.1%) non-ophthalmology applicants. Fewer than 20 hours of exposure to an applicant's selected specialty were provided in the medical school preclinical curriculum for 86.7% of ophthalmology and 42.4% of non-ophthalmology applicants (p < 0.001). Ophthalmology applicants decided on, or developed a strong interest in, their selected specialty before clinical rotations at a similar rate to non-ophthalmology applicants (60.6 vs. 58.8%, respectively). Factors influencing specialty choice cited most commonly by ophthalmology applicants include professional satisfaction (94.1%), performing surgeries/procedures (92.6%), personal fit with specialty (91.1%), work-life balance (91.1%), and ability to see patients in a clinic setting (90.6%), compared to personal fit with specialty (95.3%)%, clinical rotation in selected specialty (95.3%), professional satisfaction (91.8%), intellectual stimulation (89.4%), and subinternship or away rotation (89.4%) among non-ophthalmology applicants. Conclusion Professional satisfaction and personal fit with specialty were among the most commonly cited factors influencing specialty choice for both groups. Other factors cited most frequently by ophthalmology applicants include performing surgeries/procedures, work-life balance, and ability to see patients in a clinic setting. Despite limited ophthalmology exposure in medical school preclinical curricula, ophthalmology applicants decided on, or developed a strong interest in, their selected specialty before clinical rotations at a rate similar to non-ophthalmology applicants.

Trends in Ophthalmology Resident Operative Experience and the Early Impact of the COVID-19 Pandemic

Purpose This study aimed to evaluate trends in ophthalmology resident operative experience and the early impact of the novel coronavirus disease 2019 (COVID-19) pandemic. Design Present study is a retrospective analysis of the Accreditation Council for Graduate Medical Education (ACGME) Case Log System. Participants Anonymized graduating resident case logs from 2011 to 2020 academic years (AYs) were examined for this study. Methods Regression analysis for each procedure category was performed to identify trends between 2011 and 2019 AYs. Unpaired two-tailed t-test compared 2018 to 2019 and 2019 to 2020 AY's for each category surgeon (S) and as surgeon and assistant (S + A). Main Outcome Measures Mean and median cases as (S) and (S + A) during 2011 to 2019 AYs. Comparison between 2018 to 2019 and 2019 to 2020 AY's for each category as (S) and (S + A) to evaluate the impact of the COVID-19 pandemic. Results Total ophthalmology procedures as (S) rose from a mean of 479.6 to 601.3 (p < 0.001; R 2 = 0.96; Δ/year = 16.9) and a median of 444 to 537 (p < 0.001; R 2 = 0.97; Δ/year = 13.1). Total procedures as (S + A) rose from a mean of 698.1 to 768 (p < 0.01; R 2 = 0.83; Δ/year = 9.07) and a median of 677 to 734 (p < 0.05; R 2 = 0.61; Δ/year = 6.64). Cataract procedures as (S) rose from a mean of 152.8 to 208 (p < 0.001; R 2 = 0.99; Δ/year = 7.98) and a median of 146 to 197 (p < 0.001; R 2 = 0.97; Δ/year = 7.87). Cataract procedures as both (S + A) rose from a mean 231.4 to 268.7 (p < 0.001; R 2 = 0.95; Δ/year = 5.5) and a median of 213 to 254 (p < 0.001; R 2 = 0.93; Δ/year = 5.33). Between 2018 to 2019 and 2019 to 2020 AYs, the first pandemic year was associated with significant reductions in total procedures (601.3–533.7 [p < 0.0001]) as (S) and 768.0 to 694.4 (p < 0.0001) as (S + A), cataract surgery (208–162.2 [p < 0.0001]) as (S) and 268.7 to 219.1 (p < 0.0001) as (S + A), and glaucoma surgery (16.3–14.2 [p = 0.0068]) as (S) and 25.6 to 22.6 (p = 0.0063) as (S + A). Conclusion During 2011 to 2019 AYs, cataract, intravitreal injections, glaucoma, and total procedures increased significantly. During the early period of the COVID-19 pandemic (2019–2020 AY), national halting of elective procedures had a precipitous effect on resident cataract surgery experience to volumes similar to 2013 to 2014 AY where the mean was twice the current required minimum number. With few exceptions, other procedure volumes remained stable.

A Comparison of the Flipped Classroom Model for Medical Student Education in Ophthalmology before and during the COVID-19 Pandemic

Background The coronavirus disease 2019 (COVID-19) pandemic has necessitated a shift of medical education to online learning in lieu of traditional clinic-based rotations. The flipped classroom model, which has been shown to be an effective approach to the medical student ophthalmology curriculum, shows promise as a method of learning that can be shared virtually. As such, the aim of this study was to investigate the effectiveness of a flipped classroom approach to the primary care-focused ophthalmology clerkship delivered entirely online in the face of the COVID-19 pandemic. Methods Medical students who completed the 2-week introductory clinical ophthalmology clerkship from July 2019 to July 2020 were included in this study. The curriculum centers on a flipped classroom model and was delivered in person prior to March 2020, after which it transitioned to an online format for 5 months. A survey was administered to students completing this rotation, which utilized 6-point Likert scales to assess students' interest in the field of ophthalmology, perceptions of the flipped classroom curriculum, and confidence in evaluating ophthalmic complaints. The cohort that completed in-person learning was then compared with the cohort that completed online learning. Results A total of 112 responding students were included in our analysis, with 68/82 students from the in-person cohort and 44/66 students in the online cohort responding to the survey. Students who participated in the online virtual clerkship were equally likely to feel comfortable evaluating eye complaints than those who participated in the in-person clerkship, and more likely to report that the course enhanced their interest in ophthalmology. However, online students were less likely to feel comfortable using the direct ophthalmoscope compared with those in the in-person cohort. Conclusion Regardless of its mode of delivery, the flipped classroom model is able to impart confidence in evaluating ophthalmic complaints and interest in the field of ophthalmology to medical students. While online learning can never serve as a full replacement for learning physical examination skills and other important clinical experiences, there are aspects of the virtual flipped classroom that do not compromise student's learning and engagement and may be implemented into curricula even after clinical activities are allowed to resume.