Teaching ophthalmoscopy to medical students (the TOTeMS study)

Am J Ophthalmol. 2013 Nov;156(5):1056-1061.e10. doi: 10.1016/j.ajo.2013.06.022. Epub 2013 Sep 13.


Purpose: To determine medical student preferences for learning the ocular fundus examination and to assess their accuracy using different examination modalities.

Design: Prospective, randomized study of medical student education approaches.

Methods: First-year medical students received training in direct ophthalmoscopy using simulators and human volunteers. Students were randomized to receive vs not receive specific training on interpreting fundus photographs prior to accuracy assessments. Students' preferences for each of the 3 methods (direct ophthalmoscopy on simulators or human volunteers, or use of fundus photographs) and recognition of normal and abnormal fundus features were assessed.

Results: Of 138 first-year medical students, 119 (86%) completed all required elements. For learning ophthalmoscopy, 85 (71%) preferred humans to simulators. For learning relevant features of the ocular fundus, 92 (77%) preferred photographs to ophthalmoscopy on simulators or humans. Accuracy of answers was better when interpreting fundus photographs than when performing ophthalmoscopy on simulators (P < .001). Performance improved after specific teaching about assessing fundus photographs before testing (P = .02). Examination of the ocular fundus was found easier and less frustrating when using photographs than when using ophthalmoscopy on simulators or humans. Eighty-four students (70%) said they would prefer to have fundus photographs instead of using the ophthalmoscope during upcoming clinical rotations.

Conclusions: Students preferred fundus photographs for both learning and examining the ocular fundus. Identification of ocular fundus features was more accurate on photographs compared to examination by direct ophthalmoscopy. In the future, the increasing availability of nonmydriatic ocular fundus photography may allow replacement of direct ophthalmoscopy in many clinical settings for non-ophthalmologists.

Publication types

  • Randomized Controlled Trial
  • Research Support, N.I.H., Extramural

MeSH terms

  • Clinical Competence*
  • Education, Medical, Undergraduate / methods*
  • Educational Measurement
  • Female
  • Fundus Oculi
  • Humans
  • Male
  • Ophthalmology / education*
  • Ophthalmoscopy / methods*
  • Patient Simulation
  • Photography
  • Physical Examination
  • Prospective Studies
  • Retina / anatomy & histology
  • Retinal Diseases / diagnosis
  • Students, Medical*
  • Teaching / methods*
  • Young Adult