Evaluation of an ophthalmology virtual elective during the COVID-19 pandemic

Pamela Capellan; Benedict Harvey; Kyle Godfrey; Paul Petrakos; Jeffrey Francis McMahon; Shaily Shah; Marc Joshua Dinkin; Donald J D'Amico; Grace Sun; Ana Alzaga Fernandez

doi:10.4103/pajo.pajo_30_22

ORIGINAL ARTICLE

Year : 2022 | Volume : 4 | Issue : 1 | Page : 41

Evaluation of an ophthalmology virtual elective during the COVID-19 pandemic

Pamela Capellan¹, Benedict Harvey¹, Kyle Godfrey¹, Paul Petrakos¹, Jeffrey Francis McMahon¹, Shaily Shah², Marc Joshua Dinkin¹, Donald J D'Amico¹, Grace Sun¹, Ana Alzaga Fernandez¹
¹ Department of Ophthalmology, Weill Cornell Medicine, New York, NY, USA
² Northern California Cornea Associates, Inc., Walnut Creek, CA, 94958, USA

Date of Submission	07-Jun-2022
Date of Decision	28-Jun-2022
Date of Acceptance	08-Jul-2022
Date of Web Publication	24-Aug-2022

Correspondence Address:
Ana Alzaga Fernandez
Department of Ophthalmology, Weill Cornell Medicine, 1305 York Ave, New York 10021, NY
USA

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/pajo.pajo_30_22

Abstract

Objectives: To evaluate if the Weill Cornell Medicine (WCM) Ophthalmology Virtual Elective provided students with 1) an increased knowledge of ophthalmology, 2) an understanding of the residency program and department, and 3) an opportunity for the program faculty to become acquainted with the students. To determine how future virtual electives may be improved to increase efficacy of achieving these objectives.
Methods: A 2-week virtual ophthalmology elective was offered to 4^th-year medical students. The curriculum included dedicated medical student lectures and assignments and supplemental resources from the American Academy of Ophthalmology. Students also participated in grand rounds, resident morning lectures, and delivered case presentations to the faculty. Pre- and postassessments were performed to evaluate medical knowledge, and a subjective experience survey was distributed to evaluate faculty and student experiences.
Results: Seventeen, fourth-year medical students participated in the elective, and 12 students completed the voluntary pre- and postassessments of medical knowledge. Significant improvement in medical knowledge was noted. Median preassessment score was 80% (interquartile range [IQR]: 78%, 83%), and the median postassessment score was 100% (IQR: 90%, 100%), P = 0.0055. Sixteen students and four faculty members completed their respective subjective experiences in a Likert scale survey. Most students indicated they felt fairly confident or very confident that they had acquired knowledge, made relationships with faculty, and had become familiar with the program and departmental culture. All faculties indicated they agreed or strongly agreed that they were able to assess students' abilities and establish rapport with the students. Both students and faculty felt limited in the assessment of clinical skills due to a lack of in-person activities.
Conclusions: Despite its inherent limitations, an ophthalmology virtual elective can effectively increase interest and knowledge within the field of ophthalmology, facilitate student–faculty relations, and serve as a tool for residency programs in the era of COVID-19 and thereafter.

Keywords: Elective, ophthalmology, virtual

How to cite this article:
Capellan P, Harvey B, Godfrey K, Petrakos P, McMahon JF, Shah S, Dinkin MJ, D'Amico DJ, Sun G, Fernandez AA. Evaluation of an ophthalmology virtual elective during the COVID-19 pandemic. Pan Am J Ophthalmol 2022;4:41

How to cite this URL:
Capellan P, Harvey B, Godfrey K, Petrakos P, McMahon JF, Shah S, Dinkin MJ, D'Amico DJ, Sun G, Fernandez AA. Evaluation of an ophthalmology virtual elective during the COVID-19 pandemic. Pan Am J Ophthalmol [serial online] 2022 [cited 2023 May 28];4:41. Available from: https://www.thepajo.org/text.asp?2022/4/1/41/354532

Introduction

COVID-19 has presented obstacles in medical education and practice around the world. With the need for appropriate social distancing measures for public and personal health and safety, the Coalition for Physician Accountability recommended in May 2020 that all sub-internships and elective away rotations be halted immediately, applying pressure on institutions to adapt rapidly.^[1] This presented challenges to medical education and medical residency programs alike in the ability to foster student interest in particular specialties and facilitate the residency selection process, respectively. This is especially true for ophthalmology, a specialty that medical students receive limited training in throughout their undergraduate medical education.^[2] Limited access to away rotations during the pandemic compounded these challenges for medical students who did not have an ophthalmology department at their home medical institution, and could not gain exposure by visiting departments outside of their medical college.^[3]

An outcome of COVID-19 is the emergence of educational, virtual, and curricular offerings across various medical specialties in both pre-clinical medical education and as elective courses.^{[4],[5],[6],[7],[8]} Multiple studies have focused on how to optimize virtual learning through different platforms and venues.

Methods

The primary endpoint of the study was to determine if there was an increase in medical student knowledge of ophthalmology following the virtual elective. Secondary endpoints were to assess if the medical students acquired a more profound understanding of the residency program and department culture and if the faculty became acquainted with the students throughout the elective.

Overview

Fourth-year medical students were offered participation in a 2-week virtual ophthalmology elective through the Weill Cornell Medicine department of Ophthalmology from August to October 2020. Utilizing video communication software (Zoom™, San Jose, CA, USA), rotating medical students attended dedicated medical student lectures, departmental grand rounds, resident morning lectures, surgical conferences, neuroradiology rounds, journal clubs, and virtual pathology laboratories. In addition, the elective curriculum included ten assigned, prerecorded lectures based on the book “Basics of Ophthalmology Essentials for Medical Students, Tenth Edition” from the American Academy of Ophthalmology (AAO), followed by self-assessment evaluations. The curriculum also consisted of assigned case presentations, literature reviews, and a final project presentation which was presented virtually to faculty members. All information about assignments and curricular submissions were completed through Google Classroom (Google LLC, Mountain View, CA, USA). Students were encouraged to participate actively and engage with the faculty in lectures, by e-mail, and through departmental educational events.

Pre- and postcurriculum assessment

Before beginning the elective, students were encouraged to complete a precurriculum assessment of ten multiple-choice ophthalmology clinical questions based off the book “Basics of Ophthalmology Essentials for Medical Students Tenth Edition” from the AAO. The material was then reviewed over 2 weeks through ten prerecorded lectures utilizing the same textbook, and the identical questions were presented in different number order as a postcurriculum assessment. The goal of this assessment was to determine if the virtual elective increased the students' medical knowledge of ophthalmology. Participant performance assessment was voluntary, anonymous, and untraceable.

Subjective experience survey

At the end of the elective, students and faculty were asked to complete a voluntary and anonymous online Likert scale survey focused on their subjective experience. The survey was created based on surveys used in similar published studies.^[6],[7] Google Forms (Google LLC, Mountain View, CA, USA) was used to create and conduct both the assessments and survey. The variables of interest of the student and faculty surveys were measured. Additionally, the survey had an open-ended response section where students shared which elements of the virtual elective worked and did not work well for them and suggestions for improvement [Table 1] and [Table 2].

Table 1: Summary of the student free responses in subjective experiences survey

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Table 2: Summary of the faculty free responses in subjective experiences survey

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Statistics

The median and interquartile range (IQR) were calculated for the pre- and posttest scores. The Wilcoxon rank-sum test was used to compare median knowledge scores pre- and postassessment. All P values are two-sided, with statistical significance evaluated at the 0.05 alpha level. All analyses were performed in R Version 4.0.2 (R Foundation for Statistical Computing, Vienna, Austria).

Results

Study participants

Seventeen, fourth-year medical students participated in the virtual elective. 16/17 students completed an acquisition questionnaire as part of the subjective experiences survey. Fifty percent of the students did not have an ophthalmology department at their home institution. About 87.6% of the students had completed an in-person elective or rotation in ophthalmology before the virtual elective in this study.

Four faculty members from the department of ophthalmology participated in the elective.

Pre- and postcurriculum assessment

12/17 students completed the voluntary pre- and postmedical knowledge assessment. The median preassessment score was 80% (IQR: 78%, 83%). The median postassessment score (±standard deviation) was 100% (IQR: 90%, 100%). The Wilcoxon signed-rank showed there was a significant difference between the median posttest and pretest score (P = 0.0055) [Figure 1].

Figure 1: Box plot of pre- and postelective acquisition assessments (n = 12). Assessments were multiple-choice questionnaires with clinical scenarios

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Student subjective experience survey

16/17 completed the subjective experience survey. About 93.8% of the students indicated “agree” or “strongly agree” when asked if their fund of knowledge in ophthalmology had increased by taking this virtual elective and that the curriculum provided them with basic knowledge in ophthalmology. About 62.5% of the students indicated “agree” or “strongly agree” when asked if they felt confident in conducting an eye examination after taking this virtual elective.

Regarding exposure to the program environment, 87.6% of students indicated “agree” Weill Cornell Ophthalmology program and if they garnered a good sense of the culture and environment at the Weill Cornell Ophthalmology program. About 81.3% of the students indicated “agree” or “strongly agree” when asked if they established rapport with the faculty at the Weill Ophthalmology program. About 87.6% of the students indicated “agree” or “strongly agree” when asked if they felt confident that the faculty at the Weill Ophthalmology program were able to learn more about them [Figure 2].

Figure 2: Bar Graph of WCM Virtual Experience Subjective Student Survey (n = 16). 87.6% strongly agreed or agreed that the virtual elective provided them the opportunity to learn more about the WCM ophthalmology program. 81.3% of students strongly agreed or agreed that they were able to establish rapport with the WCM faculty. WCM: Weill Cornell Medicine

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Faculty subjective experience survey

Four faculty members (no authors of this study) completed the subjective experience survey. They were posed questions assessing their degree of confidence in evaluating the students generally, strengths and weaknesses of each individual student, communicative skills, and if they as faculty members felt they had built rapport with the students. All faculty members designated they felt either “fairly confident” or “very confident” in assessing the students for each of these items. All faculty members designated they “agree” or “strongly agree” that they built rapport with students and got to know the students on a personal level [Figure 3].

Figure 3: Bar graph of WCM Virtual Experience Subjective Faculty Survey (n = 4). 100% of faculty members strongly agreed or agreed that they were confident in assessing the students in various areas and were able to establish rapport with the students. WCM: Weill Cornell Medicine

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Discussion

The COVID-19 pandemic has presented novel challenges and obstacles to the state of undergraduate medical education potentially compounding the already limited exposure of medical students to certain fields of medicine.^[1] Many institutions have adapted to these obstacles rapidly, offering virtual curricula to medical students, but few publications have examined the efficacy of COVID-era virtual electives in ophthalmology.^{[4],[7],[10],[11],[12],[13]} The current study examines the objective and subjective outcomes of a 2-week virtual ophthalmology elective at Weill Cornell Medicine for 4^th-year medical students. We believe that we successfully accomplished the objectives of the program as assessed by the evaluation modalities and direct feedback from the student and faculty surveys. Since several of the students of our study cohort applied to our residency program, we also strongly believe that our program increased students' knowledge in our field, thus giving them the confidence to pursue ophthalmology and obtain training at various programs.

During this time, residency programs were forced to provide students virtual away electives, and many had success with its implementation. At Columbia University's Department of Urology, all participating students rated the virtual elective as “very good.” Similarly to our virtual elective, the students got a sense of the department's culture and gained foundational knowledge in urology.^[14] At the University of Rochester's orthopedic surgery virtual away elective, the students interacted with the faculty and residents through didactics, presentations, and one-on-one mentorship. The students felt the elective offered them the opportunity to get to know the faculty and residents. Meanwhile, the faculty believed it was somewhat useful to assess a student's knowledge and communication skills.^[15] In our program, the students had various interactions with the faculty and residents allowing students to build relationships with individuals of the department. Other specialties such as pathology, otolaryngology, and plastic surgery noted similar results in their respective virtual electives.^{[16],[17],[18]} Our program demonstrated similar efficacy to other virtual away electives across the country in various subspecialties, thus indicating that virtual away electives are a reasonable substitute regardless of specialty and its existence may extend beyond the COVID-19 pandemic.

As restrictions are being lifted due to the evolving nature of COVID-19 and vaccination, we hope to reinstitute the in-person away elective in a hybrid model that will incorporate components of the virtual elective along with the lessons that have been learned in the process. Along with return to patient care and in-person interactions, we hope to strengthen the elective by including the prerecorded lectures, virtual grand rounds, remote assignments, and webcam faculty interactions. With these considerations for our future planning and for other programs, it is also important to note the increased accessibility and opportunity a virtual elective may provide for those with financially limited resources.^[19],[20] Given the numerous students from medical colleges without an ophthalmology department, the virtual elective serves as an alternative option for students to gain exposure to the field post the COVID-19 era.

The surveys revealed some inherent limitations in our elective due to its virtual nature, such as the difficulty facilitating an improvement in hands-on examination skills and incorporating patient interactions. The study itself had several limitations. The multiple-choice pre- and postassessments were created based on material from the AAO's book, Basics in Ophthalmology Essentials for Medical Students, but have not been validated formally. Although the assessments and surveys were voluntary, anonymous, and untraceable, it is possible some students may have held back criticism for fear they might be identified. Only four faculty members completed the survey since they were the ones working closely with the students participating in the elective. Finally, the study did not include a control group comprised in-person students to compare with the virtual elective group. These are areas for future study.

This study highlights the success and means by which an effective virtual elective may be implemented. Despite the need for social distancing and limitations of the virtual platform, virtual learning with interactive components can offer students the opportunity to garner a rich perspective, knowledge, and understanding of ophthalmology and residency program culture, while also offering faculty the capacity to develop meaningful relationships with students located across the country. While there are inherent shortcomings of an entirely virtual curriculum, we believe the virtual away elective offers a novel opportunity for reconsidering the implementation of away-medical student education. We hope to modify the away elective with the lessons learned from this study and incorporate successful components of the virtual curriculum to dynamically engage students interested in ophthalmology through both in-person and virtual modalities to maximize curricular, residency selection, and ophthalmologic education efficacy in the future.

Acknowledgments

The authors would like to thank Anjile An, MPH, for statistical support.

Financial support and sponsorship

This study was supported in part by an Unrestricted Departmental Grant from Research to Prevent Blindness, Inc.

Conflicts of interest

There are no conflicts of interest.

References

1.	Tempski P, Arantes-Costa FM, Kobayasi R, et al. Medical students' perceptions and motivations during the COVID-19 pandemic. PLoS One. 2021;16(3 March):1-15. doi:10.1371/journal.pone.0248627.
2.	Shah M, Knoch D, Waxman E. The state of ophthalmology medical student education in the United States and Canada, 2012 through 2013. Ophthalmology 2014;121:1160-3.
3.	Linz MO, Jun AS, Clever SL, Lawson SM, Sanyal A, Scott AW. Evaluation of medical students' perception of an ophthalmology career. Ophthalmology 2018;125:461-2.
4.	Chatziralli I, Ventura CV, Touhami S, Reynolds R, Nassisi M, Weinberg T, et al. Transforming ophthalmic education into virtual learning during COVID-19 pandemic: A global perspective. Eye (Lond) 2021;35:1459-66.
5.	Ruthberg JS, Quereshy HA, Ahmadmehrabi S, Trudeau S, Chaudry E, Hair B, et al. A multimodal multi-institutional solution to remote medical student education for otolaryngology during COVID-19. Otolaryngol Head Neck Surg 2020;163:707-9.
6.	Steehler AJ, Pettitt-Schieber B, Studer MB, Mahendran G, Pettitt BJ, Henriquez OA. Implementation and evaluation of a virtual elective in otolaryngology in the time of COVID-19. Otolaryngol Head Neck Surg 2021;164:556-61.
7.	Xu L, Ambinder D, Kang J, Faris S, Scarpato K, Moy L, et al. Virtual grand rounds as a novel means for applicants and programs to connect in the era of COVID-19. Am J Surg 2021;221:956-61.
8.	Sukumar S, Zakaria A, Lai CJ, Sakumoto M, Khanna R, Choi N. Designing and implementing a novel virtual rounds curriculum for medical students' internal medicine clerkship during the COVID-19 pandemic. MedEdPORTAL 2021;17:11106.
9.	Coffey CS, MacDonald BV, Shahrvini B, Baxter SL, Lander L. Student perspectives on remote medical education in clinical core clerkships during the COVID-19 pandemic. Med Sci Educ 2020;30:1577-84.
10.	He B, Tanya S, Sharma S. Perspectives on virtual ophthalmology education among Canadian medical students. Can J Ophthalmol 2021;56:208-9.
11.	DeVaro SN, Uner OE, Khalifa YM, Graubart EB. Ophthalmology education in COVID-19: A remote elective for medical students. J Acad Ophthalmol 2020;12:e165-70.
12.	Wendt S, Abdullah Z, Barrett S, Daruwalla C, Go JA, Le B, et al. A virtual COVID-19 ophthalmology rotation. Surv Ophthalmol 2021;66:354-61.
13.	Mishra K, Boland MV, Woreta FA. Incorporating a virtual curriculum into ophthalmology education in the coronavirus disease-2019 era. Curr Opin Ophthalmol 2020;31:380-5.
14.	Margolin EJ, Gordon RJ, Anderson CB, Badalato GM. Reimagining the away rotation: A 4-week virtual subinternship in urology. J Surg Educ 2021;78:1563-73.
15.	Haws BE, Mannava S, Schuster BK, DiGiovanni BF. Implementation and evaluation of a formal virtual medical student away rotation in orthopaedic surgery during the COVID-19 pandemic: A single institution pilot experience. JB JS Open Access 2021;6:e21.00037.
16.	Koch LK, Correll-Buss A, Chang OH. Implementation and effectiveness of a completely virtual pathology rotation for visiting medical students. Am J Clin Pathol 2022;157:406-12.
17.	Bernstein JD, Ball LL, Nardone ZB, Watson D. A virtual sub-internship for otolaryngology-head and neck surgery. Laryngoscope Investig Otolaryngol 2021;6:952-7.
18.	Tucker AB, Pakvasa M, Shakir A, Chang DW, Reid RR, Silva AK. Plastic surgery away rotations during the coronavirus disease pandemic: A virtual experience. Ann Plast Surg 2022;88:594-8.
19.	Griffith M, DeMasi SC, McGrath AJ, Love JN, Moll J, Santen SA. Time to reevaluate the away rotation: Improving return on investment for students and schools. Acad Med 2019;94:496-500.
20.	Winterton M, Ahn J, Bernstein J. The prevalence and cost of medical student visiting rotations. BMC Med Educ 2016;16:291.