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A Prospective Study of the Longitudinal Effects of an Embedded Specialty Curriculum on Physical Examination Skills Using an Ophthalmology Model

Mottow-Lippa, Linda MD; Boker, John R. PhD; Stephens, Frances

doi: 10.1097/ACM.0b013e3181bb2d51
Clinical Skills

Purpose To prospectively evaluate effects of a longitudinal specialty curriculum on acquisition and retention of ophthalmic screening examination skills in a single class across three years of medical school (2004–2007).

Method Immediately after initial Year 2 skills training, preceptors evaluated students' (N = 84) acquisition of basic eye screening examination skills. Similarly, the students self-assessed their skills. In Year 3, a required ophthalmology small-group module during the family medicine (FM) clerkship reinforced these skills. The authors audited history and physicals in two Year 3 clerkships and in one Year 4 subinternship to evaluate charted examination performance. They objectively assessed simulator-based ophthalmoscopy post-FM clerkship and post-Year 3 training.

Results Preceptors rated 100% of students competent in all eye examination modalities post initial training; 98% of students self-rated themselves competent in disc visualization. An expert auditor found documented FM funduscopies (46%) surpassed those in a prior observational study (11%). Funduscopic retraining significantly improved performance on post-Year 3 objective assessment (mean score 55% retrained versus 19% nonretrained, P = .0005). However, 43% of FM and 91% of internal medicine workups reflected inadequate overall eye evaluations. Subinternship notes documented muscle excursions in 95% and pupils in 71% but recorded no funduscopies.

Conclusions Additional training successfully reinforced skills performance, which nonetheless decayed when not habitually practiced. Neither physical diagnosis preceptor ratings nor excellent performance in the FM ophthalmology module predicted subsequent skills performance in other clerkships or on simulator testing. The present study supports a reiterative retraining model for teaching this and other specialty physical examination skills.

Dr. Lippa is professor of ophthalmology and director of ophthalmology medical student education, The Gavin Herbert Eye Institute, University of California-Irvine, Irvine, California.

Dr. Boker, formerly director of medical education research at University of California-Irvine, is currently vice president, Academic Affairs, Geisinger Health System, Danville, Pennsylvania.

Ms. Stephens is editor, Educational Affairs, University of California-Irvine, Irvine, California.

Correspondence should be addressed to Dr. Linda Mottow-Lippa, Gavin Herbert Eye Institute, 118 Med Surge I, Irvine, California 92697-4375; telephone: (949) 824-4122; fax: (949) 854-8513; e-mail (

© 2009 Association of American Medical Colleges