Eyesi direct ophthalmoscope simulator: an effective training tool for medical undergraduates | BMC Medical Education

Medical undergraduates often have limited specialty knowledge, clinical experience, and confidence in practice [33]. Many of them consider becoming a doctor as their long-term career plan, with some aspiring to become general practitioners [34,35,36,37]. Therefore, the primary goal of undergraduate medical education is to deepen their understanding of disease signs and symptoms and train them to skillfully perform fundamental examinations to establish valuable diagnostic foundations. Achieving this objective requires systematic and efficient guidance from teachers.

Fundus examination is vital for the diagnosis of various ophthalmological and systemic diseases. It is widely recognized that all medical students and general practitioners should possess a solid understanding and proficiency in fundus examination [38]. In our study, a vast majority of respondents agreed that direct ophthalmoscopy is commonly used, effective, and an essential component of their training. However, it was also acknowledged that mastering this technique is challenging. The Eyesi presents various fundus findings to users, enabling them to observe what a traditional ophthalmoscope would reveal. Participants expressed that Eyesi provides realistic fundus images and offers significant advantages in identifying fundus structures compared to traditional direct ophthalmoscopy. Consequently, Eyesi training proves to be feasible and meets the needs of undergraduate medical students.

We conducted a comparative analysis of operational learning and theoretical knowledge between Eyesi and TDO. Novice learners practicing with TDO may experience discomfort and increased pressure due to repeating examination steps on volunteers or patients [39]. The lack of real-time observation sharing between teachers and students hampers timely guidance, impeding students’ progress.

In contrast, the Eyesi simulator addresses these challenges. While the Eyesi simulator simulates patients’ resistance to light after prolonged examination, it remains an unrestricted practice tool for students. The Eyesi can also automatically time the illumination of the fundus and display the already examined area, reducing patient discomfort due to inexperienced operation and alleviating the psychological burden during the learning process. Moreover, the Eyesi offers the option to simulate different pupil sizes and allows for dilation, enabling students to gradually practice and repeatedly examine until they can observe comprehensive fundus structures, even under smaller pupils, thereby facilitating the learning process. Furthermore, the Eyesi assists in the theoretical learning of relevant retinal diseases. Unlike directly showing fundus images on a screen, the Eyesi simulates the real clinical scenario of using a direct ophthalmoscope, presenting fundus lesions more realistically. Additionally, it displays relevant theoretical knowledge for learning after the user marks the lesions they observe. The Eyesi compensates for the limited availability of clinical patients or cases where patients may not cooperate with students, thereby enabling students to gain insight into typical pathological conditions and reinforce relevant theoretical knowledge. These factors collectively contribute to a more engaging and effective learning experience with the Eyesi simulator. It also emphasizes the importance of performing a comprehensive fundus examination without solely relying on retinal photography, using non-examined peripheral retinal lesions as reminders for students.

The increased confidence observed in Group A can be attributed to these advantages, potentially leading to an improved utilization rate and proficiency of the direct ophthalmoscope in primary medical practice. In conclusion, this training approach aids in identifying fundus structures, enhancing students’ operational abilities, and consolidating their theoretical knowledge of the fundus. Consequently, the Eyesi simulator is expected to be a suitable choice for novices.

The majority of respondents expressed a preference for the Eyesi simulator, considering it to be easier to understand and a more effective learning tool, while TDO is actually implemented in real-world clinical practice. However, starting with TDO as the initial training method may potentially impact participants’ interest in further learning. Therefore, we recommend that undergraduates practice with the Eyesi before transitioning to the traditional method, which is consistent with the preference of most participants in this study. This sequential training method may enhance the learning experience and better prepare students for future clinical settings.

The transition from Eyesi training to using TDO in clinical applications poses multiple challenges for students. They must effectively communicate with patients during the examination process, master precise positioning techniques due to potential instability in patients’ eyes, and adapt to varying pupil sizes. Additionally, the simulator’s limitation to simulating typical retinal lesions contrasts with the diverse and rare conditions encountered in actual clinical practice, necessitating comprehensive understanding and recognition abilities. Furthermore, this transition may lead to confidence and anxiety issues among students. It is important to emphasize that the Eyesi serves as a complement to, rather than a replacement for, real patient experiences in the clinical setting. To address these challenges, educators can offer practical opportunities through simulated clinical practices and real patient training, encouraging students to participate in clinical internships to enhance their clinical competence.

To further investigate whether the Eyesi is a superior training tool, we compared our study with previous studies. With the advancement of technology and the application of virtual reality (VR) in medical education, we have gradually phased out the use of slides or photographs to simulate the fundus in simulators, opting instead for designs that are more closely aligned with clinical practice [40, 41]. In terms of its design advantages, the Eyesi distinguishes itself by closely simulating the shape and function of a real direct ophthalmoscope, utilizing a handheld device and a head-face model, making it more akin to the tools used in actual clinical practice compared to other devices [42,43,44]. Unlike other simulators utilizing VR technology, the Eyesi does not require wearing bulky VR goggles, and according to our questionnaire results, it more accurately simulates the real fundus state [45]. Additionally, the Eyesi’s feature of enabling teachers to provide real-time guidance through a monitoring screen is a valuable asset. Furthermore, its built-in case database of retinal diseases allows students to learn independently and addresses the limitations of TDO and other simulators [41]. In comparison to other study utilizing the Eyesi, and as opposed to conducting separate studies sequentially, our research adopted a parallel-group design to more comprehensively assess participants’ perceptions of different tools simultaneously [46]. Another study focusing on the Eyesi evaluated only the impact of different tools on students’ confidence but also concluded it to be a beneficial teaching tool [47]. Regarding the Eyesi’s indirect ophthalmoscope simulator, existing researches have compared the examination time and detection scores of physicians using this tool, which were superior to those of medical students, further supporting the effectiveness of incorporating the Eyesi simulator into training as a supplementary teaching tool [48, 49]. The number of respondents in our study was significantly larger than that of past studies [25, 50].

From the collected opinions, we found that participants appreciated the Eyesi’s user-friendliness, clarity, adjustable pupil size, and the presentation of typical cases. However, the limited time for practice was noted as an area of improvement. And some challenges with TDO were highlighted, such as a small vision field hindering the identification of common fundus lesions and greater difficulty in operation. Nevertheless, students appreciated its realism and the ability to receive feedback from volunteers. Despite the favorable feedback for the Eyesi, a few students did not fully support its use. To address these concerns, we plan to enhance future courses by allocating additional practice time and thoughtfully selecting built-in cases within the Eyesi.

As for study design, we designed four questionnaires to evaluate the subjective feelings of respondents before and after training and on different training tools, as well as their confidence and willingness to use a direct ophthalmoscope in future work. We also compared undergraduates’ tendencies for different learning purposes, and offered suggestions on learning sequences. Self-reporting questionnaires provide valuable insights into participants’ subjective perceptions, feedback, and satisfaction with course content and training methods [51]. These assessments shed light on the training’s potential benefits in enhancing learners’ skills and self-assurance, allowing us to optimize the program accordingly for a more engaging learning experience. In our study, we have implemented multiple strategies to mitigate potential biases. Firstly, random group assignment was employed to ensure balanced representation in each training group, minimizing selection bias. Secondly, we crafted unbiased survey questions to prevent information bias. Moreover, measures such as respondent anonymity, blind data entry, and analysis were implemented to mitigate response and observer bias during data processing. While we acknowledge the limitations of self-reporting, we have taken meticulous steps to enhance the validity and reliability of our findings within the scope of our study’s constraints.

However, it is essential to establish more objective evaluation indicators, such as written exams and scenario simulation assessments, to effectively measure the enhancement of participants’ theoretical knowledge and practical skills resulting from the utilization of various training methodologies. Additionally, for evaluating the effectiveness of the Kirkpatrick model’s third and fourth levels, long-term observations will be required to assess the participants’ skills and performance in their daily clinical practices. While we acknowledge the current limitations, it is also essential to conduct further research by integrating feedback from both supervising physicians and patients to achieve a comprehensive understanding of the training outcomes in clinical settings. Recognizing this, we are planning a follow-up study that will address these concerns by focusing on specialized physicians who have undergone the training and gathering insights from experienced providers or faculty regarding the Eyesi. This subsequent research will encompass a more comprehensive assessment, including evaluation by teachers in clinical practice and a blinded evaluation methodology. Furthermore, before commencing further research, we will validate the psychometrics of our questionnaires and further refine them to better meet our survey needs.

In general, the Eyesi has shown potential advantages over the traditional direct ophthalmoscope in fundus observation, operational practice, and theoretical learning. Its user-friendly interface and intuitive design indicate it might effectively assist medical students acquiring fundus examination skills during clinical training. The positive reception of the Eyesi by most undergraduates suggests it could be a valuable contribution to ophthalmic preclinical training. This may help promote the use of the direct ophthalmoscope in primary medical institutions and, as a result, contribute to facilitating the early screening and diagnosis of retinal diseases, and aid in evaluating retinal microvascular abnormalities among patients with systemic diseases. This, in turn, has the potential to reduce healthcare costs and preserve medical resources.