really good stuff
What lessons were learned? Firstly, by making expli-
cit the students’ difficulties and their remedial strate-
gies, use of the reflective tool in concept mapping
was helpful to the teachers. Students’ input allowed
them to structure their individual written and verbal
feedback in a targeted, student-centred way. Stu-
dents’ common difficulties were addressed during a
group discussion, which was also used to exchange
remedial strategies. Targeted feedback and peer shar-
ing are recognised as supportive of self-regulation.1
Secondly, the reflective tool increased students’
awareness of their difficulties and prompted them
to think about remedial strategies. However,
because the actual implementation of the chosen
strategy and the remediation of difficulties after the
teacher’s feedback were not formally verified, it is
difficult to conclude that use of the tool enhanced
students’ self-regulation effectively. Furthermore,
the reflective tool was teacher-initiated and did not
encourage students to be proactive in seeking feed-
back. Therefore, ways to increase the proactiveness
of students, which is considered indispensable for
success, should be included in future projects. Fol-
low-up of feedback and strategies with students
should also be included because feedback is most
effective when it is acted upon.1
As it fits easily into a problem-based course design
without increasing students’ and teachers’ workload
and time allotted to tasks, and because of its poten-
tial support of self-regulation and student-centred
feedback in concept mapping, we think this reflec-
tive tool, with the proposed modifications, is a help-
ful addition worthy of educators’ consideration.
REFERENCE
1 Ambrose SA, Bridges MW, DiPietro M, Lovett MC,
Norman MK. How Learning Works. Seven Research-Based
Principles for Smart Teaching. San Francisco, CA: John
Wiley & Sons 2010.


Correspondence: Annie Carrier, Ecole de r
eadaptation,Facult

m
edecine et des sciences de la sant
e, Universit
e de Sherbrooke,
Quebec J1H 5N4, Canada. Tel: 00 1 819-820-6868 ext. 12917;
E-mail: annie.carrier@usherbrooke.ca
doi: 10.1111/medu.12444
A novel device for teaching fundoscopy
Christopher Schulz
What problems were addressed? Medical students
lack confidence in their fundoscopy skills.1 This
finding is not isolated to a single institution or even
524
a single country. One of the fundamental difficulties
in both teaching and assessing direct ophthalmos-
copy is the inability to enable a student and tutor to
simultaneously observe the same image of the fun-
dus. Teaching mirrors and cameras have been suc-
cessfully incorporated into slit-lamp biomicroscopy
and microsurgery, but have not yet been used as
teaching aids with the hand-held direct ophthalmo-
scope.
What was tried? A semi-reflective piece of glass was
held at 45 degrees within an enclosure attached to
the viewing hole of a traditional hand-held ophthal-
moscope. This enclosure has holes in three sides so
that the light from the patient’s fundus enters the
device and is split into two perpendicular pathways.
One beam continues along its original path and
exits the device to be observed by the student in the
conventional manner. The other beam is directed
toward a miniature video camera. This camera is
connected to a laptop computer on which the live
image can be simultaneously visualised by a third
person.
A simple pilot study was conducted to gain qual-
itative feedback on this device in two separate set-
tings. In the first setting, in which the device was
tested as an aid to teaching fundoscopy, eight par-
ticipants observed a live demonstration given by a
tutor. Participants were then able to practise with
the device, which allowed the tutor to simulta-
neously observe the image viewed by the partici-
pant and to provide directed constructive
feedback.
In the second setting the device was tested as an
assessment tool during an objective structured clini-
cal examination (OSCE) station. The same partici-
pants were asked to examine a patient’s eye as part
of a scenario. Again, the examiner observed the
patient’s fundus simultaneously with the participant.
What lessons were learned? Promising feedback
was received from all participants during this pilot
study. Students considered that ‘being able to watch
e de the tutor’s approach on screen was very helpful’
and appreciated the ‘more personalised feedback’ it
enabled. The tutor felt more empowered to provide
constructive feedback and to problem-solve when
participants were struggling.
It was noted that the use of this device in an
OSCE setting might enable the assessor to provide a
more structured and objective assessment of the stu-
dent’s approach to examining the fundus. It is
believed that this teaching ophthalmoscope may
represent a more systematic, objective and robust
tool for assessing the competence of candidates.
During this pilot study, an important drawback of
this device was encountered. Because the light must
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 522–548

travel through the attached device, the clinician’s
eye is removed from the ophthalmoscope’s viewing
hole. This reduces the field of view of the patient’s
fundus. In order to eliminate this problem, the
design has since been incorporated within the exist-
ing housing of a conventional direct ophthalmo-
scope. In due course, a randomised trial will
evaluate the impact of this new teaching ophthalmo-
scope on the teaching and assessment of medical
students in fundoscopy.
REFERENCE
1 Gupta RR, Lam W-C. Medical students’ self-confidence
in performing direct ophthalmoscopy in clinical
training. Can J Ophthalmol 2006;41 (2):169–74.
Correspondence: Christopher Schulz, Department of Anatomy,
Brighton and Sussex Medical School, University of Sussex,
Brighton BN1 9PX, UK. Tel: 00 44 1273 877810;
E-mail: chrisschulz@doctors.org.uk
doi: 10.1111/medu.12434
Clinical sketches: teaching medical illustration to
medical students
Kevin T Liou, Paul George, Jay M Baruch &
Francßois I Luks
What problem was addressed? Many physicians
draw. We are not all artists, but we often use pictures
instead of thousands of words, whether to explain
medical concepts to students or procedures to
patients. Cultural, language and educational barriers
may hinder verbal communication, and the use of
simplified diagrams can enhance patients’ under-
standing of their medical condition.1 Of course, not
all sketches are created equal. But just as medical
students can be taught how to communicate better
with patients and colleagues, so too can they develop
the rudiments of sketching as an acquired rather
than an innate talent.
What was tried? Rather than teaching detailed
artistic illustration to a few ‘talented’ individuals, we
sought to inculcate basic graphic rules to a large
group of medical students. Twenty-three first-year
medical students with different artistic backgrounds
participated in our medical illustration workshop as
part of an arts and humanities-based curriculum. We
emphasised three aspects of illustration as a tool: (i)
organising one’s thoughts and clarifying anatomic
relationships; (ii) using the optimal complexity level
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 522–548
really good stuff
of a sketch to illustrate a problem most clearly, and
(iii) choosing the most representative aspects or
steps of a procedure. The workshop combined a pre-
sentation on the historical role of medical illustra-
tion, discussions on why it remains relevant today,
and hands-on exercises on the principles of basic
drawing, perspective, lighting, shadows, shading and
texture.
In one exercise, we asked students to simplify
head and neck plates from an anatomy atlas in order
to make them easily understandable by a patient. In
another, students worked in pairs: one student
illustrated adult and foetal blood circulation with
the aid of diagrams and the other provided feed-
back. Finally, we showed a video of a laparoscopic
adrenalectomy and asked students to illustrate the
operation, limiting themselves to only three figures.
With this added constraint, students had to decide
whether to include or leave out certain steps. The
ability to select which details are relevant to the lar-
ger picture – to offer an accurate synthesis – is also
essential in non-visual aspects of clinical practice,
such as in formulating diagnoses and delivering oral
presentations.
What lessons were learned? A total of 85% of
students rated the workshop ‘valuable’ or ‘very valu-
able’. Although the intent was not to complement
anatomy classes, it may have been more useful, in
retrospect, to match the technical aspects with the
students’ anatomic knowledge. In future workshops,
we plan to coordinate the drawing exercises with
anatomy instructors and to select topics that have
already been covered. Interestingly, some students
commented that our illustration exercises high-
lighted gaps in their anatomy knowledge base,
revealing connections between anatomical structures
they had not noticed before.
Many questions remain. Is basic illustration a skill
for all, or a tool for the artistic few? When – and for
how long – should it be taught? How can it be use-
ful to all, regardless of specialty interests? Does it
really make us better communicators? And how do
we measure this?
REFERENCE
1 Stone CA. Can a picture really paint a thousand
words? Aesth Plast Surg 2000;24:185–91.
Correspondence: Francßois I Luks, Department of Paediatric Surgery,
Alpert Medical School, Brown University, 2 Dudley Street, Suite
190, Providence, Rhode Island 02905, NJ, USA. Tel: 00 1 401 228
0556; E-mail: Francois_Luks@brown.edu
doi: 10.1111/medu.12450
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