Research Letter | Medical Education

Effect of the iExaminer Teaching Method

on Fundus Examination Skills
A Randomized Clinical Trial
Kiyoshi Shikino, MD, PhD; Shingo Suzuki, MD, PhD; Yusuke Hirota, MD, PhD; Makoto Kikukawa, MD, PhD; Masatomi Ikusaka, MD, PhD

Introduction
Studies have shown that mastery of fundus examination skills is not as high as desired among general + Supplemental content
practitioners, which implies that innovative teaching methods are needed1,2 because there is no way Author affiliations and article information are
for a teacher to verify if learners have obtained a proper view of the fundus.3,4 Sharing a visual field listed at the end of this article.
between learners and their teacher would facilitate the acquisition of those skills.
The iExaminer system consists of a PanOptic ophthalmoscope, an iPhone (Apple Inc), an
adapter, and an application.5 This system allows learners and their teacher to share the same visual
perspective. Our objective was to compare the effect of the iExaminer teaching method on fundus
examination skills compared with the traditional teaching method (Figure).

Methods
A randomized clinical trial was designed to compare the effect of the iExaminer teaching method on
fundus examination skills with the traditional teaching method. The trial protocol is available in
Supplement 1. Participants consisted of medical students in a general medicine clinical clerkship
rotation from September 2017 to July 2018. They were randomly assigned through simple
randomization using Excel 2010 (Microsoft Corp) to the iExaminer method group (intervention
group) or the traditional method group (control group). All instruction time was standardized to 30
minutes. Specially developed, identical training on the iExaminer method was provided to 3
instructors, who taught students using the iExaminer teaching method or the traditional teaching
method. They were randomly assigned to the teaching method for each session.
The participants examined EYE Examination Simulator (Kyoto Kagaku Co) using a PanOptic
ophthalmoscope before and soon after an educational session. In tests before and after training,

Figure. The iExaminer Teaching Method vs the Traditional Teaching Method

A The iExaminer teaching method B The traditional teaching method

A, Faculty taught fundus examination skills while

sharing a screen with the students. B, Faculty taught
fundus examination skills while students described
what they saw. As guidance, faculty advised students
about their grip, posture, procedure, angle, and light
intensity in each group. All participants had watched
instructional videos on standard use of the PanOptic
ophthalmoscope and had been prepared for the
interpretation of typical fundus findings 1 day before
the educational session.

Open Access. This is an open access article distributed under the terms of the CC-BY License.

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 JAMA Network Open | Medical Education Effect of the iExaminer Teaching Method on Fundus Examination Skills

participants were assigned 3 cases and observed 1 eye for 90 seconds. The diagnostic accuracy of
ophthalmoscopic findings (ie, normal fundus, optic disc edema, pathological optic disc cupping, or
not observed) and time taken to identify ophthalmoscopic findings were assessed in both tests.
Statistical analyses were performed using SPSS Statistics for Windows version 22.0 (IBM), with
the level of significance set at P < .05. All tests were 2-tailed. Diagnostic accuracy and time were
compared between the groups using a 2-way analysis of variance. Assuming an α error of .05, β error
of 0.2, power of detection of 0.8, and effect size F of 0.25, a sample size of 128 tests was required
for each group to allow for the comparison. This study was approved by the Ethics Committee of
Chiba University School of Medicine. Written informed consent was obtained from all participants.
This study followed the Consolidated Standards of Reporting Trials (CONSORT) reporting guideline,
and the flow diagram is available in the eMethods in Supplement 2.

Results
The total number of participants was 115. They had a median (interquartile range) age of 23 (21-31)
years, and 81 (73.9%) were men. We found no statistically significant differences in demographic
characteristics between the intervention and control groups. No participants had a prior clinical
clerkship rotation in ophthalmology.
A 2-way analysis of variance revealed a significant effect of this intervention on diagnostic
accuracy and time (Table). In the intervention group, compared with the control group, diagnostic
accuracy was significantly higher (47.0% vs 30.0%; P = .002) and time was significantly shorter
(mean [SD], 70.1 [21.9] seconds vs 76.2 [20.2] seconds; P = .006).

Discussion
This study suggests that the iExaminer teaching method could be superior to the traditional teaching
method for fundus examination training among medical students. The challenge for teaching the
fundus examination is that teachers cannot easily determine how well the student sees the fundus.3,4
Students may not perform with confidence, potentially leading to the examination’s underuse.6
Shared visualization may explain the improved accuracy among the intervention group, but it could
also be that better visualization by the student, independent of the presence of the teacher, led to
this result. Other studies have successfully used covisualization techniques between learners and
teachers in assessments of skill acquisition.4 The iExaminer teaching method may offer advantages,
as demonstrated by the objective assessments in this study.
There are some potential limitations. First, this research was assessed in the simulator, not with
real patients. Second, there is a possibility that the educational effect may depend on the teaching
skill of faculty.

Table. Diagnostic Accuracy and Time Taken to Identify Ophthalmoscopic Findings

Intervention Group (n = 59) Control Group (n = 56) 2-Way ANOVA

Outcome Pretraining Test Posttraining Test Pretraining Test Posttraining Test F1343 P Value
Diagnostic accuracy, No. correct/total No. 43/177 (24.0) 88/177 (47.0) 42/168 (25.0) 51/168 (30.0) 10.19 .002
(mean % correct)
Time taken to identify 82.8 (13.1) 70.1 (21.9) 83.0 (13.6) 76.2 (20.2) 7.71 .006
ophthalmoscopic findings,
mean (SD), s

Abbreviation: ANOVA, analysis of variance.

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 JAMA Network Open | Medical Education Effect of the iExaminer Teaching Method on Fundus Examination Skills

Conclusions
In this randomized clinical trial, the iExaminer teaching method led to improved diagnostic accuracy
and reduced examination time for the fundus examination. The results suggest that the iExaminer
teaching method may be superior to the traditional teaching method.

ARTICLE INFORMATION
Accepted for Publication: August 4, 2019.
Published: September 20, 2019. doi:10.1001/jamanetworkopen.2019.11891
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Shikino K et al.
JAMA Network Open.
Corresponding Author: Kiyoshi Shikino, MD, PhD, Department of General Medicine, Chiba University Hospital,
1-8-1, Inohana, Chuo Ward, Chiba 260-8677, Japan (kshikino@gmail.com).
Author Affiliations: Department of General Medicine, Chiba University Hospital, Chiba, Japan (Shikino, Suzuki,
Hirota, Ikusaka); Department of Medical Education, Kyushu University, Fukuoka, Japan (Kikukawa).
Author Contributions: Dr Shikino had full access to all of the data in the study and takes responsibility for the
integrity of the data and the accuracy of the data analysis.
Concept and design: All authors.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Shikino, Hirota, Ikusaka.
Critical revision of the manuscript for important intellectual content: Shikino, Suzuki, Kikukawa.
Statistical analysis: Shikino, Suzuki.
Supervision: Suzuki, Hirota, Kikukawa, Ikusaka.
Conflict of Interest Disclosures: None reported.
Trial Registration: This research was registered at umin.ac.jp/ctr (UMIN identifier: UMIN000037397) on July 17,
2019. Due to our misunderstanding of the trial registration requirement, we registered the trial retrospectively.
Additional Contributions: Daniel Salcedo, MD (Health Professional Development Center, Chiba University
Hospital, Chiba, Japan), provided study design support. He was compensated for his time. The staff of Chiba
Clinical Skills Center provided equipment support. A signed statement of informed consent to publish patient
photographs was obtained from all persons.
Data Sharing Statement: See Supplement 3.

REFERENCES
1. Mottow-Lippa L, Boker JR, Stephens F. A prospective study of the longitudinal effects of an embedded specialty
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10.1097/ACM.0b013e3181bb2d51
2. Wu EH, Fagan MJ, Reinert SE, Diaz JA. Self-confidence in and perceived utility of the physical examination:
a comparison of medical students, residents, and faculty internists. J Gen Intern Med. 2007;22(12):1725-1730. doi:
10.1007/s11606-007-0409-8
3. Afshar AR, Oh FS, Birnbaum AD, Namavari A, Riddle JM, Djalilian AR. Assessing ophthalmoscopy skills.
Ophthalmology. 2010;117(9):1863, 1863.e1-1863.e2. doi:10.1016/j.ophtha.2010.05.012
4. Wu AR, Fouzdar-Jain S, Suh DW. Comparison study of funduscopic examination using a smartphone-based
digital ophthalmoscope and the direct ophthalmoscope. J Pediatr Ophthalmol Strabismus. 2018;55(3):201-206.
doi:10.3928/01913913-20180220-01
5. Welch Allyn. iEXAMINER. https://www.welchallyn.com/en/microsites/iexaminer.html. Accessed August 12, 2019.
6. Dalay S, Umar F, Saeed S. Fundoscopy: a reflection upon medical training? Clin Teach. 2013;10(2):103-106. doi:
10.1111/j.1743-498X.2012.00630.x

SUPPLEMENT 1.
Trial Protocol

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SUPPLEMENT 2.
eMethods. Study Flow Diagram

SUPPLEMENT 3.
Data Sharing Statement

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