1. Technical barriers to performing fundoscopy examinations.

Participants voiced several key, interconnected barriers to performing fundoscopy examinations.

Uncertainty of findings / lack of confidence. Limited confidence to visualise the fundus was common to all groups, hence interpreting the findings was unrealistic for most (1.5, 1.6). Even when a fundal view was obtained, participants expressed poor confidence interpreting anything beyond florid pathology. Consequently fundoscopy has become perceived as futile.

“…not knowing what I’m looking at. Particularly for papilledema, I guess if it’s obvious, it’s obvious, but the subtle changes. We see patients, they usually come here very early for stuff, they don’t come here with florid pathology usually. So picking up early changes and subtle things would be hard.” (GP)

Technical difficulties. The technical difficulty of using TDO was identified as a barrier by all groups (1.1). Logistical barriers included: refractive difficulties with glasses; limited availability of reliable equipment (1.3); bright department lighting constricting pupils, and; the challenge of moving unwell ED patients to a dark space (1.2).

The patient cooperation required during an already technical fundus examination was challenging, especially amongst children. Medical students worried the bright ophthalmoscope light would cause discomfort to patients, hence would avoid practicing the technique.

Closeness. The face-to-face nature of fundoscopy was somewhat confronting for all, and a significant contributor was the perception of being observed by the patient whilst feeling incompetent at the examination (1.7). By contrast, doctors felt less concerned by physical proximity than medical students. One GP noted, “There’s a lot of things that we do that we gotta get very close”. Consequently, clinicians become, “quite used to putting up a clinical shield. So you’ve got your doctor brain on, but actually when you’re doing it you don’t actually notice” (GP).

Practice patterns / ability to outsource. For GPs, particularly in more affluent areas, accessibility to specialists and optometrists meant they were more likely to refer patients when fundoscopy was indicated, than to perform the examination themselves.

Frequency of ophthalmoscope use appeared to be modulated by confidence performing and interpreting the examination, and perceived clinical utility or futility in changing patient management. An ED Advanced Trainee expressed the problem thus, “It’s inactivity. We don’t do it, we don’t remember how to do it, and then when we’re forced to do it, we’re not sure that we clinically interpret what we get. And there’s no embarrassment or weirdness about being face to face, it’s just I haven’t done it in so long.” As barriers limit practice by clinicians and medical students, expertise is lost, reinforcing a cycle of reducing fundoscopy utilisation (1.8).

2. Clinical culture and expectations regarding fundoscopy.

Clinical cultural expectations. Medical Students perceived a culture of incompetence in fundoscopy, with no expectation that it would be performed for patients (2.1). Trainees described greater expectations to perform most other examinations. A Second-Year Medical Student stated, “almost any doctor on the ward is comfortable taking blood pressures and showing us how to do it, whereas I think there’s perhaps even like, institutional avoidance of doing it [fundoscopy].” Students perceived minimal expectations about their level of ophthalmic knowledge (2.2), and consequently, “the culture of fundoscopy doesn’t really encourage us to be good at it” (Final-year medical student).

Supervisor discouragement, while not intended by senior doctors, was universally experienced by medical students and training doctors. Perceived senior clinician disapproval of fundoscopic examination was described in acts of both omission and commission. Fundoscopy was visibly omitted from patient examination, and trainees absorb cultural expectations implicit in the behavior of senior clinicians.

“I don’t think I’ve ever seen even a senior doctor do fundoscopy on any patient. And I guess you kind of model what you see in the hospital.” (Final-year medical student)

Whilst there was no conscious disapproval of fundoscopy by senior trainees and physicians, they admitted their dismissive responses could build an unconscious culture of disapproval.

“If they [a junior doctor] said, you know, does this person need a fundoscopy, I’d be like, yeah, sure. That’d be what the textbooks would say, but I wouldn’t know how to interpret it. Which would probably be read as discouragement.” (ED advanced trainee)

ED doctors described a cultural expectation to attempt fundoscopy prior to requesting an ophthalmology consult, but without any assumption of competence (2.3, 2.7). At the extreme of this, one student observed a training doctor falsifying findings to meet the clinical assumptions of their supervisors (2.4).

Medical students and ED trainees described a period of conscious incompetence in training for any clinical skill when an examination such as ultrasound or fundoscopy may be practised but not documented (2.5). However for many, fundoscopy remains at this stage as a ‘dirty secret’ of clinical examination, to be occasionally performed but not reported.

ED Junior Trainee 1: you still tend to sort of float around and do some. But you don’t really record your findings because you can’t make a clinical decision based on it, obviously unless there’s something huge and then you sort of, it gives you a clue. I don’t feel confident doing certain things, but I’ll still just put it on, have a look around, and see what I see. But I won’t document down that these are the definite findings. And I think that’s why, even if you try to do fundoscopy, I wouldn’t call it either way. I might do it secretly and not tell anyone, I might have a look, ’oh’…

Group: [laughter]

ED Advanced Trainee 2: I’ve had a peek behind the curtains.

ED Junior Trainee 3: I’ve had a few looks before and then just not told anyone that I’ve had a look because I don’t know what I’m seeing, really.

Increasing medical specialisation was noted as a driver against fundoscopy use by non-experts. Fundoscopy has been relegated to the domain of ophthalmology and to an extent neurology. Second-Year Medical Students observed senior clinicians stating, "Oh, no, no, we don’t do that. We just send them to the optometrist… or the ophthalmologist.” Even physicians noted that endocrinologists referred their diabetic patients to the ophthalmologist rather than screening the fundus themselves.

Patient expectations and therapeutic relationship. General practitioners in a more affluent area noted patient expectations to see a specialist or obtain medical imaging reduced the potential demand for fundoscopy in patient management (2.8, 2.9).

3. The influence of fundoscopy on clinical management.

Risk stratification. Currently fundoscopy findings were seen to be more specific than sensitive, “It’s more of a rule in than a rule out” (ED Advanced Trainee).

However, ED, physicians and students felt fundus imaging would help screen for serious pathology to determine the patient’s disposition and thereby triage appropriate clinical review, “hopefully it will reduce that hand-wringing” (ED Junior Trainee) (3.1, 3.2).

Clinical management: Outsourcing. ED participants preferred to refer patients to specialists or utilise tele-ophthalmology, unless they became more competent at fundus interpretation themselves. There was disagreement about the level of experience and training required to confidently and safely triage presentations based on findings. Participants described experiential journeys through various stages of confidence and competence in examination (3.2, 5.9).

Relevance / futility. Most clinicians thought their fundoscopy skills were too unreliable to safely underpin patient management (3.3).

“Unless it becomes very evident to me that what I’m seeing in fundoscopy is abnormal, I would not base my further management on that, what I’m seeing, because I don’t trust it.” (ED Advanced Trainee)

Whilst some in community practice felt fundoscopy would not change their management plans (3.4). These barriers have engendered an overall perception that fundoscopy is futile, which exacerbates avoidance of fundoscopy (2.7–2.9).

4. Motivation to perform the examination.

Motivational factors of particular importance to subgroups are summarised in Table 2.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 2. Factors affecting motivation to perform clinical examinations such as fundoscopy: Common to all groups, and; particularly noted amongst different clinical groups.

https://doi.org/10.1371/journal.pone.0280937.t002

Intrinsic motivating factors. Self-perceptions of clinical competence were important to all participant groups (4.1, 4.2). Conversely, most doctors felt inexperienced and incompetent with fundoscopy, hence were reluctant to employ it.

“Or to ask a patient to like sit through me being incompetent for that amount of time… I honestly think I’d be more comfortable, like if you were to right now give me the option of go do a speculum exam and a pap smear, or do direct ophthalmoscopy, I’d probably take the pap smear.” (Female, Second-Year Medical Student)

Beneficence was elucidated as a strong motivation behind choosing examinations (4.6), as expressed by one second-year medical student, “We come into medical school so that we can help people and so that we can hopefully make a difference, improve their quality of life.” Whilst clinical curiosity was a variable, weaker motivator (4.4). When asked their motivations to perform specific examinations, ED generally agreed, “It’s risk stratification.” (ED Junior Trainee) (4.5, 4.6).

Accordingly, ED doctors were more motivated to detect pathology which would change their emergent management, rather than subtleties of chronic eye conditions more relevant to specialists. “I’m trying not to miss the glaringly obvious, not that I’m trying to pick the really subtle.” (ED Junior Trainee)

For GPs, motivation to perform an examination was more individual. Some liked the capacity of screening to detect the occasional highly significant disease such as finding melanoma amongst many normal skin checks. Others were most proud of rare diagnoses, such as Addison’s disease, detected early through more in depth examination. Underpinning both these categories of motivation was the sentiment that, “You feel like you’ve actually saved, like altered the course of their lives.” (GP)

Extrinsic motivating factors: Assessments and protocols. Barrier assessments are the key time to ensure a skill is appropriately learnt, as the expected competency level dictates the effort applied by students and trainees (4.7).

Several checkpoints in the medical training pathway were identified as potential intervention times to motivate better fundoscopy capabilities: 1) medical student examination requirements likely set future capabilities (4.7); 2) certified accreditation courses targeted prior to specialist training admission could enhance trainees’ curriculum vitaes; 3) specialty college examinations motivate trainees to learn whatever is required to pass (4.8), and; 4) career progression hurdles may be a useful forcing function (4.9).

Clear guidelines on the relevance of fundoscopy to patient management would help motivate fundoscopy training, “Enough for me to want to commit to doing a learning programme on it when there are competing priorities” (GP). Physicians suggested using standardised protocols for ED presentations like headache may improve fundoscopy rates. However the diversity of aetiologies and presentations requiring fundoscopy would pose a greater challenge than established protocols like chest pain.

5. Novel technology including smartphone fundoscopy, and the value of a digital fundus image.

Impact on patient care. Participants noted a fundus photograph would give doctors an objective measure of clinical findings, improve confidence in fundoscopic findings and help direct clinical management. A digital image can be sent to other clinicians for advice, which could reduce the barriers to specialty consultation and streamline intervention as it currently does in other specialities such as surgery, dermatology or orthopaedics (5.1).

Fundus photographs would help workflow, on busy ward rounds when a patient may wait all day for a consultation, and especially in ED. Patient triage and discharge may become safer (5.2). ED trainees noted a concurrent educational and cultural shift would be needed as they became more confident interpreting the images themselves.

“We’ll probably still be speaking to opthalmologists about the same cases, (but) we’ll have a bit more information for them and I think it will change the disposition, and it might mean they get seen in a few days or they get seen straight away.” (ED Junior Trainee)

Integrating tele-ophthalmology feedback would likely incentivise more frequent fundus examination (5.3).

A patient education tool. A fundus photograph could help patients visualise their eye health and assist GPs to motivate lifestyle changes (5.4).

Documentation and easier interpretation. The practicality of a documented clinical image to be interpreted and reviewed at leisure with colleagues would reduce the uncertainty and discomfort surrounding TDO (5.5–5.7).

Learning. Whilst fundoscopy is currently performed rarely, it may take some time for increasing use to feed back into optimised patient management. Repeated pattern recognition seeing fundi in clinical context would help emergency physicians decide which patients need further investigation or could be safely discharged. Whilst ED may initially over-refer or over-investigate patients (5.8), outsourcing of clinical decision-making should reduce with experience and training.

Introducing novel examination technologies could be difficult for senior doctors (5.9) with some participants anticipating initial resistance (5.10). Additionally, senior physicians expressed concern that fundus interpretation would remain challenging (5.11), or that the ease of consultation using a digital photograph could provide a perverse incentive against interpreting fundoscopic findings (5.12).

Likelihood of performing fundoscopy. It was noted that a fundus image would reduce the number of examinations required of a patient, and would allow doctors to, “get a consensus from consultants” (ED Junior Trainee). A fundus image also mitigates the responsibility on the examiner to diagnose pathology which is a deterrent to performing TDO.

“I’d be more likely to do it, knowing that like, you know, it doesn’t rest with my interpretation, because like that’s the thing that’s been difficult with fundoscopy is that if you look, it rests on your interpretation.” (Final-Year Medical Student)

If novel fundoscopic technology such as smartphone adaptors or fundus cameras were integrated into medical school, many students felt the technical barriers to learning and practicing fundoscopy would be minimised: “we’re in this kind of almost transition period between what has been tradition and what might be the possibility coming.” (Final-Year Medical Student, 5.13)

6. Training requirements for successful clinical uptake of fundoscopy.

Theoretical knowledge. Participants voiced difficulties with the technical use of TDO and interpretation of their findings (6.1). All groups raised the prospect of baseline fundoscopic competencies and tailoring the extent of knowledge required within different specialties and training levels. There were mixed opinions about the appropriate training level required to interpret fundoscopy. ED trainees described learning pathways in other examinations, from unconscious to conscious incompetence, and finally expertise (3.2, 5.8).

A cultural shift towards a basic recognition of abnormal fundoscopy could be a reasonable educational target (6.2, 6.3). Medical students and ED groups expressed a need to improve understanding of the implications of fundoscopy on patient management and outcomes.

“I guess being told stories about how a simple fundoscopy can prevent so many complications to a patient and I think as medical students, we aren’t taught the value of sight and how easily it can be lost.” (Final-Year Medical Student)

Repetition. All participant groups agreed the lack of repetition of fundoscopy practice resulted in significant attrition of skills. With comparable skills such as otoscopy, looking at multiple normal patients allowed an experience and recognition of the range of normal (6.4). By comparison, the lack of repetition of fundoscopy skills means clinician expertise languishes (6.5),

“You get stuck in this cycle of not dilating people because you don’t feel confident to look at the back of their eye, and then you’re like, “well I’m not just going to dilate them pointlessly,” and then because you don’t dilate people, you don’t look at many eyes.” (ED Advanced Trainee)

Repetition of ophthalmoscopy to understand the range of normal is logistically difficult in ED, however less technically demanding fundoscopy would facilitate repetition of skills (6.6).

If fundoscopy findings were reinforced in regular teaching meetings, as occurs for radiology, trainees would more likely recognise relevant abnormalities (6.7).

Feedback. Feedback on technique and interpretation of findings reinforces clinical skill development. Large group training was felt to be insufficient for ophthalmoscopy, as there was little capacity for feedback and individual practice. Many trainees reflected that they did not feel competent in fundoscopy at the end of medical school. Objective ophthalmoscopic competence was not assessed by medical schools, and some participants felt pressured to feign competence to avoid embarrassment (6.8).

A fundus image was preferred for ED training (6.9).

Participants noted comparable training and accreditation pathways, like ultrasound, which could model improved fundoscopy. Notable steps in this process were a readily achievable fundus photograph, easy access to repeated feedback on interpretations, and re-accreditation methods like online training (6.10).

7. Use of limited resources.

Time. Time-efficient and practical learning and utilisation tools will be necessary for uptake of fundoscopy. The importance of this is absorbed early (8.1). The technical demands of fundoscopy, alongside a training structure that does not reward competence, leads trainees to abandon fundoscopy.

“…the times when I’ve tried it and I’ve just blatantly failed. And you know, it’s that moment where; do I keep wasting time just pursuing something that I’m not really going to know if I’m seeing anything or any pathology, I don’t even know if I’d recognise it; or do I just spend more time on the things that I’m more confident I’ll get.” (Final-Year Medical Student)

The practical requirements of TDO including a darkened room, dilation drops and the time required for them to work, limited uptake amongst ED and GPs.

Staff. Duplication of service currently occurs whenever a junior doctor performs fundoscopy, as the senior clinician, neurologist or ophthalmologist will have to re-examine the patient. Whereas a fundus photograph would allow convenient review.