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Top five principles for successful learning in both residency as well as practice

At one time we were all first-year ophthalmology residents, suddenly immersed into a strange and novel world. The field has an extremely steep learning curve. New residents are tasked with the challenge of simultaneously learning ophthalmic knowledge, exam skills and surgical techniques. Medical schools devote little time to these topics, and I know of no existing resources that are designed specifically to help ophthalmology residents at the beginning of their careers.

Ophthalmology is an innovative and fast-moving field, with new advances constantly evolving and occasionally revolutionizing the way we treat patients. It is just as important for an established ophthalmologist to keep up with these changes so that he can provide the best care for his patients. While many printed resources exist for continuing medical education, I increasingly see our residents using online and mobile resources. These are more interactive, can include videos and animation, and provide a convenient format that can be accessed virtually anywhere.

I was recently introduced to a new online resource, EyeGuru.org, built by two residents and a medical student from UCLA. EyeGuru is a free website that is targeted toward beginning ophthalmology residents, but the team plans to expand its breadth to help ophthalmology trainees of all years. I have personally used the website to keep up to date, particularly with fields outside of my subspecialty.

I believe that there are three types of core proficiencies that are critical for development as a physician and surgeon: basic/clinical knowledge, surgical skills and clinical decision-making skills.

Basic knowledge is the foundation of every profession. For example, residents should understand how cataracts develop and progress and know the theoretical differences between different types of IOLs. Developing surgical skill involves understanding the protocol for different surgeries, as well as developing the kinesthetic skills necessary to execute them — for example, understanding the steps involved in a cataract surgery and being able to perform the surgery itself. Finally, a provider must integrate his or her understanding of basic/clinical knowledge with sound surgical judgment in order to make good clinical decisions. To finish with the above example, being able to decide when in clinical progression a lens replacement is needed, being able to choose a lens based on a patient’s individual visual needs, and understanding how to modify a surgical procedure to suit the eye.

To best learn and retain the knowledge, there are five key principles of education:

Principle 1: Active recall — recall without contextual cues

Active recall strategies that encourage free-recall retrieval (without contextual cues) of previously learned facts improve memory retention far better than simply rereading a passage of text. An example of this is when an attending asks a resident how to distinguish the three major classifications of cataracts from one another. This is much more effective than having the resident read an article about cataracts. Studies have shown that active recall compared with passive reading improves memory retention, even when the recall attempt is unsuccessful.

Figure 1. The EyeGuru.org website organizes the knowledge base into modules that enhance learning.

Images: Devgan U

Figure 2. Spaced repetition increases the likelihood of knowledge recall.

Principle 2: The testing effect — testing directly improves learning

Standardized tests are an inescapable part of every physician’s career. While they are often seen as a method of assessing knowledge, the act of taking the test itself directly improves memory retention. The testing effect generally differs from active recall. Most tests in medicine are not a true active recall experience because they are presented as multiple choice exams that provide contextual clues for answer recognition. However, cued-recall in multiple choice questions is still an effective means for improving long-term memory retention. The greatest weakness with using testing to reinforce knowledge is the potential to reinforce incorrect facts. This is where Principle 3 can play an important role.

Principle 3: The feedback effect — feedback on both incorrect and correct answers improves learning

The testing effect can be further enhanced by providing feedback on student performance. Providing feedback is an effective way of not only rectifying incorrect answers, but also of reinforcing correct answers. This is especially helpful for those questions that the user answered correctly but with low confidence. It is not always easy to give immediate, direct feedback in clinic, but this principle can be leveraged by a well-developed online tool that uses interactive features to test and evaluate users.

Principle 4: Spaced repetition — the ‘flashcard’ effect

It makes intuitive sense that increasing repetitions of knowledge retrieval attempts increases the likelihood of memory retention. In addition to increasing the sheer quantity of repetitions, introducing a delay between repetitions further improves learning. Nowadays, spaced repetition is becoming more popular among medical students and residents who are increasingly using online and offline products that automatically schedule repetitions for them, such as Anki, Firecracker and Memorang. These are most often done in the form of virtual flashcards.

Principle 5: Distance/distributed learning — utilizing new teaching modalities

The internet has enabled web-driven, outside-the-classroom learning that can be accessed from anywhere a mobile device can go. Students can learn in a variety of settings in an on-demand fashion, while using spare time in between other appointments. The ability to learn independent of time and location increases efficiency, and getting input from different modalities may improve retention itself.

The founders at EyeGuru have integrated many of these principles into their website. After each of their articles, they include a brief quiz with immediate answer feedback to test user understanding and improve knowledge retention. Their current content is primarily written to build a core foundation of knowledge for the new ophthalmology resident. However, they recently released several reference guides that residents of all years may find useful in the clinic. These include reference guides for grading any major ophthalmic condition and a standard dosing table for intravitreal injections. In addition, they plan on introducing a new spaced repetition flashcard deck for OKAP review by the spring of 2017. While EyeGuru in its current state is useful to a target audience of first-year residents, it has the potential to become broadly applicable to all ophthalmology residents as it expands its scope and content. I encourage you to check out the website at www.EyeGuru.org.

Acknowledgement: Thank you to Ben Lin, David Xu, MD, and Shawn Lin, MD, who were instrumental in this article.

Disclosure: Devgan reports no relevant financial disclosures.

At one time we were all first-year ophthalmology residents, suddenly immersed into a strange and novel world. The field has an extremely steep learning curve. New residents are tasked with the challenge of simultaneously learning ophthalmic knowledge, exam skills and surgical techniques. Medical schools devote little time to these topics, and I know of no existing resources that are designed specifically to help ophthalmology residents at the beginning of their careers.

Ophthalmology is an innovative and fast-moving field, with new advances constantly evolving and occasionally revolutionizing the way we treat patients. It is just as important for an established ophthalmologist to keep up with these changes so that he can provide the best care for his patients. While many printed resources exist for continuing medical education, I increasingly see our residents using online and mobile resources. These are more interactive, can include videos and animation, and provide a convenient format that can be accessed virtually anywhere.

I was recently introduced to a new online resource, EyeGuru.org, built by two residents and a medical student from UCLA. EyeGuru is a free website that is targeted toward beginning ophthalmology residents, but the team plans to expand its breadth to help ophthalmology trainees of all years. I have personally used the website to keep up to date, particularly with fields outside of my subspecialty.

I believe that there are three types of core proficiencies that are critical for development as a physician and surgeon: basic/clinical knowledge, surgical skills and clinical decision-making skills.

Basic knowledge is the foundation of every profession. For example, residents should understand how cataracts develop and progress and know the theoretical differences between different types of IOLs. Developing surgical skill involves understanding the protocol for different surgeries, as well as developing the kinesthetic skills necessary to execute them — for example, understanding the steps involved in a cataract surgery and being able to perform the surgery itself. Finally, a provider must integrate his or her understanding of basic/clinical knowledge with sound surgical judgment in order to make good clinical decisions. To finish with the above example, being able to decide when in clinical progression a lens replacement is needed, being able to choose a lens based on a patient’s individual visual needs, and understanding how to modify a surgical procedure to suit the eye.

To best learn and retain the knowledge, there are five key principles of education:

Principle 1: Active recall — recall without contextual cues

Active recall strategies that encourage free-recall retrieval (without contextual cues) of previously learned facts improve memory retention far better than simply rereading a passage of text. An example of this is when an attending asks a resident how to distinguish the three major classifications of cataracts from one another. This is much more effective than having the resident read an article about cataracts. Studies have shown that active recall compared with passive reading improves memory retention, even when the recall attempt is unsuccessful.

Figure 1. The EyeGuru.org website organizes the knowledge base into modules that enhance learning.

Images: Devgan U

Figure 2. Spaced repetition increases the likelihood of knowledge recall.

Principle 2: The testing effect — testing directly improves learning

Standardized tests are an inescapable part of every physician’s career. While they are often seen as a method of assessing knowledge, the act of taking the test itself directly improves memory retention. The testing effect generally differs from active recall. Most tests in medicine are not a true active recall experience because they are presented as multiple choice exams that provide contextual clues for answer recognition. However, cued-recall in multiple choice questions is still an effective means for improving long-term memory retention. The greatest weakness with using testing to reinforce knowledge is the potential to reinforce incorrect facts. This is where Principle 3 can play an important role.

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Principle 3: The feedback effect — feedback on both incorrect and correct answers improves learning

The testing effect can be further enhanced by providing feedback on student performance. Providing feedback is an effective way of not only rectifying incorrect answers, but also of reinforcing correct answers. This is especially helpful for those questions that the user answered correctly but with low confidence. It is not always easy to give immediate, direct feedback in clinic, but this principle can be leveraged by a well-developed online tool that uses interactive features to test and evaluate users.

Principle 4: Spaced repetition — the ‘flashcard’ effect

It makes intuitive sense that increasing repetitions of knowledge retrieval attempts increases the likelihood of memory retention. In addition to increasing the sheer quantity of repetitions, introducing a delay between repetitions further improves learning. Nowadays, spaced repetition is becoming more popular among medical students and residents who are increasingly using online and offline products that automatically schedule repetitions for them, such as Anki, Firecracker and Memorang. These are most often done in the form of virtual flashcards.

Principle 5: Distance/distributed learning — utilizing new teaching modalities

The internet has enabled web-driven, outside-the-classroom learning that can be accessed from anywhere a mobile device can go. Students can learn in a variety of settings in an on-demand fashion, while using spare time in between other appointments. The ability to learn independent of time and location increases efficiency, and getting input from different modalities may improve retention itself.

The founders at EyeGuru have integrated many of these principles into their website. After each of their articles, they include a brief quiz with immediate answer feedback to test user understanding and improve knowledge retention. Their current content is primarily written to build a core foundation of knowledge for the new ophthalmology resident. However, they recently released several reference guides that residents of all years may find useful in the clinic. These include reference guides for grading any major ophthalmic condition and a standard dosing table for intravitreal injections. In addition, they plan on introducing a new spaced repetition flashcard deck for OKAP review by the spring of 2017. While EyeGuru in its current state is useful to a target audience of first-year residents, it has the potential to become broadly applicable to all ophthalmology residents as it expands its scope and content. I encourage you to check out the website at www.EyeGuru.org.

Acknowledgement: Thank you to Ben Lin, David Xu, MD, and Shawn Lin, MD, who were instrumental in this article.

Disclosure: Devgan reports no relevant financial disclosures.