The Journal of the Association of Schools and Colleges of Optometry

Volume 32, Number 1 Fall 2006

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Shared Visions ^^^m-An international art exhibit at Southern,Cafifprnia College of Optometry showcases artists who are blind or v isual ly impa i red .

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Association of Schools and Colleges of Optometry The Association of Schools and Colleges of Optometry (ASCO) represents the professional programs of

optometric education in the United States. ASCO is a non-profit, tax-exempt professional educational association with national headquarters in Rockville, MD.

OFFICERS AND MEMBERS BOARD OF

Executive President Hector C. Santiago, O.D., Ph.D. Dean Inter American University of Puerto Rico, School of Optometry

DIRECTORS Committee

Secretary-Treasurer Gerald E. Lowther, O.D., Ph.D. Dean Indiana University, School of Optometry Bloomington, Indiana 47401

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President-Elect John P. Amos, O.D. Dean University of Alabama at Birmingham, School of Optometry Birmingham, Alabama 35294-0010

At Large Member *Arol R. Augsburger, O.D. President Illinois College of Optometry Chicago, Illinois 60616

Immediate Past-President * Larry J. Davis, O.D. Dean University of Missouri at St. Louis College of Optometry St. Louis, Missouri 63121

Executive Director Martin A. WalLCAE

BOARD MEMBERS Kevin L. Alexander, O.D., Ph.D., Dean Michigan College of Optometry at

Ferris State University Big Rapids, Michigan 49307

*William E. Cochran, O.D., President Southern College of Optometry Memphis, Tennessee, 38104

*George E. Foster, O.D., Dean Northeastern State University,

College of Optometry Tahlequah, Oklahoma 74464

Dennis M. Levi, O.D., Ph.D., Dean University of California at Berkeley,

School of Optometry Berkeley, California 94720-2020

*Alan L. Lewis, O.D., Ph.D., President The New England College of Optometry Boston, Massachusetts 02115

*Thomas L. Lewis, O.D., Ph.D., President

Pennsylvania College of Optometry Elkins Park, Pennsylvania 19027-1598

*David S. Loshin, O.D., Ph.D., Dean Nova Southeastern University,

:~i=^s^CMegS"drOpt6lrietry;: :

""" :Ft~Lauderdale7 Florida 33328

Steven Schwartz, O.D., Ph.D. Dean and Vice President for Academic

Affairs SUNY State College of Optometry New York, New York 10036-8003

James E. Sheedy, O.D., Ph.D., Dean Pacific University, College of Optometry Forest Grove, Oregon 97116

Melvin D. Shipp, O.D., MPH, Dr.PH, Dean The Ohio State University,

College of Optometry Columbus, Ohio 43210

Earl L. Smith, III, O.D., Ph.D., Dean University of Houston,

College of Optometry Houston, Texas 77204-2020

*Lesley L. Walls, O.D., M.D., President Southern California College of

Optometry Fullerton, California 92831

''Past Presidents

ASCO Affiliate Members

Dr. Jacques Gresset, Director University of Montreal — Optometry Montreal, Quebec H3C 3J7

Dr. Thorn Freddo, Director University of Waterloo — Optometry Waterloo, Ontario, Canada N2L 3G1

Ms. Pamela Happ, Exec. Dir. College of Optometrists in Vision Development

Aurora, OH 44202

Mr. Robert Williams, Exec. Dir. Optometric Extension Program Foundation

Santa Ana, California 92705-5510

Dr. John Townsend, Director VA Optometry Service Department of Veterans Affairs Baltimore, MD 21202

Dr. Jairo H. Garcia, Dean Universidad de la Salle Facultad de Optometria Bogota, Colombia

Editorial Review Board

Editor: Elizabeth Hoppe, O.D., M.P.H., Dr. P..H.

ASCOTECH Coeditors: Dominick M. Maino, O.D., M.Ed. Geoffrey W. Goodfellow, O.D.

Communications Editor: David Damari, O.D.

Diane T. Adamczyk, O.D. Norman Bailey, O.D., M.S., M.P.H. John Baker, O.D., M.S.Ed. Etty Bitton, O.D., M.Sc. Nancy B. Carlson, O.D. N. Scott Gorman, O.D., M.S., Ed.D. Michael G. Harris, O.D., J.D., M.S. Christopher W. Lievens, O.D. Nada J. Lingel, O.D., M.S. Richard E. Meetz, O.D., M.S. Jeffrey Nyman, O.D. Doug Penisten, O.D., Ph.D. Hector Santiago, O.D. Ph.D. Paulette P. Schmidt, O.D., M.S. Julie'ArScrrorfrackfOTD:, M.Ed. Leo P. Semes, 0:D. Marlee M. Spafford, O.D., M.Sc, Ph.D. Mark Swan, O.D., M.Ed. Timothy Wingert, O.D.

2 Optometric Education

OPTOMETRIC EDUCATION ISSN 0098-6917

VOL 32 NO.l CON

FALL 2006

The Journal of the Association of Schools and Colleges of Optometry

ARTICLES Effectiveness of Co-Facilitation as a Teaching Methodology in an Integrative Seminar Course Aurora Denial, O.D., EA.A.O. Mark Zorn, O.D., Ph.D., F.A.A.O. The authors'study shows that, in the opinions of students and faculty, co-facilitation by a scientist and a clinician

enhanced students' learning and was an effective teaching methodology.

Student Assessment of an Integrative Seminar Course Aurora Denial, O.D., F.A.A.O. Mark Zorn, O.D., Ph.D., F.A.A.O. Second year students at the New England College of Optometry were surveyed to determine the effectiveness of the Integrative Seminar Course.

13

17 Teaching Basic Science Courses Using Web-based Clinical Cases: Experiences with BACIC Steven H. Schwartz, O.D., Ph.D., F.A.A.O. Leon Nehmad, O.D„ M.S.W., F.A.A.O. Mark Rosenfield, M.C.Optom., Ph.D., F.A.A.O. William H. Swanson, Ph.D., F.A.A.O. Ayxa Calero-Breckheimer, Ph.D. Patricia Modica, O.D., F.A.A.O. John Picarelli, Ph.D. The authors present a curricular model, centered on Web-based asynchronous student discussions of clinical cases, which promotes the integration of J B | 4% basic and clinical science material. . ^ S ^ P

Scholarly Publications by Optometric Residents, 1999 - 2003 Michael H. Heiberger, O.D., M.A., F.A.A.O. Irwin B. Suchoff, O.D., D.O.S., F.A.A.O., FC.O.V.D.-A The authors evaluated residency program supervisors' interpretation of ike ACOE standard for scholarly activity and determined the number of publishable papers produced j ^ g± and published by residents from 1999 - 2003. jmk JW

FEATURES Focus on the President Optometrists for the 21st Century Hector C. Santiago, O.D., Ph.D., F.A.A.O.

Think Tank - Commencement Speakers Challenge Optometry's Newest Graduates

Communication - Development of a New Clinical Training Model Charles F Mullen, O.D., F.A.A.O.

8

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DEPARTMENTS Industry News

Editorial Measuring Teaching and Learning Outcomes Elizabeth Hoppe, O.D., M.P.H., Dr. P.H, F.A.A.O. 36

Cover photo: "Red Hibiscus" by Ms. Doris Carlton. The watercolor is part of "Shared Visions 2006," an exhibit at SCCO featuring works of art by blind and legally blind artists. Following vision loss from macular degeneration, Ms. Carlton now uses a video magnifier to allow use of her remaining peripheral vision.

OPTOMETRIC EDUCATION is published by the Association of Schools and Colleges of Optometry (ASCO). Managing Editor: Patricia Coe O'Rourke. Art Director: Carol Nansel, The Darwin Group, Inc.. Business and editorial offices are located at 6110 Executive Boulevard, Suite 510, Rockville, MD 20852 (301) 231-5944. The ASCO website is www.opted.org Subscriptions: JOE is published three times a year distributed at no charge to dues-paying members of ASCO. Individual subscriptions are available at $30.00 per year, $40.00 per year to foreign subscribers. Postage paid for a non-profit, tax-exempt organization at Rockville, MD. Copyright © 2006 by The Association of Schools and Colleges of Optometry. Advertising rates are available upon request. OPTOMETRIC EDUCATION disclaims responsibility for opinions expressed by the authors. Indexed in Current Index to Journals in Education (ERIC).

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OPHTHALMIC

INDUSTRY NEWS Volk Optical

Volk continues to provide the best quality and value in patented dou­ble aspheric optics. The recently launched Digital High Mag™ lens is the perfect complement to the Digital Wide Field™ and Digital l.Ox lens to deliver the highest resolution retinal imaging in lenses designed to last a lifetime.

Volk established standards of eye care imaging with the original patented double aspheric 78D and 90D lenses over 30 years ago. Evolution led to the development of the Super 66® and Superfield® lenses through to the Digital Series lenses now available - the best value tools that help ensure diagnostic accuracy. Personalize your own lenses with color ring options and free engrav­ing. When you purchase our lenses, ask for a free multi lens case to keep them together.

Volk Optical is an innovator in the design and manufacture of diag­nostic and therapeutic ophthalmic lenses, equipment, and accessories. The company is based in Mentor, Ohio, and has representatives and distributors around the world.

To order or obtain more informa­tion about Volk products, visit www.volk.com, phone Volk at 1-800-345-8655 (toll free) or 440-942-6161, or contact your Authorized Volk Distributor.

CooperVision CooperVision announced the

expansion of the Global Clinical and Professional/Academic Affairs Team. Dr. Harvard Sylvan joined CooperVision as director of profes­sional developments. Dr. Sylvan's most recent employment has been at Opticare Eye Health and Vision Center, a large multi-specialty oph­thalmology and optometry practice in Waterbury, CT, where he has been working as a contact lens specialist. Prior to this position he was vice president, professional services for Biocompatibles Eyecare and very

knowledgeable with the PC hydro-gel products. His practice experience includes both private practice and owning and managing multiple offices in a professional retail envi­ronment.

Mark Andre, F.A.A.O., a consul­tant to CooperVision for several years, now leads Academic Affairs at CooperVision. Mark has been on staff at Casey Eye Institute in Portland, Oregon, and is an associ­ate professor at Pacific University. In this role Mark will assure that a legacy of academic leadership con­tinues and will work to broaden Coopervision's partnership with the schools of Optometry.

Alcon Alcon, Inc. announced that the

Ministry of Health, Labor and Welfare in Japan has approved its VEGAMOX™ (moxifloxacin hydrochloride ophthalmic solution) 0.5 % for the treatment of bacterial infections of the eye including, among others, conjunctivitis and keratitis (including corneal ulcer), as well as for surgical prophylaxis.

VEGAMOX™ solution is a fourth-generation fluoroquinolone eye drop formulated at a 0.5% concentration, providing high drug concentration throughout relevant ocular struc­tures. Its near-neutral pH of 6.8 pro­vides for ocular comfort. In clinical studies, VEGAMOX™ solution has demonstrated excellent efficacy and therapeutic penetration.

Alcon Japan President Scott Manning said the approval will pre­sent an opportunity for increased sales in Japan, the world's second largest ocular anti-infective market.

"The approval of VEGAMOX™ solution provides Alcon Japan with an important opportunity to expand its pharmaceutical offerings in Japan to include anti-infectives and more fully serve Japanese ophthalmolo­gists," said Manning. "Because of its clinical profile and our experience with it in the U.S., where it is the number one prescribed ocular anti-

infective, as well as the strong prefer­ence for fluoroquinolones by Japanese ophthalmologists, we expect it to be a strong participant in the anti-infective market in Japan. In anticipation of the commercial launch of VEGAMOX™ solution this year, we are expanding our sales force in order to reach physicians with information about how this product may contribute to the treat­ment of bacterial eye diseases."

VEGAMOX™ solution is currently approved as VIGAMOX® solution in more than 40 countries around the world.

Transitions To complement the clinical review

paper "Ocular Effects Associated with Medications," Transitions Optical (www.transitions.com) has a new medications database plus other tools offering eyecare practitioners information on medications that may cause vision problems, and aids in discussing the problems with patients. Developed by ocular phar­macologist Siret Jaanus, Ph.D., as part of the Transitions Partners in Education program, the paper offers ECPs a reference guide of drugs that might affect vision.

Transitions has also created a free online Ocular Side Effects Database (www.transitions.com/medications) so ECPs can search drugs by name and determine which affect vision.

"While patients might know their medications carry a possibility of side effects, they may not realize there could also be vision- and eye-related health consequences," said Carole Bratteig, manager, training and education. For additional infor­mation contact Transitions Optical Customer Service at (800) 848-1506.

Vision Service Plan Vision Service Plan (VSP) provid­

ed the Illinois College of Optometry

(Continued on page 12)

Volume 32, Number 1 /Fall 2006 5

DITORIAL Measuring Teaching and

Learning Outcomes Elizabeth Hoppe, O.D., M.P.H., Dr. P.H., F.A.A.O.

How do we know whether it's really sinking in? As educators, an important goal is to impact students'

knowledge, skills, attitudes, and behaviors to prepare them for their roles as doctors of optometry. What are the benchmarks along the way to graduation and licensure, and how do we know if we are successful? In post-graduate residency education, how does the training go beyond entry-level, and how is scholarship developed and demonstrated?

In recent years, educational assessments have shifted from rely­ing solely on measures of teaching effectiveness to include measures of student learning - the ultimate pay­off for our time spent laboring in the classroom, lab, and clinic. This issue highlights several approaches that target the heart of student-centric learning.

Schwartz, et al, along with Denial and Zorn, describe two different approaches to promote the integra­tion of basic science and clinical approaches to patient cases. These two examples of innovative teaching techniques strive to enhance student learning and to integrate clinical and didactic knowledge in a more effi­cient and effective manner.

Two recent publications from nursing education underscore that optometric educators are not alone in recognizing the importance of these educational cornerstones. Waterson, et al., found that the per­formance of learners in a nursing college is hindered by a lack of theo­

ry and practice integration in the curriculum, as well as teaching and assessment methods that do not pro­mote critical thinking.1 Research by Mangena and Chabeli suggests that significant obstacles exist to the facil­itation of critical thinking among nursing students, including educa­tors' lack of knowledge and the use of teaching and assessment methods that do not facilitate critical thinking of learners.2 We can both benefit from, and contribute to, these educa­tional efforts by other health care disciplines.

The descriptions by Schwarz, et al, and Denial and Zorn illustrate some of the difficulties of fully attaining these complex goals. The challenges of assessing the curricular impact, by measuring students' per­spectives of their own improve­ments in knowledge base and thought process, are also described in these articles.

Difficulty in measuring teaching and learning outcomes may be expected. Materials from the University of Michigan's Center for Research on Learning and Teaching suggest that there is no simple sys­tem for evaluating the quality of teaching3 The Center identifies the development of curricula, new courses, and class materials as key elements among teaching activities, yet it also recognizes that the evalua­tion of teaching is not a science, with much still left to learn.

Heiberger and Suchoff have demonstrated a very concrete and tangible measure of one outcome of

residency education: the publication of scholarly works. Even though the measure is specific/it also encom­passes intangibles, such as personal satisfaction, enhancement of creden­tials, and engagement in research.

These innovative approaches serve as excellent examples of edu­cation in action. How can we do things better? How can we ensure greater learning success? How do we measure the impact of new teaching strategies? In an evolving and dynamic field, these articles give us a great snapshot of what is happening in optometric education in 2006.

We are also fortunate to be able to include excerpts from commence­ment addresses from optometry schools and colleges around the country in this issue's Think Tank. Inspiration, perspective, and chal­lenges can be found in these quotes to help us re-energize for the new academic year.

1 Waterson E, Harms E, Qupe L, Maritz J, et al. Strategies to improve the performance of learners in a nursing college. Part I: Issues pertaining to nursing education. Curationis. 2006 May; 29(2):56-65,

2 Mangena A, Chabeli MM. Strategies to overcome obstacles in the facilitation of critical thinking in nursing education. ** finish reference!

3 Guidelines for Evaluating Teaching. http://www.crlt.umich.edu/tstrate-gies/guidelines.html accessed on August 30, 2006.

Optometric Education

Focus on the President

Optometrists for the 21st Century Hector C. Santiago, O.D., Ph.D., F.A.A.O.

The American Optometric Association recently completed three excellent summits with the purpose of determining

desired futures for the profession. The profession challenges us as educators to facilitate the development of Doctors of Optometry who are prepared for the demographic, technological and soci­etal changes of the next decades.

The Minds of the Future: Respectful and Ethical Behavior

Howard Gardner, the psychologist who introduced us to the concept of multiple intelligences, recently wrote a little book in Spanish called Las mentes del futuro (The Minds of the Future).1 In the essay/he describes the characteristics of the educated citizen in the near future.

One of these minds of the future is the respectful mind. This mind, according to Gardner, "goes beyond tolerance and celebrates diversity as a fact of life." It requires a genuine intention to understand others using both emotional and interpersonal intelligence.

For a good portion of its history, America was a mirror of Europe. As early as 1751, Benjamin Franklin, wor­ried by the influx of German immi­grants said:

"Why should Pennsylvania, founded by the English, become a Colony of Aliens, who will shortly be so numerous as to Germanize us instead of our Anglifying them, and will never adopt our Language or customs, any more than they can acquire our Complexion?"

Today, 40 million Arnericans, more than any other group, claim German ancestry. They have not destroyed the United States. Through their work, cul­ture and tradition, they have con­tributed to the welfare of the nation.

Census 2000 brought news about the changing face of the nation. Hispanics became the largest minority group in America, growing four times as fast as the general population. Within the next two \ decades, the Hispanic population will constitute a fourth of the nation. Like the Americans of German ancestry, they contribute to the ethnic richness of the United States. Along with Asians, African Americans and other groups, they are the face of the new Americans.

The optometric profession has to respond as a whole to these challenges. Our profession does not yet reflect the diversity of our population. Unless we embrace diversity and cultural compe­tence we will not be able to serve our

patients well, nor close the gap for the disenfranchised of America.

Another mind of the future is the eth­ical mind. This mind, Gardner claims, promotes the pursuit of excellence and socially responsible work such as humanitarian endeavors. It is based on intrinsic motivation, or the satisfaction that comes from doing the right thing, as opposed to work done to achieve external rewards or avoid punishment.

Service learning activities, in which students learn by providing service to their communities, are exactly those that promote the development of the ethical mind. Volunteer Optometric Services to Humanity (VOSH) groups across the United States and the world embody the highest ideals of the pro­fession by providing primary eyecare services to the most disadvantaged communities of the globe,2

Gardner further indicates that the respectful and ethical minds will not be nurtured in students unless all of us "parents, teachers and leaders" exhibit them. In short, our behavior will speak for our values.

Empathy Daniel Pink also wrote a recent

book that tried to answer a similar question regarding the knowledge and skills that will be critical for suc­cess in the future. Empathy "the abili­ty to put ourselves in someone's shoes, rationally and emotionally" is a crucial skill. To succeed as health practitioners of the 21st century we must move from "a detached attitude to concern and then to empathy."3

As our use of data gathering tech­nology and ancillary personnel increas­es, our role as communicators, coun­selors and empathic listeners becomes more important. Clinical work in

(Continued on page 12)

Volume 32, Number 1 /Fall 2006 7

Ohio Sim- University COIICLV of Optometry

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I

ILLINOIS C O L L E G E OF O P T O M E T R Y . . . . SO AS YOUR GRADUATION SPEAKER, I OFFER YOU THIS CHALLENGE: MANIFEST THE CHARACTER AND COMMITMENT OF A TRUE HEALTH CARE PRO­FESSIONAL, A DOCTOR OF OPTOMETRY.

CHARACTER IS QUALITY WHICH VIDUAL. IT IS INSIDE! K E E P

DEFINED AS YOUR DISTINCTIVE DISTINGUISHES YOU AS AN INDI-WHAT YOU REALLY ARE ON THE I N M I N D THAT A REPUTATION IS

NEW ENGLAND COLLEGE OF OPTOMETRY

Life's greatest rewards are derived from the contribu­tions you make to others. Your legacy will ultimately be defined by your contribution to your family and your community.

For several decades a printed copy of a verse written by Edwin Markham has been displayed in our home. Markham, who was born in Oregon City in the mid-1800s, was an important voice in American poetry at the start of the 20th century.

There is a destiny that makes us brothers: None goes his way alone; All that we send into the lives of others Comes back into our own.

Our work, our gifts, our support, our mentoring is passed from person to person and back again. This is a never ending circle that sustains us all — wherein the good you do comes back to you - sometimes when you least expect it, sometimes when you need it most.

We live in a world of constant change. The typical grad­uate today will change jobs at least eight times in his/her career. Some of you today are already on your second, third or even fourth career. Of course, some of you will enter private practice and find uncharacteristic stability staying in that practice the rest of your profes­sional life, but many will pursue multiple paths including residencies, employment, clinical practice in various set­tings, perhaps graduate education or even teaching. Regardless, all paths provide an opportunityfor continu­ous growth and renewal, and for SERVICE TO OTHERS.

Larry Clausen, O.D., M.Ed. Dean, Allied Health and Science Division,

Portland (OR) Community College and former President of NECO.

WHAT OTHERS " T H I N K " YOU A R E . . . B U T C H A R A C T E R IS WHAT YOU ARE REGARDLESS O F WHAT OTHERS THINK. T H E WORD ITSELF IS DERIVED FROM THE G R E E K AND COMES FROM AN "ENGRAV­ING TOOL." T H I S IMPLIES THAT YOU WERE S H A P E D AND MOLDED INTO THE DOCTORS YOU ARE T O D A Y . T H E R E F O R E , Y O U A R E A W E L L - T R A I N E D , H I G H L Y S K I L L E D P R O F E S S I O N A L A N D A R E C A P A ­B L E OF DELIVERING THE HIGHEST QUALITY OF OPTOMETRIC CARE POSSIBLE WITH KINDNESS AND COMPASSION. YOU HAVE THE HEAD (KNOWLEDGE), HANDS (SKILLS), AND HEART (ATTITUDE) OF A PROFESSIONAL.

LESLEY L. WALLS, O . D . , M.D. , PRESIDENT, SOUTHERN CALIFORNIA COLLEGE OF OPTOMETRY

8 Optometric Education

U n i v e r s i t y ©ff M i s s o u r i a t S t . L o u i s ) C o l l e g e off O p t o m e t r y

Indiv idual visual brain cells are dumb. • Isolated braan cells are ineffective and bave only a very rudimentary capacity to encode visual in format ion.

The power of t be bra in Is der ived f r o m i ts iuterconnectivity. • Every cell interconnects with many other cells - 10,0©© other cells on average. • The iuterconnectivi ty forms neural networks. • Interactions among cells In the network make possible the elaborate processing tha t gives us our exquisite vision.

Neural networks are l ike social networks, and they both have two propert ies in commons plasticity and stabil i ty. S Plasticity simply means tha t the connectivity depends on use. Mult ip le or repeated interactions establish new or

strengthen existing connections; bu t If interact ion ceases, the connection is weakened and broken. • This is t rue

^ in both neural and social networks. • Individuals ... l i l\ i- 1M,mi n l N „ HHI*>I i i i i i i i m (innilv interactive

in 1 1111111-1 Tn ii \ 1̂ in-*! £ •»!! (list l ike the 1 finli.wv ur ni i i i i \ .ui ihlMipi i i - we can use

mil- 1 u 11111 1 hi.n*. 111 IUM- them.

Northeastern State University Oklahoma College of Optometry

M a j o r health reform appears to be 00 the horizon at the federal level. However, sigi

'experimentation has beeo attempted at state levels. The ioitiatives io Maryland, Hawaii, Vermont

t recently and boldly, in Massachusetts, are examples of state undertakings (public health lectures of

SUNY State College of Optometry

Mi-phi-n \\. I.olimkuhle, Ph.D. Si'iiior \iro President for Academic

VIInirs Tor l he UM system, iind former Professor of

Optometry at UMSL

Massachusetts has mandated coverage for all of its citizens paid for by a combination of

'resources from the federal government, frnm the state government, from employers and from indi­

vidual citizens is a major step toward achieving the goal and concept of universality of coverage. It certainly

has fueled the healthcare debate more intensely and particularly in the state capitals across the country. I view

that as a very positive development.

( O ^ - W time there is a new initiative in healthcare, there is a renewed understanding that the need

V ^ 4 n r leadership in the optometric community, at both state and national levels, is ot paramount

importance. It has always been so and it remains our prufession's ongoing and orgont concern. And you, my

new colleagues, are expected to" step up to the plate" to help to structure optometric care and services at

both state and national levels in every new paradigm that develops.

ge you to use your talents and your extraordinary knowledge to benefit the penple whom you will

' serve. Be devoted to their needs and to those of the larger community. Because nf your talents, ynu

must serve. Moreover, the public has placed its trust in you and confidently expects your leadership and intel­

ligence to be applied well beyond your clinical environment. Indeed, that is civic engagement. And as a prac­

titioner nf an important health discipline, your obligation is to join with the consortium of other health work­

ers in the American Public Health Association.

inyal IN HIH institution that prepared you for your life's career. Your abiding obligation is for-

/ H ' K I tu sii|i;].j.l and honor it along with the devoted men and women faculty who are its strengths.

FinH'l;. the Amuhnn Ooiometric Association and its state entities are your professional homes, They earn

evoiy ilav ynui identity, commitment and sustenance.

Firmer President,

In my view of the world and future, we will all build on collaborations. I'll bet COLLABORATIONS are what have

gotten you through the years in optometry school. You've

collaborated with your classmates by studying together, socializing, encouraging each other, taking care of difficult patients, and backing each

other up. You've collaborated with your parents and significant others to pay for

your schooling. You've collaborated with your teachers: they teach and you learn. That's the educational contract, but it belies a back-and-forth exchange—they teach a little bit better, you learn a little bit more. Mert Flom, one of the grand old men of optometric research

in binocular vision and a gifted classroom and clinical teacher, says, "Teach less better." My version of that to the student would be "Learn less better." Have a deeper understanding of what you do know and know where to look for what you don't.

Karla Zadnik, O.D., Ph.D. Associate Dean and Professor, Ohio State University College of Optometry

f State

I., Ph.D.

of Optometry

PENNSYLVANIA COLLEGE OF OPTOMETRY

In contrast to the United States, German optometric education put the emphasis for too long

on the technical aspect of optometry, ignoring the clinical side of our profession. This has

changed and one of the reasons for this change is the globalization of modern optometry and the vision and leadership of

institutions such as the Pennsylvania College of Optometry.

The WCO/ARBO Planning Committee on Optometric Competencies presented in 2004 "A Global Competency-based Model of Scope

of Practice in Optometry." This committee was chaired by Dr. Norman Wallis, president of PCO from 1972 to 1979. This model has

since been adopted by the World Council of Optometry, whose general secretary is the dean of PCO, Dr. Anthony Di Stefano.

Optometry is internationally oriented from its beginning and global exchange is still one of the great strengths of optometry.

Wolfgang Cagnolati, M.S., MCOptom. Visiting Associate Professor at PCO, and President of the European Chapter of the American Academy of Optometry

>" W'.&ir:,- • *ul*!i.':X£.\ ca/i&jfe&'f KjttfvjsV.

Volume 31, Number 2 / Winter 2006 9

COMMUNICATION

Development of a New Clinical Training Model

Charles F. Mullen, O.D., F.A.A.O.

Background

Since the 1970's, optometry has been in a state of meta­morphosis with the intro­duction of pharmaceuticals

and advanced clinical procedures. Optometric clinical education like­wise has evolved in response to the expanded patient management and treatment responsibilities of opto­metric practice. However, the tradi­tional clinical training model and terminology is not consistent with the current functional reality and presents obstacles to inclusion in and compliance with major federal programs.

The profession of optometry has benefited from inclusion in the fed­eral program Medicare by being classified in medical terminology as physicians and are treated on a par with other physicians (MD, DO, DMD, DPM) regarding payment for patient services. Optometric educa­tion, however, does not conform to medical terminology nor the med­ical training model. Federal agen­cies administer health care and health education programs based on the medical model and terminology. While optometry is included in the Health Professions Student Loan programs, it is excluded from numerous special Federal Health Professions Education Programs sponsored by the Health Resources and Services Administration (HRSA) and from the Graduate Medical Education (GME) program, the edu­cational component of Medicare. The Federal Government appropri-

Dr. Mullen was president of the Illinois College of Optometry from 1996 to 2002. Previously he was director of the VA Optometry Service. He is currently on the Board of Trustees at the Pennsylvania College of Optometry and on the Board of Directors of the New England Eye Institute. Dr. Mullen may he reached at cfmalex@aol.com or at his website at charlesmullen.com

ates billions of dollars per year for the programs, but optometry is not eligible for these funds while all other health professions participate in these programs.

The premise behind why GME payments are made to financially support clinical training of physi­cians, dentists and podiatrists is that clinical training is inherently ineffi­cient. All clinical tiaining for optom­etry students, however, must take place in the four-year curriculum and not in postgraduate residency programs since the graduate must be prepared to enter practice after graduation. The financial burden for the inherent inefficiencies in clinical training is placed upon the optome­try student in the form of higher tuition. Inclusion of optometry in GME would provide additional rev­enue to optometric clinical facilities to partially offset the cost of these inefficiencies.

Medicare bases its regulations on the medical teaching model. Optometry's traditional teaching model and terminology is not analo­gous to the medical model. However, functionally optometry's model is consistent in several impor­tant aspects with the medical model. Current Medicare regulations regarding student supervision sig­nificantly impede optometry stu­dents from acquiring patient evalua­tion and management skills, since regulations do not permit third and fourth year optometry students to contribute to billable services. Medical interns, residents and fel­lows, however, can contribute to bill­able services and have ample oppor­tunity to acquire patient evaluation and management skills without sig­nificantly affecting the efficient pro­vision of health care.

Realignment of the traditional optometric clinical training model and terminology is necessary to facil­

itate inclusion in and compliance with major federal programs and to reflect the current functional reality.

Objectives of a New Clinical Training Model

The main objective of a new model and terminology would be to position optometry to be consistent with current Federal law and regula­tions pertaining to eligibility for GME, National Health Service Corps (NHSC), and Medicare billable ser­vices regulations and facilitate inclu­sion in and compliance with these programs. Participation in GME and NHSC would provide signifi­cant Federal resources currently not available to optometry. Realignment of the clinical training model would also ensure that third and fourth year optometric trainees receive meaningful and cost-effective train­ing in patient evaluation and man­agement (E/M) by placing optomet­ric trainees in full compliance with Medicare billable service regulations without the need for the attending to repeat all clinical procedures.

Other objectives include increas­ing participation in Medicare, increasing the number of communi­ty-based training sites, and control­ling educational debt. Inclusion in GME would result in significant funds paid to optometric clinical facilities for participation in the Medicare program. Given the financial benefit, GME participation would encourage an increase in Medicare services provided. The NHSC would provide significant resources and loan repayment for optometric residents and graduates practicing in federally-qualified health centers. Inclusion in the NHSC would encourage schools and colleges of optometry to increase the number of affiliated community-based tiaining sites.

10 BUSH Optometric Education

Community-based training has proven to be highly cost-effective. The NHSC provides an opportunity for student loan repayment up to $50,000, thus providing a means to help control educational debt.

Functional Reality of Current Optometric Training Model

Optometry residents are not truly residents, but function as medical attending or fellows according to the Department of Health and Human Services (HHS). The fourth year of optometric edu­cation has evolved into an intense clinical experience in response to the expansion of patient manage­ment and treatment responsibilities of optometric practice and is analo­gous to medical residency training. Fourth year students are expected to evaluate and manage patients and function as medical residents. Third year optometry clinical train­ing has also increased in intensity in response to the expanded scope of optometric practice. This is the transitional year from classroom and laboratory activity to patient care. Supervised third year optom­etry students function as medical interns. First and second year optometry students have limited clinical training and function, for the most part, in a manner similar to medical students. (Table 1.)

Actions Required to Realign the Optometric Clinical Training Model

The following actions are required to place the traditional optometric clinical training model in conformance with functional reality and medical terminology. Current third year optometry stu­dents would be redesignated as interns and current fourth year stu­dents would be redesignated as first year residents (Post-Graduate 1 or PG-1). Current optometric res­idents would be reclassified as PG-2, PG-3 or Fellows. First and sec­ond year students would remain classified as students. Since fel­lows, residents and interns can con­tribute to Medicare billable ser­vices, optometric trainees in this new configuration could receive meaningful and cost-effective train-

Table 1: Comparison of Optometric Clinical Training Model lo Medical Model

TRADITIONAL OPTOMETRIC MODEL

Optometry Residents Function as

Qualified to: • Bill for Medicare services when licensed • No GME • No NHSC

Optometry 4th year students Function as

Qualified to: • Cannot contribute to Medicare

billable services • No GME • No NHSC

MEDICAL MODEL

Medical Attending or Fellows

Qualified to: • Bill for Medicare services • Receive GME Payments • Qualify for NHSC

Medical Residents

Qualified to: • Contribute to Medicare

billable services • Receive GME Payments • Qualify for NHSC

Optometry 3rd year students Function As Medical Interns

Qualified to: • Cannot contribute to

Medicare billable services • No GME • No NHSC

Optometry 1 st and 2nd year students

Qualified to: • Cannot contribute to

Medicare billable services • No GME • No NHSC

Function As

Qualified to: • Contribute to Medicare

billable services • Receive GME Payments • Qualify for NHSC

Medical Students

Qualified to: • Cannot contribute to

Medicare billable services • No GME • No NHSC

ing in patient evaluation and man­agement (E/M), while in full com­pliance with Medicare billable ser­vices regulations.

In order to qualify for GME, the Social Security Act needs to be amended to require the Secretary of HHS to make Medicare, Graduate Medical Education (GME) payments to optometric affiliated facilities for certain costs associated with the clin­ical training of optometric interns and residents (PG-1 - PG-3), includ­ing resident stipends. Existing law/regulations need to be amend­ed to direct HRSA to include optom­etry in the National Health Service Corps (NHSC). Inclusion in the NHSC would provide for resident stipends and educational loan repayment for up to $50,000 as well as other potential resources.

Conclusion and Recommendation

The traditional optometric train­ing model and terminology are not consistent with the functional reality, with medical terminology and feder­ally-supported programs and pre­sent obstacles to inclusion in and compliance with major Federal pro-grams.There is need to comply with Medicare regulations regarding stu­dent billable services and significant benefits of inclusion in GME and the NHSC. Formation of a broad-based task force is recommended to thor­oughly review the issue regarding clinical training models, terminology and related considerations. Also, the task force would contribute to the political strategy to include optome­try in GME and NHSC.

Volume 32, Number 1 /Fall 2006 11

Focus on the President (Continued from page 7)

underserved multicultural popula­tions is an excellent model for the promotion of empathy in our stu­dents.

Servant Leadership The growth of the profession

depends, to a significant extent, on the willingness of its members to pursue leadership positions. What is the role of the leader of the future?

Robert Greenleaf, an extraordi­nary visionary, defined for us the nature of the leader several decades ago:

"The servant leader is a servant first...[and] makes sure that other peo­ple's needs are being served by asking: do those served grow as persons, do they while being served become healthier, wiser, freer, more autonomous? And what is the effect on the least privileged in society, will they benefit or at least, will they not be further deprived?'"1.

The Challenge of Service More than 80 years ago, an extra­

ordinary woman, blind and deaf, challenged humanity in a famous speech:

"I appeal to you...you who have your hearing, you who are strong and brave and kind. Will you not constitute your­selves Knights of the Blind in this cru­sade against blindness?"5

That challenge of Helen Keller reminds us that our ultimate mission is to protect and preserve that most precious gift of sight through the prevention of blindness and visual impairment. Allowing our patients

Industry News (Continued from page 5)

(ICO) with a $200,000 grant to expand its Pediatric Outreach Program. In appreciation, the college renamed the initiative the "VSP Pediatric Outreach Program" and dedicated a lecture hall in VSP's honor.

The grant will allow ICO to sig­nificantly increase its comprehensive

to blossom and develop their full potential as human beings is our greatest satisfaction as. health care professionals.

Service learning activities,

in which students learn

by providing service

to their communities,

are exactly

those that promote

the development of

the ethical mind.

Parting Words I will end this short essay with

the words of two great world lead­ers. Their examples are a source of inspiration to those who see their lives within the larger context of Humanity. One is the great humani­tarian Albert Schweitzer:

"I don't know what your destiny will be, but one thing I know: the only ones among you who will be really happy are those that have learned how to serve."6

Closer to home, Martin Luther King added:

"Every man must decide whether he will walk in the light of creative altru-

eyecare for children from birth to five years of age, according to VSP. The goal is to serve 1,000 children per year, approximately one-third of them uninsured.

VSP's president and chief execu­tive officer, Rob Lynch, represented VSP at the dedication ceremony, along with James Short, O.D., vice chairman of the VSP board of direc­tors, and VSP Illinois state profes­sional representative Al Lever, O.D.

ism or the darkness of destructive self­ishness. This is the judgment: Life's most persistent and urgent question is, what are you doing for others?"7

Our unique challenge as educa­tors is the development of a respect­ful mind that appreciates diversity, an ethical mind committed to com­munity service, and an empathic, culturally competent mind allowing all students to become the servant leaders of society. Let's work togeth­er for this future.

1. Gardner H. Las cinco mentes del futuro: un ensayo educative Barcelona: Paidos, 2005.

2. VOSH website: http://www.vosh.org 3. Pink D. A whole new mind. New York:

Riverhead Books, 2005. 4. Greenleaf RK. Servant as a leader.

Westfield, Indiana: Robert K. Greenleaf Center, 1982.

5 Lash JP. Helen and teacher. New York: Delta/Seymour Lawrence, 1981.

6 http://www.learningtogive.org/search /quotes/Display_Quotes.asp?author_id =560&search_type=author

7 http://www.brainyquote.com/quotes/ authors / m / martin_luther_king_jr.html

Dr. Santiago is dean at Inter American University of Puerto Rico School of Optometry. He received his bachelor's degree in Physics and Mathematics from the University of Puerto Rico at Mayaguez, his M.S. and Ph.D. in Experimental Psychology from the University of Texas Graduate School of Biomedical Sciences at Houston and his O.D. degree from the New England College of Optometry. He is Vice-President of the Colegio de Optometras de Puerto Rico (Puerto Rico Optometric Association), Secretary of the Latin American Association of Optometry and Optics, Co-Pounder of the Latin American Association of Schools and Faculties of Optometry, Past-President of Puerto Rico Lions Eye Bank and Chairman of the Puerto Rico Lions Sightfirst Program. He has been an invited lecturer in over eleven countries of Latin America, Europe as well as the United States.

Lynch reaffirmed VSP's commitment to comprehensive eyecare, saying, "VSP is dedicated to providing access to quality vision care for all children, while helping to establish healthy eye habits that can last a life­time."

12 Optometric Education

Effectiveness of Co-Facilitation as a Teaching Methodology In an Integrative Seminar Course Aurora Denial, O.D., F.A.A.O. Mark Zorn, O.D., Ph.D., F.A.A.O.

Abstract The Integrative Seminar Course

(ISC) at the New England College of Optometry (NECO) was developed to help students integrate their existing knowledge base and to develop the tools needed for clinical problem solving. A novel strategy for the course involved assigning a scientist and a clinician to co-facilitate discussion within a small group seminar. The purpose of this study is to determine if the combined facilitation by both a clinician and a scientist enhanced the student's learn­ing and to evaluate the effectiveness of this team teaching methodology. Data generated from this study shows that, in the opinions of the students and fac­ulty, co-facilitation by a scientist and a clinician enhanced students' learning and was an effective teaching method-

Key Words: Optometric education, team teaching, co-facilitation, teaching methodology

Dr. Denial is assistant professor of optometry and Dr. Zorn is professor of optometry at the New England College of Optometry.

Introduction

The education of clinical pro­fessionals provides unique challenges. Students must acquire a wide knowledge

base in both basic and clinical sci­ences. In many cases, the information is taught by lecture and tested by multiple-choice exams.1 This educa­tional scheme encourages the individ­ual to acquire large amounts of infor­mation organized by scientific discipline. Information learned in this way tends to remain isolated in disci­plinary silos. The desired endpoint of professional education requires stu­dents to implement a clinical thought process integrating and applying knowledge across scientific disci­plines while working effectively as a member of a health care team. Moreover, the rapidly changing advances in medical fields require that students develop skills to evalu­ate new scientific information and decide how to incorporate this infor­mation into their practice.

In the 1990's many medical schools struggled to integrate the basic and clinical sciences.2 Small group, prob­lem-based learning seminars were one method used by medical schools to integrate the knowledge base.3

Early patient based clinical education, presenting clinical cases in basic sci­

ence courses and synchronizing basic science concepts with hands-on med­ical procedures were also used to pro­mote integration of material.2

In the profession of optometry, expanded scope of practice and changes in health care delivery also dictated changes in the curricula of optometry schools.4 In 1999, the facul­ty at the New England College of Optometry (NECO) developed goals for the 2010 graduate of optometry. In order to meet these educational chal­lenges, the Integrative Seminar Course (ISC) at NECO was devel­oped. The goals of the ISC include: helping students utilize their existing knowledge base by integrating basic and clinical sciences to solve clinical problems, developing the tools need­ed for clinical problem solving, foster­ing self-directed learning and empha­sizing the team approach in teaching and patient care. With the aim of pre­senting a more integrated approach to optometric education and to help achieve the course goals, the ISC adopted the novel teaching strategy of assigning both a scientist and a clinician to co-facilitate discussion of small group seminars. A clinician was defined as a faculty member who pro­vides patient care. A scientist was defined as a faculty member who is primarily involved in research or teaching basic science.

Both clinicians and scientists have expert knowledge and experience in complex problem solving. Clinicians tend to have a broader, but less focused knowledge base than the sci­entists, who have a narrower but deeper knowledge base. The purpose of this study was to determine if the combined presence of a clinician and a scientist enhanced the student's learning and to evaluate the effective­ness of this team teaching methodolo­gy in achieving the course goals.

Methods The ISC is a required, core course

for first and second year students at NECO. Course activities include problem based learning cases, critical literature review, case development and debates. The course philosophy and goals remain the same each year. However, each year represents a more complex level of problem solving and reflects the students' greater knowl­edge base. Eighteen faculty members, consisting of nine clinicians (OD) and nine scientists (PhD, MD, OD/PhD,

Volume 32, Number 1 /Fall 2006 13

OD) participated in the course along with 163 students. Fifteen facilitators (83%) had previously participated in small group problem based learning seminars as a single facilitator. At the end of the year, the faculty and stu­dents were surveyed about the effec­tiveness of co-facilitation. <

The faculty was surveyed using two questionnaires. The first survey was a general questionnaire regarding the concepts of co-facilitation. The questionnaire consisted of a total of 12 questions; six questions were rated on a 4-point Likert scale (1= strongly dis­agree, 4 = strongly agree), and six

questions asked for background infor­mation or required short answers. The second questionnaire compared spe­cific aspects of the co-facilitation rela­tionship. It contained six questions, four of which were rated on a 4-point Likert scale (1= strongly disagree, 4 = strongly agree) and two that required short answers. An opportunity for comments was available.

The students' survey was part of the overall course evaluation. Five questions were dedicated to the co-facilitation teaching arrangement. Four questions were rated on a 4-point Likert scale (1= strongly dis-

Table 1: General Survey/Faculty

Question

Have you ever served as a single facilitator in a problem-based Teaming, case analy­sis, seminar, or similar small group format?

Have you ever taught in this type of environment where both a scientist and a clinician co-facilitated a class?

Would you recommend this method of teaching to a colleague?

Co-facilitating, as compared to a single facilitator, enhances stu-dent Teaming and perform ance.

The students learned to integrate clinical and didactic knowledge in a more efficient and effective manner than they would have with a single facilitator.

The students are better equipped to evaluate the scientific basis of clinical practice when instructed by co-facilitators rather than in a single facilitator situation.

Co-facilitating helped to emphasize the team approach in teaching, patient care, clinical practice and student interactions. Co-facilitating, as compared to a single facilitator, better demonstrated the integration of basic and clinical sciences to form a unique approach in the delivery of eye care and patient care. In my opinion, this teaching experience will help to build a more cohesive faculty.

Strongly disagree

1/18 5.6%

1/18 5.6%

2/18 11.1%

0/18 0%

1/18 5.6%

0/18 0%

Disagree

1/18 5.6%

1/18 5.6%

1/18 5.6%

1/18 5.6%

1/18 5.6%

1/18 5.6%

Yes

15/18 83.3%

2/18 11.1%

15/18 83.3%

Agree

8/18 44.4%

10/18 55.6%

11/18 61.1%

9/18 50%

8/18 44.4%

7/18 38.9%

No

3/18 16.6%

16/18 88.9%

2/18 11.1%

Strongly agree

8/18 44.4%

5/18 27.8%

4/18 22.2%

8/18 44.4%

8/18 44.4%

10/18 55.6%

Maybe

1/18 5.6%

Neutral

1/18 5.6%

agree, 4 = strongly agree) and one question required a short answer. Comments were encouraged.

The results from the surveys were tabulated for response frequencies.

Results The response rate for the faculty

questionnaires was 100% (Tables 1&2). The response rate for the students' questionnaires was also 100% (Table 3).

The results show that 89% of the fac­ulty and 83% of the students thought that co-facilitation demonstrated the integration of basic and clinical sci­ences to form a unique approach in the delivery of eye and patient care. Eighty-three per cent of the faculty felt the students learned to integrate clini­cal and didactic knowledge in a more efficient and effective manner and were better equipped to evaluate the scien­tific basis of clinical practice when instructed by co-facilitators rather than a single facilitator. Ninety-four percent of the faculty and seventy-seven per­cent of the students felt that co-facilita­tion helped to emphasize the team approach in patient care and student interactions. Additionally, ninety-five percent of the faculty felt that this teaching experience helped to build a more cohesive faculty.

Eighty-three percent of the faculty and 83% of the students would recom­mend this method of teaching to a col­league. The faculty cited diversity in knowledge base, opinions, and per­spectives as the main reasons to rec­ommend this teaching method to other faculty. The students echoed this per­ception. Comments from the students also indicated that role modeling inte­gration of basic science into clinical practice was one of the main benefits of this teaching method (Table 4).

Eighty-nine per cent of the faculty felt that having co-facilitators, as com­pared to a single facilitator, enhanced student learning and performance. Overall most of the faculty comments indicated that having two different perspectives enhanced the students' learning environment (Table 5). The faculty cited the development of mutual respect and mutual learning as a unique outcome of this teaching experience.

Discussion The New England College of

Optometry is fortunate to have many optometrist /scientist (OD/PhD) fac-

14 Optometric Education

Table 2: Co-Facilitation Relationship/Faculty Table 4: Student Comments Question

Did you benefit by having a co-facilitator?

Did any friction develop between you and your co-facilitator?

This experience enabled me to heighten mv respect for my fellow co-facilitator.

This experience gave me a new perspective on how a scientist/clinician approached problem solving.

1 modified my image of "scientist" or "clinician" based on this teaching experience.

This teaching experience influenced my practice of optometry/science (circle one).

Strongly disagree

0 /24 0%

2 /24 8.3%

2 /24 8.3%

4 / 2 4 16.7%

Disagree

1/24 4.2%

4 / 2 4 16.6%

9/24 37.5%

9/24 37.5%

Agree

9 /24 37.5%

6 /24 25%

6 /24 25%

5 /24 20.8%

Strongly agree

13/24 54.2%

9 /24 37.5%

2 /24 8.3%

4 / 2 4 16.7%

Yes

24 /24 100%

0 /24 0%

Did not answer

1/24 4.2%

3 /24 12.5%

3 /24 12.5%

1/24 4.2%

No

0 /24 0%

24 /24 100%

Neutral

2 /24 8.3%

1/24 4.2%

Table3: Student Survey

Question

Co-facilitating helped to emphasize the team approach in teaching, patient care, clinical practice and student inter­actions.

Co-facilitating demonstrated the integra­tion of basic and clinical sciences to form a unique approach in the delivery of eye care and patient care.

1 would recommend a course taught by co-facilitators (a scientist and clinician).

1 felt that 1 learned different perspectives on patient care from having two facilita­tors with different backgrounds, experi­ences, and education.

Strongly disagree

7/163 4.3%

5/163 3.1%

9/163 5.5%

6/163 3.7%

Disagree

30/163 18.4%

22/163 13.5%

19/163 11.7%

24/163 14.7%

Agree

85/163 52.1%

102/163 62.6%

84/163 51.5%

74/163 45.4%

Strongly agree

41 /163 25.2%

34/163 20.9%

51/163 31.3%

59/163 36.2%

ulty members who have expert knowledge in both the clinical and the scientific aspects of vision. However, the basic sciences are still taught mainly by scientists while clinicians teach the clinical sciences. It has been reported that students in other disci­plines tend to compartmentalize their knowledge5 and to memorize lecture material without understanding the relationship among the basic con­cepts.6 Personal experience with

optometry students indicates that iso­lation of knowledge and memoriza­tion without understanding also occurs. As optometric educators, we are continually exploring new ways to help students integrate their knowledge base into clinical practice. Co-facilitation was used to demon­strate the integration of basic science to real world clinical cases. The clini­cal cases were based on the student's clinical experience. The clinical activi-

One facilitator could explain how a treatment is integrated in her office and how the patients respond and the other facilitator was good to explain the science behind the procedures. It was good to see both sides of the situation.

I got two different views and realized how what we are learning now (basic sciences) actually applies to practice.

Co-facilitation allowed us to get a different perspective on how to under­stand and apply the knowledge in a clinical setting.

I have a better understanding not only from a clinical standpoint but also from a scientific point of view of underlying optometric problems.

Co-facilitation enabled me to link different issues/problems from ocular to systemic conditions.

Co-facilitation gave two perspectives. If one facilitator didn't know some­thing, the other would fill in.

Co-facilitation lets you see both perspectives, which is necessary when trying to give the best care to patients.

Table 5: Faculty Comments

The student got two opinions-one sci­ences based and one clinical based, both leading to the same answer.

It was nice for students to have differ­ent perspectives.

Improved communication within the group by having different people pre­sent/field questions.

Two points of view enhanced discus­sion, more argument? More passion. More definitions of areas not fully known

The different knowledge base of both added greatly.

Clinical and basic science faculty worked together and got to know each other and what the "other side" does better.

A unique outcome was being able to teach with someone within a different discipline, obtaining a new respect for the co-facilitator.

Volume 32, Number 1 /Fall 2006 15

ties for the first year students are screenings and observations. The sec­ond year students work in optometric practices, doing a variety of tasks. Co-facilitation gave the scientist the opportunity to demonstrate how the basic sciences could be applied in a clinical situation. The ability to inte­grate material from both within a dis­cipline and across different disci­plines is essential in good patient care. The understanding of the scien­tific basis underlying clinical presen­tations helped to emphasize an inte­grated cross-disciplinary approach to patient care. This approach included developing an awareness of the qual­ity and limits (standard deviation, standard error, confidence interval etc.) of the data from which basic optometric equations such as Donder's rule were developed as well as the meaning and use of outcome based clinical care.

Co-facilitation provided a positive learning experience for both faculty and students. The faculty felt that this teaching method enhanced student learning and performance by present­ing different perspectives and opin­ions. The students agreed and felt that they learned different perspectives on patient care from having two facilita­tors with different backgrounds and experiences. Co-facilitation encour­aged the use of a variety of ways to look at problems, search literature and evaluate strategies. As a tribute to the enhanced learning experience, the majority of both students and faculty would recommend a course taught by a scientist and clinician.

In many instances, health care delivery is dependent on collabora­tive teamwork. Different disciplines have different roles and strengths that can be used to provide good patient care.7 Lack of skills needed for suc­cessful team work and ingrained competitive behaviors can render stu­dents inefficient at working in teams. Small group seminars and co-facilita­tion help to form a learning commu­nity in which "the essence of team­work is pooling expertise and experience."8 Co-facilitation helped to emphasize the team approach in teaching, patient care, clinical practice and student interaction.

Optometry schools cannot teach, in four years, everything that will be needed during the lifetime of a practi­tioner. The growth of scientific knowl­edge combined with the increasing and changing scope of practice

demands that students develop the self-directed learning skills needed to evaluate the scientific basis of clinical practice essential to the optometrist. Co-facilitation and the Integrative Seminar Course curriculum were designed to promote self-directed learning skills. The clinical faculty supported the students' efforts by demonstrating how evidence based decision making skills can influence both patient care and standard of care. The expertise of the scientific faculty strengthened and supplemented the acquisition of these skills by empha­sizing the critical review of literature.

Co-facilitation helped

to emphasize the

team approach in

teaching, patient care,

clinical practice and

student interaction.

Traditionally, the clinical and acad­emic faculties at many colleges are not fully aware of each others' expertise and knowledge, which can manifest as a split along the clinical/didactic lines. This divide can lead to issues in promotion and tenure decisions, workload calculations, and other fac­ulty projects. Each "side" remains ignorant of the responsibilities of the "other side." Although faculty work together successfully on many com­mittees and projects, in most cases they do not get the opportunity to interact with each other, teaching the same material. All the faculty mem­bers who participated in ISC felt that they benefited by having a co-facilita­tor and that no friction developed between the co-facilitators. Co-facilita­tion gave faculty more insight into how clinicians/scientists solve prob­lems and their unique perspectives. This teaching method helped to build

faculty cohesiveness and potentially defuse clinical/didactic faculty issues.

Conclusion The goal of optometric education is

to produce a successful optometrist who has skills in complex problem solving, integration of knowledge, independent learning, communica­tion, and working successfully in a team. With the aim of producing a successful clinician, optometric edu­cators strive to design and implement creative approaches to teaching that will enhance learning.

This study shows that, in the opin­ions of the students and faculty, co-facilitation by a scientist and a clinician enhanced students' learning and was an effective teaching methodology. Co-facilitation effectively assisted the stu­dents in achieving some of the course goals. An additional bonus was the building of a more cohesive faculty.

Acknowledgments We would like to thank Dr. Clifford

Scott for his editorial help, Maria Pitcher for her technical help, and the facilitators who made the course pos­sible: Drs. Scott, Frankel, Farra, Gwiazada, Gilman, Mertz, Chauncey, McCormack, Lewis, Troilo, Quinn, Koevary, Suchow, Colletta, Patel and Moore.

References 1 Regan-Smith MG, Obenshain S, Woodward

C, Richards H, Zeitz J, and Small PA. Rote learning in medical school. JAMA 1994 272: 1380-1381.

2 Schmidt H. Integrating the teaching of basic sciences, clinical sciences, and biopsychoso-cial issues. Academic Medicine Supplement 1998 Sept; 73(9):S24-31.

3 Bruhn JG. Outcomes of problem based learning in health care professional educa­tion: a critique. Farm Community Health 1997 20(l):66-74.

4 Murphy J. Optometry schools raise the grade. Review of Optometry 2003 Aug: 49-56.

5 Nichol, MB. A Multidisciplinary Approach to Teaching Pharmacy Students. American Journal of Pharmaceutical Education 1991 Winter; 55: 369-73.

6 Galley WR. What is the future of problem based learning? Adv Physiol Educ 1998; 20:12-15.

7 Wilkinson T. Teaching team work to medical students: goals, roles and power. Medical Education 2002 36:1084-1110.

8 Henderson J, Conchie L, Steinert Y. Co-tutors in the basis of medicine. Clini Invest Med 2000 23(l):86-89.

16 Optometric Education

Student Assessment of An Integrative Seminar Course Aurora Denial, O.D., F.A.A.O. MarkZorn O.D., Ph.D., F.A.A.O.

Abstract Introduction: The Integrative

Purpose: Over ike past two decodes, the topic of information processing has been brought to the forefront of health care education. The New England College of Optometry (NECO) developed the Integrative Seminar Course (ISC) to develop and strengthen the skills needed for information processing and to emphasize the collaborative approach in teaching and clinical practice. The unique aspects of this course included a diversity of activities, a "just in time" teaching philosophy and a distinctive teaching method utilizing a clinician and a scientist.

Purpose: The purpose of this paper is to describe the Integrative Seminar Course and to evaluate its effectiveness in achieving the course goals.

Methods: The ISC is a required course for all first and second year stu­dents at NECO. At the end of the second year the students were surveyed to determine the effectiveness of the course.

Conclusion: In the opinion of the students the ISC achieved its goals by improving students' skills in informa­tion processing, critical acumen and col­laboration.

Key Words: clinical thought process, health care education, informa­tion processing

Dr. Denial is assistant professor of optometry and Dr. Zorn is professor of optometry at the New England College of Optometry.

Introduction Health care professionals such as

physicians, optometrists, podiatrists, nurse practitioners and dentists must often manage complex problems that involve ambiguity, inconsistency, novelty and surprise.1 The successful management of complex patient sce­narios requires both factual knowl­edge and skills in information pro­cessing. Satish states that "factual knowledge can be gained from read­ing or memorizing lecture notes and from repeating successful prior activi­ties in response to repetitive chal­lenges."2 Information processing involves cognitive strategies that pro­fessional decision makers use to regu­late the process of attending, learning, remembering and thinking.3 The information processing strategy must allow practitioners to adapt in an effi­cient manner to a variety of situa­tions, some of which they may not have previously encountered. Additionally, to be successful in the 21st century, health care providers need to develop the skills needed to engage in collaborative health care.4 5

In the 1990's, with the aim of facili­tating information processing, many health care institutions moved away from the traditional lecture-based, single discipline courses to a curricu­lum that incorporated the integration

of disciplines and problem-based (or case-based) learning. 6-7-8 Early patient based clinical education, the presenta­tion of clinical cases in basic science courses, and the synchronization of basic science concepts with hands-on medical procedures were also used to promote information processing.6

In 1999, the faculty of the New England College of Optometry (NECO) developed goals for the 2010 graduate of optometry. In order to meet these educational goals, NECO designed the Integrative Seminar Course (ISC). The goals of the ISC were twofold: to develop and strengthen the skills needed for infor­mation processing (clinical thought process, retrieval and integration of knowledge base, and critical acumen) and to emphasize the collaborative approach in teaching, and clinical practice.

The ISC was a required course for all first and second year students. The first year was an introduction to ISC and relied mainly on problem-based learning cases. The second year was unique — in addition to problem-based learning cases, a group of activ­ities, including a case development exercise, debates, critical literature review and written self-reflection exercises was developed to broaden the students' learning. A "just-in-time" philosophy (material covered is reflective of current knowledge base) and a distinctive teaching methodolo­gy (co-facilitation) were also used to create this innovative course. The seminar, which included 10 to 16 stu­dents, met for two hours every other week. The first year students took the course for one semester, the second year students for two semesters. The course philosophy relied on self-guid­ed learning by students to promote organizational, analytical and critical thinking skills while fostering self-motivation and self-reliance.

The ISC supported the many ways in which a doctor and a patient inter­act. The cases included refractive, functional, and pathological compo­nents. Additional case components included: ethics, biostatistics, epi­demiology, psycho-social issues, cost and payment issues, communication, compliance, community and public health issues, behavioral science and preventative medicine.

The purpose of this paper is to describe the Integrative Seminar Course and to evaluate its effective­ness in achieving the course goals.

Volume 32, Number 1 /Fall 2006 17

Course Description

Reasoning in Novel Situations — "Just-in-Time-Philosophy"

The "just-in-time-philosophy" was reflective of the students' existing fac­tual knowledge base. In the first two years of optometric education, stu­dents have more extensive didactic knowledge than clinical experience. This educational scheme allows for the construction of educational activities that give students an opportunity to retrieve, organize and integrate their existing knowledge base and apply this information to novel clinical cases. Some education activities reflected the student's current or past clinical expe­rience. These activities were used to reinforce the student's knowledge base and thought process.

The ISC drew from all areas of the curriculum in an organized, chrono­logical method. The "just-in-time" philosophy was implemented by requesting that professors, who taught a course presented in the first or sec­ond year of optometric education, submit a list of overarching concepts related to their individual course. The development of the activities incorpo­rated the overarching concepts, the education timeline and the clinical experience of the students to develop the learning strategies within the cases. The clinical activities for the first year students are screenings and observations. The second year stu­dents work in optometric practices, performing a variety of tasks.

Co-Facilitation With the aim of presenting a more

integrated approach to the curricu­lum and demonstrating collaboration, the ISC adopted an innovative teach­ing strategy of assigning both a scien­tist and a clinician to co-facilitate dis­cussion within each seminar session. Co-facilitation demonstrated the sci­entific basis of clinical practice and critical review of the literature. This teaching methodology gave the scien­tist the opportunity to demonstrate how the basic sciences could be applied in a clinical situation. The understanding of the scientific basis underlying clinical presentations helped to emphasize an integrated cross-disciplinary approach to patient care. This approach included devel­oping an awareness of the quality and limits (standard deviation, standard error, confidence interval, etc.) of the

data from which basic optometric equations such as Donder's rule were developed as well as the meaning and use of outcome based clinical care.

Twenty faculty members com­prised of nine clinicians (OD) and eleven scientists (PhD, MD, OD/PhD, OD) participated in the course. In a separate article in this issue, co-facili­tation is fully described and its effec­tiveness is evaluated.9

The understanding of the

scientific basis undedying

clinical presentations helped

to emphasize an integrated

cross-disciplinary approach

to patient care.

Grading System The grading system was particular­

ly challenging. The design of the course called for interactive participa­tion by students. Students were encouraged to share with us their knowledge base and thought process. However, many students were hesi­tant to participate for fear of being "wrong." The grading system needed to identify students with a weak knowledge base or thought process while creating an environment that was not threatening. Each year the grading system was revised. The first year of the course the students were graded on a pass/fail basis, the sec­ond year of the course the grades were changed to a letter grade. This year a

grading rubric was developed that allows for student self-assessment with faculty review. Educational Activities (case develop­ment, problem based learning cases, debates, literature review, and self-reflection)

Case Development The case development exercise was

designed to help students organize and integrate their existing knowledge base and utilize clinical thinking. Cognitive psychology suggests that meaningful organization of knowledge ultimately enhances retrieval of relevant informa­tion and promotes problem solving skills.6 This exercise presented the stu­dents with a diagnosis, patient profile and a list of required elements. Students needed to recall information from their existing knowledge base in an organized manner to create a case scenario that followed typical clinical thought processes. Additionally, stu­dents needed to identify areas of knowledge that were needed to pre­sent a complete case scenario. A brief example is presented that illustrates the principles of this exercise: Example

Patient profile: 50-year old male, home­less, chronic alcoholic, heavy smoker Diagnosis: Branch retinal vein occlu­sion with macular involvement Requirements: The case must include a: systemic disease that would put a patient at risk for BRVO pupillary irregularity or abnormality. Students were encouraged to be cre­

ative. The most common systemic condi­tions chosen for this case were hyperten­sion or diabetes, but others (hyperviscosity syndromes, vasculitis, and polycythemia) were possible. Once a systemic disease was chosen the case had to include information at the cellular and physiological level for both the ocular and systemic findings. The case also had to include pharmacological information, diagnostic testing, systemic treatment, risks and prognosis, systemic and ocular consequences of the disease.

The pupillary abnormality or irregu­larities were diverse; possible selections were: • Horner's syndrome related to the

patient's smoking habit • Afferent pupil defect related BRVO • Argyll Robertson-like pupil related to

alcoholism or DM • Trauma related to blackouts associated

with chronic alcoholism Other issues to be discussed were: evi­

dence-based medicine, ethics, epidemiolo­gy, psycho-social issues, communication,

18 Optometric Education

compliance, community and public health issues and preventative medicine.

The psycho-social issues were the most difficult for the students to discuss. Communication and compliance strate­gies were required and role playing was used when appropriate.

Problem-Based, Self-Directed Learning Problem-based learning (PBL) is

characterized by the use of the patient's problems as a context for students to learn problem-solving skills and acquire knowledge about the basic and clinical sciences.10

Problem-based learning is used in many professional school curricu-lums for a variety of educational goals.11 The goals include clinical problem solving, integration of knowledge base, encouraging life­long learning, skills needed for team work and hypothesis generating.11

Debates and Critical Literature Review Life-long learning relies on an

individual's ability to critically eval­uate the literature and utilize tech­nology to access information. The rapidly changing advances in health care fields require that students develop skills to evaluate new scien­tific information and decide how to incorporate this information into their practice.

Several activities were used to help students acquire these skills. A supervised library session was mandatory for both first and second year students to facilitate accurate and efficient search techniques. Learning issues in the PBL cases were structured with specific guidelines for research strategies.

"Judging Information"12 was an activity used to develop the ability of students to judge the value of the information that they have accessed. Specifically we asked for a comparison of the value of the information derived from a newsletter or newspaper sum­mary with that of the original journal article. The students made both a writ­ten and oral presentation. All students were encouraged to challenge the pre­senters during the oral presentation. This activity was designed to develop critical thinking skills.

Structured formal debates were used to promote development of crit­ical thinking and information skills. Lieberman states that "debates pro­vide a format for developing and improving skills in literature searches, critical thinking, including evaluation

of studies, reconciling results of con­flicting studies, teamwork, formal presentation, communication and spontaneous scholarly discussion."13

Self-Reflection Exercise A goal of health care education is to

create professionals who develop life­long learning skills. The ability to cri­tique oneself is vital to the development of professional life-long learning skills.14

One of the objectives of this exer­cise was to develop critical acumen. Students were to reflect on their own knowledge base, thought process, the team's dynamics and the effectiveness of the co-facilitators. Brief examples of the questions are listed below: • How effectively did your group

work together?

• Did you feel that you had any defi­ciencies in knowledge base or thought process?

• Identify the best intervention (stu­dent comment or question) of the session. What made it the best?

• Give one specific example, in one sentence, of something that the other group members learned from you that they probably would not have learned working alone.

• Identify one moment when you thought you had something worth­while to say and you held yourself back. What made you do so? Or, Identify one moment when you were unsure of what you wanted to say and said it anyway. What made you do so, and how did the group accept it?

Methods — Course Evaluation A total of 175 second year students

(2004, 2005) were surveyed at the end of their second academic year.

The first 22 questions of the survey remained the same in both 2004 and 2005. Questions 1-16 asked students to rank their progress in the course and they were scored on a 5- point Likert scale (5 greatly improved — 1 demonstrated great loss). Questions 17 -22 evaluated the course and teaching method and were based on a 4- point Likert scale (1 strongly disagree — 4 strongly agree). In 2005, questions 23-25 were added to the survey. All students were given the opportunity to add comments on the benefits of co-facilitation, extra­curricular activities conceived in the course, suggestions for improvement and general comments. The surveys

were anonymous and the results were tabulated for response frequency.

Results The data (Table 1) from the sur­

veys indicates that the majority of students (>50%) felt that their indi­vidual skills in each area surveyed, with the exception of one area, had improved and the course was helpful in their accomplishments.

In areas related to retrieval and inte­gration of information, seventy-eight per cent of the students felt that their recall and use of knowledge base had demonstrated improvement. Seventy-three percent of the students felt the course demonstrated the integration of basic and clinical sciences. In the area of developing clinical thought process, eighty per cent felt that their overall individual clinical problem-solving ability had improved. Seventy-six of the students felt the course helped them to develop the tools needed for clinical problem solving. The ability to create and rank order a differential diagnosis and problem and plan list were specific areas in which students felt improved.

Critical acumen was divided into two areas: the ability to self/group assess and-the ability to critically eval­uate information, which includes rec­ognizing gaps in knowledge base and the ability to evaluate new scientific information and decide how to incor­porate this information into their prac­tice. The majority of students (>50%) ranked the ability to define and articu­late the need for information and the ability to evaluate fellow students, co-facilitators and the team as improved. However only forty-nine percent of the students rated their ability to self-assess as improved.

Sixty-four percent of the students felt that the course helped to develop the tools needed for independent learning. These tools included the ability to independently learn, sum­marize and evaluate new materials, the ability to conduct an efficient library search and the ability to criti­cally evaluate information.

In the area of developing skills in col­laboration, fifty-eight percent of the stu­dents felt that their ability to help, encourage and support other team members had improved. The majority (>50%) of the students felt their ability to participate in advancing the discus­sion as well as leading the group discus­sion had demonstrated improvement.

Volume 32, Number 1 /Fall 2006 19

Seventy-one per cent felt that the teaching method helped to emphasize the team approach in teaching, patient care, clinical practice and stu­dent interactions. Seventy-eight per cent of the students felt that co-facili­tation demonstrated the integration of basic and clinical sciences to form a unique approach in the delivery of eye and patient care. Seventy-four percent of the students felt that they learned different perspectives on patient care from having two facilita­tors from different disciplines. Seventy-eight percent of the students would recommend a course taught by co-facilitators.

Discussion Health care educators strive to

design and implement innovative strategies that effectively assist stu­dents in their journey to becoming professionals. Expertise in a field has been associated with the memory of multiple, coordinated representations of knowledge.15 A well-organized and elaborate knowledge structure has been shown to support effective clini­cal problem solving16 The ISC used a diverse group of activities to stimu­late the acquisition of skills in infor­mation processing, critical acumen and collaboration.

The case development exercise and PBL cases were exercises that taught information processing skills. These activities challenged the students in different ways. One exercise started with the diagnosis and required the students to retrieve and integrate from their existing knowledge base while applying clinical thought pro­cessing. Consistency of thought process, knowledge base and data were stressed throughout the case. The PBL exercises started with case history and allowed the students to exercise their thought process from the case history to the end of the case. Both exercises allowed students the opportunity to identify gaps in their knowledge base. Critical acumen was developed by analytic review of the literature, PBL cases, self-reflection exercises, and debates. Collaborative skills were encouraged by the debate exercise, working in pairs while researching learning issues and role modeling by the co-facilitation teach­ing method.

The education of clinical profession­als is a continuum. Students acquire factual knowledge that builds on itself

throughout their careers. Technical skills are usually taught through labo­ratory assignments and early clinical experience. In most cases, early clinical experience is segmented and requires continuous supervision. Students are only responsible for small segments of the examination or patient interaction. At some point in all health care profes­sional training, students are given more responsibility and are involved in direct patient care. This responsibil­ity calls on the student to manage more complex and comprehensive

The ISC used a diverse

group of activities

to stimulate the

acquisition of skills

in information processing,

critical acumen and

collaboration.

patient scenarios. The ISC was a "pre­clinical" course designed to help ease the students into the role of student clinician. Student clinicians are often faced with patient care in a setting that demands efficiency and a high level of productivity. Developing skills in information processing can maximize the students' learning experience in clinic as well as provide the founda­tion for success as professionals.

Clinicians approach information processing in a dynamic manner. Clinicians work simultaneously with several different hypotheses and may sometimes have to act without a defi­nite diagnosis.16 Decisions about diag­nosis and treatment are made on prob­ability with consideration of whether the possible condition may be danger­ous or treatable16 The activities of the

ISC provided students with concrete steps to organize their thought process and gather information.

The small group seminar provided a safe, non-threatening environment for students to practice clinical problem solving. Students were given real world cases to think through without the pres­sure of being in a patient care situation. Students were relieved of the stress of data collection and time constraints that are part of the clinical encounter.

The ISC meetings provided a col­laboration of several minds. All the students were actively engaged in clinical problem solving. Unlike the clinical exam where a student finds him/herself alone with the patient, several minds could contribute to the thought process. The support of col­leagues led to an environment in which it was safe to take risks.

The seminar also provided stu­dents the opportunity to be active in directing their learning experience and to learn skills in critical acumen. Learning issues were researched by the student and taught to their fellow students. Critical acumen was divid­ed into two areas: the ability to self/group assess and the ability to critically evaluate information. The ability to critically evaluate oneself was the only area in which the major­ity of students did not see improve­ment. The ability to evaluate their fel­low students, the co-facilitators and the group only showed slight improvement. Although this was dis­appointing, self and peer evaluation may be difficult since it is rarely asked for in other areas of the curriculum. The ISC course may need to include other activities such as self-grading with faculty review to aid students in acquiring these skills. The majority of students did show improvement in identifying gaps of knowledge and in critically evaluating information.

In the first 16 questions of the sur­vey, there are a percentage of students who documented no improvement in each area. At this point in their train­ing, most of the students are not yet responsible for direct patient care. The students may not appreciate the full value of the course until they are challenged in the clinical setting. Additionally, in the first two years of the course the overall course goals were listed in the syllabus but indi­vidual goals for each activity were not stated. This year the goals and objec­tives for each activity were clearly stated at the beginning of the exercise.

20 Optometric Education

Table 1: Survey

Question

1. My recall and use of knowledge base has

2. My clinical problem solving ability has

3. My creation and rank ordering of a differential diag­nosis has

4. My creation and rank ordering of a problem/plan list has

5. My participation in advancing group discussion has

6. My ability to lead group discussions has

7. My ability to define and articulate the need for infor­mation, and the nature and extent of the information needed has

8. My ability to independently learn, summarize, and evaluate new material has

9. My search time efficiency has

10. My ability to critically evaluate information has

11. My ability to critically evaluate myself has

12. My ability to critically evaluate fellow students has

13. My ability to critically evaluate the co-facilitators has

14. My ability to critically evaluate the team has

15. My ability to help, encourage, and support others has

16. The performance of the team has

Greatly improved

11.1%

9.4%

8.8%

13.5%

16.4%

14.6%

11.7%

11.7%

11.7%

8.2%

7.0%

6.4%

5.3%

6.4%

12.3%

21.1%

Question

17. The course helped me to develop the tools necessary for clinical problem solving.

18. The course helped me to develop the tools needed for independent learning.

19. Co-facilitating helped to emphasize the team approach in teaching, patient care, clinical practice and student interactions

20. Co-facilitating demonstrated the integration of basic and clinical sciences to form a unique approach in the delivery of eye care and patient care.

2 1 . 1 would recommend a course taught by co-facilitators (a scientist and clinician).

22. 1 felt that 1 learned different perspectives on patient care from having two facilitators with different back­grounds, experiences, and education.

23. The course demonstrated the integration of basic and clinical sciences to form a unique approach in the delivery of eye care and patient care.

Question

24. How has this course affected your ability to work productively in a team?

25. How has this course affected your ability to work as a leader?

Somewhat improved

66.7%

70.8%

59.1%

52.0%

46.2%

38.6%

46.8%

44.4%

43.3%

56.1%

42 .1%

45.0%

50.3%

46.2%

45.6%

56.1%

Strongly disagree

3.5%

4.7%

5.3%

3.5%

4.7%

3.5%

4.0%

Greatly improved

8.9%

10.9%

Not improved

21.1%

18.7%

31.0%

33.9%

33.3%

43.9%

39.2%

41.5%

40.4%

34.5%

50.0%

47.4%

42.7%

46.2%

39.8%

20.5%

Disagree

21.1%

31.6%

24.0%

18.7%

16.9%

22.8%

22.8%

Somewhat improved

49.5%

38.6%

Not improved

38.6%

49.5%

Demonstrated some loss

0.6%

0.6%

0.6%

0%

2.9%

2.3%

1.8%

1.8%

4 . 1 %

0%

0.6%

0.6%

1.2%

0.6%

1.2%

1.2%

Agree

62.0%

55.0%

46.8%

57.8%

53.8%

31.0%

21.8%

Demonstrated great loss

0.6%

0.6%

0.6%

0.6%

1.2%

0.6%

0.6%

0.6%

0.6%

1.2%

0.6%

0.6%

0.6%

0.6%

1.2%

1.2%

Strongly agree

13.5%

8.8%

24.0%

19.9%

24.6%

42.7%

51.5%

Demonstrated some loss

1.0%

0%

Demonstrated great loss

2.0%

1.0%

Volume 32, Number 1 /Fall 2006 21

This will help the students identify and monitor in a more concrete man­ner the development of their thought process and knowledge base.

Overall the students' comments supported the survey findings. Negative comments focused on group size, inconsistencies between different sections, learning styles of the student and survey design. The group size var­ied from 10-16 students. The size of each group was determined by the overall class size and available FTE. The teaching method of co-facilitation, which was used with the aim of pre­senting a more integrated approach to the curriculum and of demonstrating collaboration, necessitated two facilita­tors in each seminar section. These conditions resulted in a less than ideal seminar group size. Smaller group size may have allowed some students to feel less inhibited about participating. Possible solutions to this issue could include hiring more faculty, utilizing students who have advanced degrees or extensive research experience as facilitators or having each seminar group split into smaller groups for a small portion of each session.

The facilitators were given a detailed syllabus and case outlines. The syllabus dictated inter-group con­sistency in the following areas: activi­ties, work load, quality of learning issues, level of participation, integra­tion of basic and clinical science and development of critical evaluation skills. However, each facilitator was also given some creative license to manage the actual seminar, and inconsistencies did occur.

A requirement of the seminar was active verbal participation by all stu­dents. Due to personality, culture backgrounds, or individual learning styles, some students found this for­mat difficult. Although emotional support through the counseling ser­vice was offered to all students who felt that verbal participation was diffi­cult for them, few students took advantage of the offer.

A few students commented that the design of the survey, specifically questions 1-16, made it difficult for them to admit that they did not demonstrate progression. However, many of the conclusions were sup­ported from data derived from ques­tions 17-25. As a consumer of educa­tion, most students welcome the opportunity to anonymously voice their opinion about the effectiveness

of a course. In the future, the end-of-the-year survey will be revised.

Conclusion The desired endpoint of educating

health care professionals is a student who is able to provide a high level of patient care and who values life-long, self-directed learning. The Integrative Seminar Course strived to impart and teach students the skills needed to be successful health care providers. This course provided an opportunity to teach ethical issues, biostatistics, epi­demiology, psycho-social issues, com-

Smaller group size

may have allowed

some students to

feel less inhibited

about participating.

munication, compliance, public health issues, behavioral science and preven­tative medicine in a clinical context. The course design allows for flexibility in response to changes in the profes­sion. In the opinion of the students, the ISC achieved its goals by improving students' skills in information process­ing, critical acumen and collaboration. While the results of this study are promising, the correlation to student performance in actual clinical care is yet unknown. Future studies may include the comparison of the clinical performance of students who have been exposed to an Integrative Seminar Course and those who have not.

References 1. Isenberg DJ. How senior managers think.

Harvard Bus Rev 1984:84608. 2. Satish U, Streufert S. Value of a Cognitive

simulation in medicine: towards optimizing

decision making performance of healthcare personnel. Qual. Saf leath Care 2002; 11; 163-167.

3. Breuer K. Cognitive development based on process learning environments. In: DijstraS, Krammer HPM, van MerrienboerJJG, eds Instructional models in computer based learning environments. Berlin: Springer Verlog, 1992.

4. Pipas C, Peltier D, et al Collaborating to Integrate Curriculum in Primary Care Medical Education: Successes and Challenges From Three US Medical Schools, Family Medicine. Vol 36 January Supplement 2004.

5. Wilkinson T. Teaching team work to medical students: Goals, Roles and Power. Medical Education 2002 36:1084-1110.

6. Schmidt H. Integrating the teaching of basic sciences, clinical sciences, and biopsychoso-cial issues. Academic Medicine Supplement 1998 Sept; 73(9):S24-31.

7. Bruhn JG. Outcomes of problem based learning in health care professional educa­tion: a critique. Farm Community Health 1997 20(l):66-74.

8. Murphy J. Optometry schools raise the grade. Review of Optometry. August 2003 49-56.

9. Denial A, Zorn M. Effectiveness of co-facili­tation (scientist/clinician) as a teaching methodology in an integrative seminar course, Optometric Education 2006 32(l):ppl3.

10. Barrows HS. Problem-based, self-directed learning. JAMA. December 1983 250 (22): 3077-80.

11. Stevenson F, Bowe C, et al Paired basic sci­ence and clinical problem -based learning faculty teaching side by side: to students evaluate them differently? Medical Education 2005; 39:194-201.

12. Gwiazda J. Syllabus, Integrative Seminar Course. New England College of Optometry 2003,2004.

13. Lieberman SA. The impact of structured student debates on critical thinking and informatics skills of second-year medical students. Academic Medicine. October 2000 75 (10): S84-9.

14. Maudsley G, Strivens J. Promoting profes­sional knowledge, experiential learning and critical thinking for medical students. Medical Education. 2000 34:535-44.

15. Norman G. Research in clinical reasoning: past history and current trends. Med Educ. 2005 Apr; 39(4):418-427.

16. Werner DL. Teaching critical thinking. Optometry and Vision Science. 1989 66 (11): 788-92.

Acknowledgements: We would like to thank Dr. Cliff Scott for his help in editing the manuscript, Maria Pitcher for her technical support and the faculty who participated in the course. We would also like "to thank Drs. Rich Frankel and Bill Chauncey for their contributions to the concept of the seminar.

22 Optometric Education

Teaching Basic Science Courses Using Web-based Clinical Cases: Experiences with BACIC Steven H. Schwartz, O.D., Ph.D., F.A.A.O. Leon Nehmad, O.D., M.S.W., F.A.A.O. Mark Rosenfield, M.C.Optom., Ph.D., F.A.A.O. William H. Swanson, Ph.D., F.A.A.O. Ayxa Calero-Breckheimer, Ph.D. Patricia Modica, O.D., F.A.A.O. John Picarelli, Ph.D.

Abstract The expanding scope of optometric

practice continues to place pressure on an already crowded curriculum. First and second year students may spend 25 - 30 hours per week in classes and laboratories, making the inclusion of additional courses difficult. Rather, the solution to ever increasing curricular material could derive from improved pedagogical efficiencies. In this paper, we present a curricular model that pro­motes the integration of basic and clin­ical science material. The model is cen­tered on Web-based asynchronous student discussions of clinical cases. Our experiences highlight certain lim­itations of such discussion forums for teaching pre-clinical students.

Key Words: Problem-based learn­ing (PBL), outcomes-based education (OBE), basic and clinical integration curriculum (BACIC)

Drs. Schwartz, Nehmad, Rosenfield, Swanson, Modica and Picarelli are on the faculty of the State University of New York, State College of Optometry. Dr. Calero-Breckheimer is a faculty member at Columbia University, School of Dental and Oral Surgery.

Introduction

In traditional curricula that edu­cate health care professionals, the content of basic science courses is generally discipline-based, rather

than driven by clinical priorities. If untended, the linkage of basic science and clinical concepts may not be as strong as it could be for clinical train­ing. Curricula utilizing problem-based learning (PBL) have been adopted by a number of health professions schools, in part, as an effort to come to grips with the limitations inherent in the traditional curriculum.1 In such an approach, entering medical students, for instance, are given clinical cases and accompanying questions that can be answered only if a student has mas­tered and integrated certain key con­cepts in the basic and clinical sciences. Students meet both in small groups and individually with faculty mem­bers as they work through their cases.

PBL curricula are personnel inten­sive (requiring substantial faculty resources), making them too expen­sive to be utilized effectively by insti­tutions with more limited resources. Schools of optometry, podiatric and osteopathic medicine, pharmacy, allied health, and dentistry and cer­tain allopathic medical schools may not have the resources to sustain bona fide problem-based learning curricula.

The economic pressures brought on medical school educational budgets by managed care may threaten the quality and continuance of existing PBL programs.

Over the past twenty years, the scope of optometric practice has been expanded in all 50 states and the District of Columbia to include the diagnosis and medical treatment of eye disease. The expanded scope of practice has hastened the need to add additional basic science material to an already crowded curriculum,2 and to integrate basic science and clinical concepts within this curriculum.3 A problem-based curriculum, using the approach taken by certain other health professional schools to address these (and other) concerns, is proba­bly not a sustainable solution due to its high cost.

In 1992, the Association of Schools and Colleges of Optometry (ASCO), in conjunction with the American Optometric Association, sponsored a national conference on curricular reform (the Denver Conference).3-4

Using an outcomes-based education (OBE) approach, learning objectives were developed for various curricular tracks (e.g., sensory processes, ocular biology). The learning objectives were derived from selected clinical condi­tions (clinical priority conditions). While the Denver conference familiar­ized the profession's educational leaders with the concept of a clinical­ly driven basic science curriculum, it was apparent that more work would be necessary to further develop, implement, and test a model based on these concepts.5

To address this, we instituted a multi-institutionb project to develop and test a Basic and Clinical Integration Curriculum (BACIC) model that is intended to promote the integration of basic science and clini­cal concepts from the outset of the curriculum. Fundamental to the ped­agogical strategy underlying the BACIC model is the development of clinical cases by teams of basic scien­tists and clinicians. The cases are included as part of basic science courses, but are presented and dis­cussed in Web-based asynchronous student discussion groups. Teams of basic science and clinical faculty members serve as moderators for these groups.

In this paper, we review the experi­ences of one of the sites — SUNY State College of Optometry. We find

Volume 32, Number 1 /Fall 2006 23

that the BACIC approach has poten­tial to enhance integration of basic and clinical concepts, but that the exclusive use of Web-based discus­sion groups is limiting.

Methodology

Learning Objectives Integration was centered on four

primary conditions — glaucoma, dia­betes, myopia, and amblyopia - that are of high prevalence and impact in optometric practice. As a first step, a team of basic scientists and clinicians drafted competencies for each condi­tion.6 These clinical competencies, in turn, served as the bases for establish­ment of learning objectives that must be met in order for the clinical compe­tencies to be mastered. The learning objectives were crafted to link basic and clinical concepts and to cover a range of different areas, but not all areas. Table 1 provides examples of learning objectives written for the pri­mary condition of glaucoma.

Development of Clinical Cases and Web Site

All participating, faculty members received instruction in the formula­tion of clinical cases and their use for teaching purposes. Three workshops that addressed these issues, led by an educational psychologist from Columbia University School of Dental and Oral Surgery, were held on the SUNY Optometry campus.

Each clinical case was developed by a team consisting of a member of the BACIC steering group, a basic sci­ence faculty member, and a clinical faculty member. The previously devel­oped learning objectives informed the development of the cases. Cases were posted on the project Web site and made accessible to students through the use of a password.

We contracted with an educational technologist from Columbia University School of Dental and Oral Surgery to develop a dedicated Web site for the project (www.bacic.net). The consultant has extensive experi­ence developing Web sites and, of particular significance, is experienced with issues related to the education of health care professionals.

The Web site includes components that permit the posting of clinical cases and facilitate asynchronous stu­dent discussions regarding these cases. Clinical cases, which include

Table 1: Sample Learning Objectives for Glaucoma Prior to graduation, the student must demonstrate to the satisfaction of the faculty:

1. The ability to explain the vulnerability of the eye to glaucomatous damage in terms of the normal anatomy and physiology of the optic nerve and its sup­porting structures.

2. Knowledge of the epidemiology and clinical risk factors for the glaucomas and the mechanisms underlying these factors.

3. The ability to explain the strategies of the various medical, laser, and surgical interventions in terms of the mechanisms of aqueous production and flow.

4. The ability to apply the principles of visual psychophysics and visual neuro­physiology to the measurement of visual fields and their analysis and interpre­tation.

5. The ability to explain the mechanisms whereby the (normal and abnormal) anatomy of the anterior chamber angle influences aqueous outflow.

6. The ability to explain the appearance of the posterior pole and the angle of the eye based upon the optical principles and limitations of the instrument(s) being used for viewing.

7. The ability to justify a course of medical treatment in terms of the mechanisms of action and efficacy of the pharmaceutical agents.

8. The ability to apply knowledge of the anatomy and physiology of the ganglion cell layer and optic nerve to patterns of visual loss seen in glaucoma.

9. The ability to apply posited mechanisms of cellular insult to treatment strategies.

10. The ability to access information (electronic and print) pertaining to a specific clinical case and to critically analyze this information.

images, were posted in PDF format as a pop-up window on a bulletin board.

At the beginning of each targeted basic science course, the instructor of record explained the project to the stu­dents, provided the Web site address and relevant instructions, and informed students that participation in the asynchronous, on-line discussions of the clinical case was mandatory.0

The discussions were typically moder­ated by faculty members who formu­lated the case, with a clinical faculty member generally taking the lead role. An example of a clinical case for Biochemistry and Molecular Biology is given in Table 2 (with instructions for the moderators given in parenthesis following the sample questions).d

Implementation The clinical cases were part of basic

science courses taught in the first year of the professional curriculum (e.g., General Histology, Biochemistry and Molecular Genetics, Geometrical Optics). In the first quarter (fall) of the implementation, three cases were intro­duced simultaneously and the students worked in groups of about 17 on these cases.6 Results of a survey showed that students were overwhelmed by the workload associated with the three

cases. They also revealed that the dis­cussion groups were too large and that student responses tended to be too wordy, interfering with the discussion group atmosphere that we hoped to engender.

Based on this feedback, the number of cases was reduced to two for the sub­sequent (winter) quarter (Literature Evaluation and Neuroscience/ Physiology). Moreover, the discussion groups were made considerably small­er (7 students per group), a word limit was placed on the length of student responses, and discussion questions were presented on a weekly basis (as opposed to presenting all questions at the beginning of the case, as in the fall quarter).

In the following quarter (spring), there were also two cases (Physical Optics/Physiology and Neuroscience 11). Rather than running these cases simultaneously, as in the prior quarter, they were presented sequentially, with students working on each case for one half of the quarter. We maintained this strategy throughout the remainder of the project. Table 3 provides a brief example of the dialogue that occurred for the neuroscience case.

Ultimately, cases were developed for the topics of biochemistry, geo-

24 Optometric Education

Table 2: Sample Discussion Case

Are Mrs. Green's Ganglion Cells Committing Suicide?

Learning Objective(s) The ability to apply posited mechanisms of cellular insult to treatment strategies.

Resources Biochemistry lectures: Apoptosis

Readings: 1. Glaucoma and apoptosis: Nickells, R W, Apoptosis of retinal ganglion cells in glaucoma: an update of the molecular pathways involved in cell death,Survey of Ophthalmology, Volume 43, Supplement 1, June 1999, Pages SI 51 -SI 61. URL: (http://www.sciencedirect.eom/science/article/B6VvYB-45D98KD-3GC/1/4c8c6930b5677aaceeacad788985cf1d)

Osborne, N N; Wood, J P; Chidlow, G; Bae, J H; Melena, J; Nash, M S, Ganglion cell death in glaucoma: what do we really know?, The British Journal of Ophthalmology, Volume 83, Issue 8, August 1999, Pages 980-986. http://ra.sunyopt.edu:2103/cai/reprint/83/8/980.pdf

2. General apoptosis references: http://www.edc.eom/%7Eikimball/BioloayPages/A/Apoptosis.html http://www.sghms.ac.uk/depts/immunoroay/~dash/apoptosis/nuclear.html

3. Clinical glaucoma references a. http://www.alaucoma-foundation.org/dihaq/index.htm b. http://www.nei.nih.aov/health/glaucoma/g1aucoma facts.htm

Images: Optic nerve photos, both normal & glaucomatous (attached to this file).

Case: Mrs. Green is a 45-year-old African-American female who does not require spectacle correction. She is a successful businesswoman

with an inquisitive and outgoing personality. She states that her mother went blind from glaucoma, so she gets her eyes checked yearly because she is gfraid of developing glauco­

ma. She is worried today because her vision seems to have become worse over the past year. Mrs. Green is in good physical health, and her internist of the past 10 years reports no systemic problems. She does not smoke, is a

social drinker, and has no known allergies. Refraction is piano in each eye. Distance acuity is 20/20 in each eye. Near acuity is 20/20 OU with reading glasses she purchased

at a drugstore. For the post 5 years, her lOPs have been 21 -24 mmHg in each eye, which is higher than the normal range. Her cup/disc ratios are

0.8, which are enlarged. She has had visual fields performed yearly on each eye, and they are now suggestive of glaucoma.

Sample Questions (with prompts for moderator in parenthesis): 1. Ganglion cell damage is traditionally considered to take place in the area of the lamina cribrosa as a result of mechanical damage

or ischemia secondary to elevated IOP. Discuss how this could lead to apoptosis.

(Moderator: Below are items that should be covered in the discussions of this point. If the students do not raise them, then the facilitator can.)

a. The intracellular molecules that detect cellular damage, (sensor proteinoidentity as yet unknown, and p53) b. In the case where apoptosis is signaled by external cellular signals, the role that receptors in the plasma membrane play in trig­

gering apoptosis, and how the signal is relayed internally, (see my handout for diagram) c. The role that p53, p21, bcl-2, ana bax, apaf-1, cytochrome C, play in apoptosis. (See handout) d. The biochemical reactions that execute the apoptotic program, in particular proteolysis by caspases. (See handout) e. The appearance of cells that have undergone apoptosis, vs. one that has been injured and is undergoing necrosis. (Cell shrink­

age, loss of normal intercellular contacts, appearance of dense chromatin, fragmentation of nuclei, cytoplasmic blebbing, and ultimately fragmentation of the cell into small "apoptotic" membrane-bound bodies.)

f. The enzymes that are involved in generating the DNA "ladder" that is characteristic of these cells. (The DNA ladder is a result of several steps including: enzymes involved in DNA repair are inactivated, enzymes involved in cell replication are inactivated by caspases including such enzymes as DNA topoisomerase II, a nuclear enzyme essential for DNA replication and repair, degra­dation of structural nuclear proteins such as lamins by caspase 6, and finally, fragmentation of DNA by CAD, or caspase activat­ed DNase.)

2. Cells that have undergone apoptosis must ultimately be removed. This can occur without the inflammation associated with necrotic cell death, making apoptosis more difficult to detect than necrosis. Discuss: a. the mechanism of removal, (ingestion by phagocytes) b. the mechanism of degradation of the cellular material (lysosomal degradation within phogocytic cells)

Volume 32, Number 1 /Fall 2006 25

Table 3: Examples of Dialogue for Neuroscience Case

Discussion Question: What do you think is the cause of the patient's diplopia?

Student #1 - 10:50am Mar 18. 2003 EDT Cranial Nerve VI Palsy Palsy of the abducens nerve causes paralysis of the lateral rectus muscle. In this palsy the eye is medially deviated and movement laterally from the midline is not possible. Thus, the patient has diplopia because images fall on different retinal space for the two eyes. The eyes are not looki ng in the same direction when the patient gazes to the left.

Student #2 - 01:24pm Mar 18, 2003 EDT Diabetes and VI Cranial Nerve Palsy Just to add a little something to the previous statement, since VI cranial nerve palsy in this case was related to the patient's diabetic history, the VI cranial nerve is vulnerable to ischemic infarct (smaller blood flow to the nerve) as a result of the dia­betes. This problem will generally improve within 3-4 months as was stated, or could also be improved faster through eye muscle surgery.

Student #3 - 04:37pm Mar 2 1 . 2003 EDT Fixing Double vision Student #1 already stated the cause of the patient's diplopia, and Student #2 commented on recovery. If the problem can eventually clear up on its own, would it be possible to use prisms to supply a temporary fix until the condition improves on its own?

Clinical Instructor - 05:09pm Mar 2 1 . 2003 EDT Great Points!!!!! Great start everyone. You've made some interesting comments regarding the nature of the sixth nerve palsy in this diabetic patient. And certainly, it's an excellent idea to make the patient comfortable while we wait for recovery. Fresnel prisms can be very useful here. But, often, if the deviation is great (and in this case the palsy is complete), these patients do a bit better with simple patching of one eye. As they recover, we can sometimes switch them to the Fresnel prism. We need to address something else in this patient's history and that is the fact that she has a bitemporal visual field defect. Forget about the sixth nerve palsy for now and tell me what comes to mind when you see a patient with this type of visual field loss.

Table 4: Survey Items 1. The clinical cases discussion(s) made me feel more connected to the clinical

practice of optometry.

2. I would rather participate in the Web based discussions than meet on campus each week.

3. When posting and reading responses, it seemed as though I was participating in a discussion.

4. The clinical case disCussion(s) enhanced my educational experience.

5. The Web site is easy to move through.

6. The directions for the Web site are clear.

7. I experienced no technical problems with the Web site.

8. The Web site, overall, was of high quality.

Open-ended Items: What would enhance this learning experience? Please include any other comments regarding this learning experience. Include recommendations for improvement.

metrical optics, histology, neuro­science and physiology, literature evaluation, neuroscience, lasers, physiology and biochemistry, and optometric methods. These cases were part of nine separate courses.

Results The outcome assessment was

focused on student and faculty percep­tions as ascertained through surveys (Likert scale, 1 — 5) and focus groups. Perhaps of most use was the survey

administered at the conclusion of the first quarter of implementation, partic­ularly the responses to the open-ended questions (Table 4). The students pointed out several significant short­comings of BACIC that detracted from its effectiveness. In addition to their already heavy course load, the stu­dents were now required to participate in three on-line case discussions per week. They found this to be an over­whelming assignment. The cases were more time-consuming than expected, and students felt that they were unable to give the cases the attention that they would have liked to.

Another concern was that the on­line discussion groups did not have the "feel" of a back-and-forth dia­logue. A list of questions was posted at the beginning of each quarter for each case, with a question assigned each week for each case. To the students, it seemed as if they were simply answer­ing questions without having a true dialogue with the instructors or each other. This was compounded by the relatively large size of the groups (about 17 students per group).

Students were discouraged when a classmate would provide a lengthy,

26 Optometric Education

Figure 1: Survey Results for Items 2 and 4 (see Table 4). The survey was administered at the conclusions of the first (Series 1, N = 65)) and third (Series 2, N =53) quarters of

implementation.

Survey Item 2: I would rather participate in the Web based discussions than meet on campus each week.

30 -

25 -

20

15

10 '

5 '

1 2 Strongly Disagree Disagree

--. \\ ' ^ H

,"-*\'

I

- • • .

" j "

'K .-.a •5T

3 4 Mixed Feelings Agree

1 Series 1 I ISeries2 |

Strongly Agree

Survey Item 4: The clinical case discussion(s) enhanced my educational experience.

30

25

20

15

10 -

5

0 '-

Jm

" H i

^

m Strongly Disagree Disagree

3 4

Mixed Feelings Agree

I Series 1 ISeries2

Strongly Agree

detailed response to a question, leav­ing them no opportunity to respond to the same question. Sometimes, a student would cut and paste a lengthy narrative from another Web site. Again, rather than taking the form of a dialogue, the discussion seemed more like a question and answer forum, with the early, exhaus­tive responses leaving the remaining students with little to say,

Based on these findings, several changes were made so that the stu­dents had more time to attend to the cases and so that discussions were more akin to a dialogue. The number of cases was reduced to two, and

rather than running simultaneously they were presented sequentially, with students working on each case for one half of the quarter. The group size was reduced from about 17 to 9 students. Instead of presenting all the questions at the beginning of the quarter, a new question was released each week. The instructors who led the groups were asked to take a more active role by clarifying issues and asking follow-up questions. To pre­vent rambling answers and to encour­age concise and precise thinking, the software was programmed to limit the number of words per response. Finally, students were given a more in

depth orientation to the project, clari­fying and amplifying the project's goal to make the on-line discussion groups operate as a dialogue - not a question and answer page.

As part of the evaluation, the sur­vey was re-administered to the same cohort of students at the conclusion of the spring quarter, 2003. Following the modifications, there was an increase in the number of students who would rather participate in Web-based discussions than meet weekly on campus, believe that the case dis­cussions enhanced their educational experience, and found the Web site easy to move through and of high quality (Figure 1). The changes, how­ever, did not impact the number of students who felt that the clinical cases made them feel more connected to the clinical practice of optometry or felt that the Web experience seemed like participation in a discussion.

Student attitudes toward integra­tion of basic and clinical sciences within the SUNY curriculum were ascertained for second-year students who had not partaken in the BACIC project (Class of 2005) and compared to those of the students that had par­ticipated in BACIC (Class of 2006). Surveys (Likert scale, 1 — 5) were again used. Differences in student perceptions were not apparent.

Following these surveys, partici­pating faculty were invited to a focus group. Members of the focus group believed that students benefited from the case discussions. They believed, however, that the cases would be more relevant to the (first-year) stu­dents if they were to observe in clinic. There was a perception that the pro­ject would benefit if clinical faculty members were to introduce the cases in the basic science courses - specifi­cally, as a role-play demonstration -prior to the Web-based discussions. All faculty members believed that there should be a live discussion to sum up the case.

In spring, 2004, focus groups were held with randomly selected students from the Class of 2006, which partici­pated in BACIC for the 2002-2003 aca­demic year, and the Class of 2007, which participated in BACIC for the 2003-2004 academic year. This quali­tative assessment was useful in ascer­taining several continuing challenges. Perhaps most significantly, partici­pants in both focus groups believed that face-to-face meetings would be preferable to the Web-based discus-

Volume 32, Number 1 /Fall 2006 27

sions. Some students believed that the cases were too advanced for first-year students. It was voiced that the cases were "independent" and not well integrated into the lecture courses with which they were associated.

Discussion and Conclusions In the course of this project, we

developed and implemented a peda­gogic strategy aimed at furthering the integration of basic and clinical mate­rial within the optometric curriculum. This was accomplished through the development of a custom designed Web site that allowed students to enter into Web-based discussions of clinical cases. These clinical cases, which were linked to basic science courses in the first year of the curricu­lum, were written jointly by basic sci­ence and clinical faculty members using previously derived learning objectives as a guide.

Probably the most important les­son we learned from this project is that the Web-based discussions did not substitute for live face-to-face dis­cussions. For first year students, who have no or very limited clinical expo­sure, the clinical cases did not seem to be as engaging as we would have liked. It was expected that the text

and abundant images would have captured the excitement of a clinical case, but this did not seem to occur. Even with significant modifications based on student input, we were unable to obtain this goal.

Based, in part, on our experiences with BACIC, small group discussions and clinical observations were intro­duced into the first year of the cur­riculum. We continue to believe that the BACIC can be a useful pedagogi­cal tool, but its value may be enhanced if integrated with more tra­ditional face-to-face small group dis­cussions and clinical experience.

Acknowledgements This research was funded by a grant

from the United States Department of Education, Fund for Improvement of Postsecondary Education (FIPSE). Preliminary versions of this research were presented at the 2001, 2002, 2003 and 2004 meetings of the American Academy of Optometry.

We thank Mr. Douglas McAndrew for his able assistance in developing the project's Web site.

Footnotes a The necessity to include the traditional bio­

logical basic sciences as well as optics and the vision sciences places substantial time demands on the four-year optometry cur­riculum.

b The other institutions that participated in aspects of the project on their campuses were Pacific University College of Optometry, Southern California College of Optometry, and The New England College of Optometry.

c In some courses, questions based on the BACIC discussions were included in the final examination. These usually accounted for about 5% of the final exam questions or final grade.

d These instructions were not visible to the students.

e Each student had access to only his/her group.

References . Colliver JA. Effectiveness of problem-based

learning curricula: research and theory. Academic Medicine 2000; 75(3): 259-266.

. Maeir H, Smith A, Coffey B. A curriculum comparison of U.S. optometry schools: Looking back over the decade 2005; 30(2): 39-55.

. Association of Schools and Colleges of Optometry. (1995). Optometry Curriculum, Version 1.1. Rockville, Maryland.

. Berman MS. Curriculum model for optome­try: outcomes of the process. Optometric Education 1994,20(1): 15-18.

. Schwartz, SH. Priority conditions as a basis for basic science course content. Optometric Education 1997; (22)4: 125-127.

, Chambers, D.W. Toward a competency-based curriculum. Journal of Dental Education 1993; (57) 790-793.

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28 Optometric Education

Scholarly Publications By Optometric Residents, 1 9 9 9 - 2 0 0 3 Michael H. Heiberger, O.D., M.A., F.A.A.O. Irwin B. Suchoff, O.D., D.O.S., F.A.A.O., F.C.O.V.D.-A

Abstract Abstract It is the purpose of this study to

evaluate residency program supervi­sors' interpretation of the ACOE stan­dard for scholarly activity and to deter­mine the number of publishable papers produced and published by residents from 1999-2003. There were 75 responses to the survey (response rate of 58%). For the programs responding, a total of 411 papers were produced over the period, 1999-2003, 89 papers were submitted for publication and 60 were accepted for publication. It is estimated that approximately 150 papers of publishable quality are pro­duced each year by optometric resi­dents, about 33 are submitted for pub­lication and about 2/3 of these are accepted for publication.

Key Words: Residencies, Publications, Scholarly Activity

Dr. Heiberger is associate clinical professor and director of Planning and Evaluation at the State College of Optometry, State University of New York. Dr. Suchoffis a distinguished service professor emeritus at the State College of Optometry, State University of New York.

Introduction

Accreditation of optometric residency programs was begun in 1976 by the Council on Optometric

Education (COE), now known as the Accreditation Council on Optometric Education (ACOE). The initial guide­lines devoted to this process were included in the Accreditation Manual: Optometric Residency Programs.1 The guidelines in the Manual were in place from 1979-1994, with an update in 19822, and a revision in 1985. The Council adopted a new set of require­ments based in specific Standards in 1993; this became effective on July 1, 1994 3 j ^ e m o s t recent version of the Standards was adopted on June 24, 2000, revised in July and December of 20034 and became mandatory on June 1, 2004 .

All versions of the accreditation process addressed the inclusion of the preparation of a paper as a require­ment, to one degree or another. Thus, the initial version placed this activity under Scholarly Development:

Some activities that seem generally appropriate in this regard are the preparation of scientific clin­ical papers, clinical research and clinical teaching...1

The version that went into effect in 1994 placed this activity under

Standard VIII- Research and Scholarly Activity, and more specifically:

8.2 It is expected that the resi­dent will produce a manuscript of publishable quality or be involved in an equivalent scholarly activity during the course of the residency under the guidance of faculty? The most recent version addresses

authoring a paper under Standard II-Curriculum:

2.4 The curriculum must include scholarly activities (for example-research, teaching, journal club, poster or paper presentations, and/or the preparation of a manu­script of publishable quality.f The purposes of the present study

are to (1) evaluate residency supervi­sors' interpretation of ACOE Standard 2.4 for scholarly activity relative to the preparation of a publishable paper as part of the requirements for completion of a residency and, (2) to determine the number of publishable papers pro­duced as well as the number actually published during the period 1999-2003.

Methods In the summer of 2004, the supervi­

sors of 129 ACOE-accredited residen­cy programs were sent a one-page sur­vey instrument (Figure 1) developed at the State University of New York, State College of Optometry (SUNY). The supervisors were asked for their interpretation of ACOE Standard 2.4 for residency programs. As well, they were asked if their program required a manuscript of publishable quality and, if so, how many were actually submitted for publication. In addition, the supervisors were asked if they felt that the preparation of a manuscript of publishable quality was an appropri­ate scholarly activity for a residency program. They were also queried as to whether they or other faculty worked closely with the residents as they prepared their manuscripts.

Three weeks were allowed for the responses to be returned. There was no follow-up.

Results A total of 75 responses were received

for a response rate of 58%. The responding programs represent a total of 113 residency positions. The respon­dents represent eight different types of residency programs (Table 1) with Primary Care and Ocular Disease resi­dencies predominating (45 of the 75).

Volume 32, Number 1 /Fall 2006 29

Table 1: Types of Programs Responding

Table 2: Programs Requiring a Manuscript

Primary Care

Ocular Disease

Cornea/Contact Lens

Family Practice

Hospital Based

Pediatric

Low Vision

Secondary Care

30

15

8

6

6

5

4

1

(40%)

(20%)

(11%)

(8%)

(8%)

(7%)

(5%)

(<1%)

Primary Care

Ocular Disease

Cornea/Contact Lens

Family Practice

Hospital Based

Pediatric

Low Vision

Secondary Care

30

14

4

5

6

5

4

1

(100%)

(93%)

(50%)

(83%)

(100%)

(100%)

(100%)

(100%)

Of the residency program supervi­sors responding, 62 (84%) interpreted Standard 2.4 to mean that a paper of publishable quality was to be pro­duced but not necessarily published while 12 (16%) interpreted the stan­dard to mean that the paper had to be eventually published.

In 69 (93%) of the programs responding, a manuscript of publish­able quality is required of all resi­dents. All types of residency pro­grams have a high rate of requiring manuscripts of publishable quality with the exception of Cornea/Contact

Figure 1: Survey of Residency Supervisors

This survey relates to the ACOE's accreditation standard 2.4 for residency programs. One option for the scholarly activities required in the standard is "...the preparation of a manuscript of publishable quality." Please respond to the following items as they relate to the residency program that you supervise.

1. My interpretation of the standard is (check one): A manuscript of publishable qualify is to be produced but not necessarily published. A paper that is eventually published is the desired outcome. Not sure.

In the residency program that I supervise, a manuscript of publishable quality is required of all residents. Yes No If no, skip to item 7.

How many residents does your program have per year?

2.

3.

4. For the years 1999 - 2003, how many publishable manuscripts were produced?

5. For the years 1999 - 2003, how many of these were actually submitted for publication?

6. For manuscripts produced during the years 1999 - 2003, how many were actually accepted for publication?

For those that were accepted, please list the citation(s) on the back of this form indicating title of the paper and the name of the journal.

Please use the following scale for the remaining items: 4 = strongly agree 3 = agree 2 = disagree 1 = strongly disagree 0 = not applicable

7. I believe that the preparation of a manuscript of publishable qualify is an appropriate scholarly activity for a residency program.

8. I work closely with the residents as they prepare their manuscripts.

9. Other faculty work with the residents as they prepare their manuscripts.

The title of my program is: Residency in

THANK YOU FOR YOUR PARTICIPATION IN THIS SURVEY!

30 Optometric Education

Lens programs where only half of the eight programs require it (Table 2).

For the 75 programs responding, there were 419 papers produced dur­ing the period, 1999-2003. Of these 89 (21%) were actually submitted for publication. Of those submitted for publication, 60 (67%) were accepted for publication (Figure 2). Several programs indicated that they did not know how many papers were submit­ted or published.

Fully 73 of the 75 respondents either agree or strongly agree that the preparation of a manuscript of pub­lishable quality is an appropriate scholarly activity for a residency pro­gram. Of these 73 supervisors, 56 either agree or strongly agree that they, or other faculty, work closely with their residents to prepare their manuscripts. Seven supervisors did not respond to this item.

Discussion The requirement for scholarly

activity to occur in all optometric accredited residency programs results in the production of a significant num­ber of manuscripts of publishable quality each year. However, based on this study, only one in five of these manuscripts is actually submitted for publication. Of those submitted, two out of three are eventually published.

The actual number of papers pro­duced each year is difficult to estimate since 54 of the programs surveyed did not respond. Likewise, the number of papers submitted for publication and the number that actually are accepted for publication are not known as some programs did not track this statistic. Therefore, the total of 419 papers pro­duced during the period, 1999-2003, is probably a gross underestimate. The actual number of papers produced in all accredited programs probably exceeds 100 papers per year and may well be substantially higher.

Conclusions There is~ nearly unanimous agree­

ment among residency supervisors, who responded to the survey, that the preparation of a manuscript of pub­lishable quality is an appropriate scholarly activity for an optometric resident. This is probably because the supervisors feel that this activity pro­vides the resident with the opportuni­ty to engage in research as well as to hone his/her writing and presenta-

Figure 2: Papers Produced by Residents 1999-2003

1 Total papers

Submitted for publication

i Submitted and accepted

100 200 300 400 500 Number of Papers

tion skills. What may not be recog­nized is that this activity has the potential for making a very signifi­cant contribution to the optometric lit­erature as well as to the literature in related disciplines.

Based on this study, and without introducing any new residency pro­gram requirements, one could conser­vatively estimate that more than 60 additional papers per year could be available for publication. One diffi­culty lies in the fact that residency programs are typically one year in length and publishable manuscripts are usually completed near the end of that year. Submission of a manuscript for publication would, of necessity, require some effort on the part of the resident subsequent to the completion of the residency program.

There are other meaningful reasons for the resident to pursue publication of his/her manuscript. In addition to personal satisfaction, the resident has an important credential to add to a curriculum vitae that could well be helpful in securing a professional position. For example, many former residents seek faculty positions at schools and colleges of optometry

which, almost uniformly, require clin­ical faculty to have completed a resi­dency program. Those who have publications to their credit would likely fare better in the hiring process than those who do not.

References 1. Council on Optometric Education.

Accreditation Manual: Optometric Residency Programs. 1979

2. ibid, 1982 3. ibid, 1994 4. Accreditation Council on Optometric

Education, Accreditation Manual: Optometric Residency Programs. 2003

Volume 32, Number 1 /Fall 2006 31

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