This study used a quantitative survey to assess changes in the implementation ratio of fundoscopic exams effected by a checklist intervention, as well as a qualitative survey to assess the psychological backgrounds of the study subjects thought to affect the implementation ratio. We found that the introduction of the checklist elevated the implementation ratio of the fundoscopic exam, and post-intervention, there was an elevated level of confidence and educational initiative.
Reasons for implementing the exam
Despite the reported demand to learn fundoscopy techniques among medical students and interns6, 7, as well as doctors who have completed training14, there are limited opportunities to learn the skills needed to implement fundoscopic exams. The qualitative results of this study – <Self-directed learning opportunity > and < Desire to learn procedure> – have also shown a desire among physicians.
The fundoscopic exam possesses significance as < Significance for evaluating complications from chronic diseases>, <Significance for evaluating retinal diseases>, and < Significance for evaluating increased brain pressure>. Insufficient understanding of these concepts (< Lack of understanding significance>) and the < Lack of knowledge > of the fundoscopic exam itself became negative motivations in the category of [Negative motivation: physician factors].
Among the questionnaire results, there was no significant difference pre- and post-intervention in the survey items, “Do you feel it is indispensable for diagnosis?”; “Do you feel it is indispensable in the management of chronic diseases?”; and “Do you think it will benefit the patient?” Even in the interviews, the participants understood the significance of fundoscopic exams, but their responses remained formulaic. Specifically, participants had little experience with the procedure being clinically useful (< lack of successful experiences in detecting abnormalities>); thus, the weighting of the motivation to use the fundoscopy appeared small.
Reasons for not implementing the exam
In the self-completed questionnaire and the interviews, many participants cited reasons for not implementing fundoscopic exams as follows: <Lack of understanding significance>, <Lack of confidence>, <Inexperience in procedure>, <Time performance>, and < Forgetting>. Questionnaires in prior studies14 reveal barriers to the fundoscopic exam as “ophthalmoscope not working,” “no ophthalmoscope available,” “unable to see,” “not attempted,” and “not allowed.” Similar to this study, the inability to see through the fundoscopy was a reason not to implement the exam.
In the self-completed questionnaire administered post-intervention, the survey item, "I'm not confident in how to use the fundoscopy'' had a statistically significant decrease; the survey item, "Even though I always use the fundoscopy, I can’t conduct medical exams well with it" decreased as well, although it was not a significant difference. The results showed that the intervention using the checklist could potentially resolve a < Lack of confidence > or < Inexperience in the procedure>. We believe that these two concepts have a large weighting with respect to the motivations driving the decision not to implement the fundoscopic exam.
Because the fundoscopic exam is a simple exam that can be performed by a primary care physician (i.e., not an ophthalmologist), physicians felt the exam to be < Inferior to ophthalmology>, <Inferior to alternative testing > and < False positive/negative findings>. These concepts acted negatively during motive formation, and were associated with the concepts < Inexperience in procedure>, <Lack of knowledge > and < Lack of confidence>.
Decrease of < Forgetting > through use of the checklist
An independent negative motivation was < Forgetting>. Opportunities are present in internal medicine, primary care, and emergency medicine to use the fundoscopy, but fundoscopic exams are often not performed unless there are obvious ocular symptoms.15
Checklists are useful in reducing postoperative mortality and major surgical complications16, 17, reducing human error during extracorporeal circulation18, and providing reminders to mitigate missed collections of outpatient guidance and management fees19. In the qualitative survey, the use of a checklist served as a reminder to reduce < Forgetting > and led to the motivation to implement the fundoscopic exam (< usefulness of the checklist>).
However, in the survey inquiring the reason for not performing the fundoscopic exam, there was no significant difference in the number of people who responded, "I forgot," despite the checklist. In short, the < Forgetting > also occurred in post-intervention interviews. We speculate that the elimination of < Forgetting > factors will require not only the checklist but a system to remind the physicians during the consultation.
Impact of frequency on confidence
The quantitative results revealed that the checklist intervention increased the implementation ratio and the confidence to implement fundoscopic exams. We combined the quantitative study with a qualitative study to analyze and clarify the causal relationship between implementation ratio and confidence, as well as its process.
The qualitative study revealed that a < Lack of successful experiences in detecting abnormalities > resulted in a < Lack of confidence>, which became a reason for non-implementation. These results are similar to those of prior studies.7, 20 Sixty-three percent of medical students responded that they had experience with an abnormal fundus less than 3 times, while 23% had never seen one. Medical students who had had fewer opportunities to observe abnormal findings were more likely than those who had observed many abnormalities to report a lack of confidence in identifying optic disc edemas and proliferative retinopathy.20
On the contrary, this study confirmed the process of < successful experiences and confidence building > through [Successful implementation]. Participants gained confidence by having more practice in the procedure, which led to the < Progress of skill>. The following strategies have been proposed to increase confidence: having the participants perform a task1, hosting a teaching session21, having the participants practice a lot7, and daily use of the fundoscopy.20
Impact of confidence on frequency
Studies have shown that increased confidence in fundoscopic exams leads to skilled use.1 In this study, we found that < Lack of confidence > is also related to the concepts < inferior to ophthalmology > and < False positive/negative findings > due to a synergistic effect with < Inexperience in technique>; we were able to verify the process in which these became the motivation for non-implementation. We believe that, apart from < Environmental pressures>, <Successful experiences and confidence building > reduced the < Lack of confidence>, which led to an increase in exam implementation. From this, we believed an important strategy to increase exam implementation frequency would be to reduce negative motivations in addition to increasing positive motivations.
Increased aggressiveness to education
Qualitative feedback through instruction is said to increase confidence in implementing fundoscopic exams.7, 20 Confidence is lost from continued lack of exposure20, and it is possible that ongoing extracurricular instruction may lead to an increase and/or maintenance of confidence. Our qualitative survey also found that < Lack of confidence > is related to the < Lack of educational initiative>, and conversely, gaining confidence increases < Educational initiative>.
We expect that the number of implementations would have been maintained if the checklist intervention maintained its reductive effects on [Negative motivation: physician factors] after completion. However, two months post-intervention, the implementation ratio had returned to the same level as two months pre-intervention. The residual effects of education on healthcare professionals is proportional to the time of training received and the time engaged in related tasks.22 It is possible that a checklist intervention over a long period of time could change physicians' actions.