Competency and Level of Confidence of Emergency Residents When Dealing with Ocular Emergency Cases in Saudi Arabia

Abstract

Patients with ocular emergencies often visit emergency doctors before they visit an ophthalmologist. Therefore, emergency physicians must have adequate knowledge for preliminary diagnosis. We aimed to assess emergency resident doctors’ training in managing eye emergencies, as well as their level of confidence, competence, and equipment use skills in dealing with ocular emergencies. This cross-sectional, multicenter, questionnaire-based study included all emergency resident doctors in the Western, Central, and Eastern regions of Saudi Arabia. In total, 181 emergency residents were enrolled. Moreover, 28.2% received adequate training in the management of eye emergencies, and 72.2% reported that they received training from senior emergency medical staff. Overall, 14.9% of residents expressed confidence in handling emergency eye cases, compared with 66.3% who expressed less confidence. The prevalence of residents demonstrating confidence in the management of emergency eye cases was significantly high among those who received instructions on how to use an ophthalmoscope (p < 0.001), those who had been taught to use the slit lamp (p < 0.001), and those who expressed confidence in using the slit lamp (p < 0.001). We advise integrating basic ophthalmic clinical skills into emergency resident training programs to help gain greater insight, reduce the workload of ophthalmic services, and provide proper emergency eye care.

1. Introduction

The prevalence of various ophthalmic emergency conditions observed in emergency departments has increased over the years. The incidence of ocular emergencies in the United States was estimated to be nearly 2 million visits per year, with a rate of 212 visits per 100,000 persons in 2011. The nature and speed of onset of ocular emergencies vary from case to case and can be classified as trauma-related and non-trauma-related, such as acute glaucoma, retina-related conditions, and inflammatory conditions [1,2]. Timely diagnosis is an essential factor for better outcomes. Having a well-trained eye care physician helps to achieve an accurate diagnosis and identify when to interfere—immediately, within 24 h, or refer the patient to an ophthalmologist [1]. Delayed ophthalmic care may result in serious adverse effects, as some acute eye conditions/presentations can be sight or life-threatening, which ultimately decreases the quality of life and leads to substantial personal and societal costs [3]. Patients that present to emergency departments may face clinicians of varying skill levels, as the first-line physician in emergency departments is often an emergency physician or general practitioner. This could lead to misdiagnosis by physicians who are not well-trained in ophthalmic cases. One study showed that the diagnostic accuracy rate of emergency physicians was only 39% in ophthalmic cases. Another study reported that one-third of all referred urgent and emergent ophthalmic cases are misdiagnosed [4,5]. Additionally, in the UK, 68.8% of emergency doctors reported little to no confidence in dealing with ophthalmic cases. Furthermore, in Australia, more than 90% deemed learning about ophthalmic emergencies necessary [6,7].

Studies on the role of emergency physicians in delivering eye care in Saudi Arabia are scarce. However, a study conducted locally reported a low level of knowledge and poor practice among primary care physicians in diagnosing and managing corneal abrasion. In addition, resources for diagnosing corneal abrasion are not uniform throughout Saudi Arabia, with limited availability in some centers [8].

Ophthalmic care is routinely provided on an outpatient basis or by trained eye care professionals in a tertiary ophthalmic emergency department. Therefore, emergency physicians must have the necessary knowledge, skills, and confidence to diagnose and manage such cases.

In this study, we aimed to assess the training of emergency resident doctors in managing eye emergencies, as well as their level of confidence, competence, and equipment-use skills in dealing with ocular emergencies. We also aimed to determine the availability of appropriate diagnostic tools in emergency departments. To our knowledge, this is the first study to assess these parameters among emergency physicians in Saudi Arabia.

2. Materials and Methods

2.1. Study Design

This cross-sectional, multicenter, questionnaire-based study included all emergency resident doctors in the Western, Central, and Eastern regions of Saudi Arabia. Ophthalmology and pediatric emergency residents were excluded from our study.

2.2. Study Procedures

After obtaining IRB approval from Imam Muhammed ibn Saud Islamic University, data were collected via an online questionnaire conducted between September and December 2022. The questionnaire consisted of two parts: part one inquired about demographic data, such as gender, region of practice, and year of residency (

Table 1. Basic demographic characteristics of emergency residents (n = 181).

Study Data	n (%)
Gender
Male	108 (59.7%)
Female	73 (40.3%)
Region of Practice
Western Region	44 (24.3%)
Central Region	83 (45.9%)
Eastern Region	54 (29.8%)
Year of Residency
R1	88 (48.6%)
R2	42 (23.2%)
R3	26 (14.4%)
R4	25 (13.8%)

), whereas part two consisted of 14 items adapted from a previously published questionnaire [9]. It is a valid and reliable questionnaire that has been used in multiple examples in the literature [9,10,11], it was distributed in its original language (English), and no item was eliminated nor added; however, some items were modified linguistically to ensure a better understanding for the participants (

Table 2. Assessment of confidence and competency of the residents in dealing with emergency ocular patients (n = 181).

Statement	n (%)
Received formal training and instruction in the management of eye emergencies in the A&E department:
No	48 (26.5%)
Some	82 (45.3%)
Enough for my needs	51 (28.2%)
Mentor for formal training and instruction in the management of eye emergencies in the A&E department (n = 133):
Senior A/E medical staff	96 (72.2%)
Ophthalmic nurse practitioner	12 (09.0%)
Ophthalmic medical staff	13 (09.8%)
Senior A/E medical staff and Ophthalmic nurse practitioner	07 (05.3%)
Senior A/E medical staff and Ophthalmic medical staff	05 (03.8%)
Is there an ophthalmoscope that you can use?
No access to one at all	42 (23.2%)
Access to one outside the A&E department	51 (28.2%)
Within the A&E department itself	88 (48.6%)
Have you been taught to use the ophthalmoscope ever?
No	67 (37.0%)
Yes	114 (63.0%)
How confident do you feel in the use of the ophthalmoscope?
Not confident at all	47 (26.0%)
A little confident	101 (55.8%)
Confident enough	33 (18.2%)
Is there a slit lamp that you can use?
No access to one at all	78 (43.1%)
Access to one outside the A&E department	64 (35.4%)
Within the A&E department itself	39 (21.5%)
Have you been taught to use the slit lamp ever?
No	125 (69.1%)
Yes	56 (30.9%)
How confident do you feel in the use of the slit lamp?
Not confident at all	110 (60.8%)
A little confident	56 (30.9%)
Confident enough	15 (08.3%)
How easy or difficult is it for you to refer patients for specialist opinion and management?
Difficult	21 (11.6%)
Relatively easy	101 (55.8%)
Not a problem at all	59 (32.6%)
Reason for having difficulties to refer patients for specialist opinion and management (n = 21):
There was no eye department nearby	04 (19.0%)
The eye department was often reluctant to accept your referral	07 (33.3%)
The patient could not be seen as quickly as you had hoped	01 (04.8%)
There was no eye department nearby or the eye department was often reluctant to accept referral	4 (19.0%)
The eye department was often reluctant to accept the referral or the patient could not be seen as quickly as hoped	02 (09.5%)
All of the above	03 (14.3%)
On an average working day, how many eye cases do you see?
None	37 (20.4%)
1–2	118 (65.2%)
3–5	23 (12.7%)
>5	03 (01.7%)
How confident are you in the management of eye emergencies in the A&E department?
Not confident at all	34 (18.8%)
A little confident	120 (66.3%)
Confident enough	27 (14.9%)
Reason for being not confident/a little confidence in the management of eye cases (n = 154):
Not confident about diagnosis and management	37 (24.0%)
Afraid that you may miss something important	63 (40.9%)
Not sure about what you should refer to the eye department	17 (11.0%)
Not sure about what you should refer to the eye department and afraid that you may miss something important	11 (07.1%)
All of the above	26 (16.9%)
Anticipated happening to give greater confidence in the management of eye patients:
Formal training and teaching	66 (36.5%)
Better equipment in the A&E department	32 (17.7%)
Close and better links with the eye department	24 (13.3%)
Formal training and teaching and better equipment in the A&E department	04 (02.2%)
All of the above	55 (30.4%)

A&E: accident and emergency department.

). The 14 questions served to ascertain the level of training that emergency residents receive regarding the management of ophthalmic emergencies, their self-perceived level of confidence when dealing with such cases, and the availability of appropriate diagnostic tools, such as slit lamps and ophthalmoscopes in emergency departments (Table 2).

2.3. Statistical Analysis

Data were analyzed using the Statistical Package for Social Sciences, version 26 (SPSS, Armonk, NY, USA). Categorical variables are shown as numbers and percentages, whereas continuous variables are summarized as means and standard deviations. The relationship between the level of confidence in dealing with ocular emergency cases and basic demographic characteristics or related practices in the management of emergency cases was determined using Fischer’s exact test. Significant results were then gathered in a multivariate regression model to determine the independent factors associated with sufficient confidence in dealing with ocular emergency cases with corresponding odds ratios (ORs) and 95% confidence intervals (CI). Statistical significance was set at p < 0.05.

3. Results

A total of 181 emergency residents were enrolled in the study. Table 1 presents the basic demographic characteristics of the participants. Most participants (59.7%) were male, and 45.9% were practicing in the Central region. Additionally, 48.6% were resident level 1, whereas 23.2%, 14.4%, and 13.8% were resident levels 2, 3, and 4, respectively.

Table 2 shows that the proportion of residents who indicated that they received adequate training and instruction in the management of eye emergencies in the accident and emergency (A&E) department was 28.2%. Moreover, 72.2% of participants reported that they were trained by senior medical staff. Of the residents, 48.6% indicated that an ophthalmoscope was available within the A&E department, and 63.0% were familiar with using it. However, only 18.2% expressed confidence in the use of an ophthalmoscope. Only 21.5% reported having slit lamps in their A&E department, and 30.9% had been taught how to use them; most residents (60.8%) were unconfident when using slit lamps. Moreover, 11.6% expressed no difficulties in referring patients for a specialist’s opinion. The most common reason for having difficulties referring patients for a specialist’s opinion and management was that “the eye department was often reluctant to accept referral” (33.3%). Approximately 65.2% of the participants saw one to two eye cases per day. Additionally, 14.9% of residents expressed confidence in handling emergency eye cases. Among those who had no or little confidence (n = 154), the most common reason was the fear of missing important steps (40.9%). In addition, the most common method indicated to increase confidence in the management of eye patients was formal training and teaching (36.5%).

When measuring the factors that influence the level of confidence of residents in the management of ocular emergency cases (

Table 3. Factors that influence the level of confidence in the management of eye emergency cases (n = 181).

Factor	Confident n (%) (n = 27)	Not/Little Confident n (%) (n = 154)	p-Value §
Gender
Male	17 (63.0%)	91 (59.1%)	0.832
Female	10 (37.0%)	63 (40.9%)
Region of Practice
Western Region	05 (18.5%)	39 (25.3%)	0.003 **
Central Region	20 (74.1%)	63 (40.9%)
Eastern Region	02 (07.4%)	52 (33.8%)
Year of residency
Junior residents	20 (74.1%)	110 (71.4%)	1.000
Senior residents	07 (25.9%)	44 (28.6%)
Received formal training and instruction in the management of eye emergencies in the A&E department:
No	01 (03.7%)	47 (30.5%)	0.002 **
Yes	26 (96.3%)	107 (69.5%)
Availability of ophthalmoscope:
No access to one at all	0	42 (27.3%)	<0.001 **
Access to one outside the A&E department	04 (14.8%)	47 (30.5%)
Within the A&E department itself	23 (85.2%)	65 (42.2%)
Been taught to use the ophthalmoscope ever:
No	01 (03.7%)	66 (42.9%)	<0.001 **
Yes	26 (96.3%)	88 (57.1%)
Perceived confidence in the use of the ophthalmoscope:
Not confident	02 (07.4%)	45 (29.2%)	0.017 **
Confident	25 (92.6%)	109 (70.8%)
Availability of slit lamp:
No access to one at all	01 (03.7%)	77 (50.0%)	<0.001 **
Access to one outside the A&E department	11 (40.7%)	53 (34.4%)
Within the A&E department itself	15 (55.6%)	24 (15.6%)
Been taught to use the slit lamp ever:
No	08 (29.6%)	117 (76.0%)	<0.001 **
Yes	19 (70.4%)	37 (24.0%)
Perceived confidence in the use of the slit lamp:
Not confident	07 (25.9%)	103 (66.9%)	<0.001 **
Confident	20 (74.1%)	51 (33.1%)
Difficulties to refer patients for specialist opinion:
Difficult	01 (03.7%)	20 (13.0%)	0.005 **
Relatively easy	10 (37.0%)	91 (59.1%)
Not a problem at all	16 (59.3%)	43 (27.9%)
Average of eye cases seen per day:
None	0	37 (24.0%)	0.004 **
1–2	23 (85.2%)	95 (61.7%)
>2	04 (14.8%)	22 (14.3%)

^§ p-value was calculated using Fisher’s exact test. ** p < 0.05.

), we found that the prevalence of residents demonstrating confidence in the management of emergency eye cases was significantly higher among those who were practicing in the Central region (p = 0.003); who received formal training and instruction for eye emergency cases (p = 0.002); reported the availability of ophthalmoscopes within the A&E department (p < 0.001); received instruction on how to use an ophthalmoscope (p < 0.001); expressed confidence in using an ophthalmoscope (p = 0.017); reported slit lamp availability within the A&E department (p < 0.001); had been taught to use a slit lamp (p < 0.001); expressed confidence in using a slit lamp (p < 0.001); expressed having no difficulties in referring patients to a specialist (p = 0.005); and were seeing one to two eye patients per day (p = 0.004).

The results of the multivariate regression analysis to determine the independent predictors of confidence in managing eye emergency cases are shown in

Table 4. Multivariate regression analysis to determine the independent significant factor with having enough confidence in the management of eye emergency cases (n = 181).

Factor	AOR	95% CI	p-Value
Region of Practice
Western Region	Ref.
Central Region	0.149	0.018–1.255	0.080
Eastern Region	0.157	0.025–0.978	0.047 **
Received formal training and instruction in the management of eye emergencies in the A&E department:
No	Ref.
Yes	5.672	0.543–59.216	0.147
Been taught to use the ophthalmoscope ever:
No	Ref.
Yes	19.543	0.933–409.26	0.055
Perceived confidence in the use of the ophthalmoscope:
Not confident	Ref.
Confident	0.141	0.012–1.713	0.124
Availability of slit lamp:
No access to one at all	Ref.
Access to one outside the A&E department	15.012	1.524–147.8	0.020 **
Within the A&E department itself	1.638	0.532–5.040	0.389
Been taught to use the slit lamp ever:
No	Ref.
Yes	1.288	0.304–5.457	0.731
Perceived confidence in the use of the slit lamp:
Not confident	Ref.
Confident	3.252	0.700–15.110	0.132
Difficulties to refer patients for specialist opinion:
Difficult	Ref.
Relatively easy	17.953	1.686–191.22	0.017 **
Not a problem at all	6.494	2.007–21.012	0.002 **

AOR: adjusted odds ratio; CI: confidence interval. ** p < 0.05.

. Having access to the slit lamp outside of the A&E department and having relative ease or no problem at all in referring patients to specialists were the independent predictors of increased confidence, while practicing residency in the Eastern region was an independent predictor of decreased confidence in the management of emergency eye patients. Residents who had access to a slit lamp showed increased confidence in the management of eye emergency cases by at least 15 fold (adjusted OR [AOR] = 15.012; 95% CI = 1.524–147.8; p = 0.020). Residents who expressed relative ease in referring patients to specialists had a 17.9% higher chance of being confident compared with those who expressed difficulties (AOR = 17.953; 95% CI = 1.686–191.2; p = 0.017) and 6.5% higher odds of confidence compared with those who expressed no problem at all (AOR = 6.494; 95% CI = 2.007–21.012; p = 0.002). By contrast, compared with residents practicing in the Western region, residents practicing in the Eastern region had decreased odds of having sufficient confidence by at least 84% (AOR = 0.157; 95% CI = 0.025–0.978; p = 0.047). However, variables such as receiving formal training and instruction in the management of eye cases, being taught how to use an ophthalmoscope, having confidence in the use of an ophthalmoscope, being taught how to use the slit lamp, and confidence in the use of the slit lamp were not predicted to have a significant effect on residents’ confidence levels in the management of emergency eye cases after adjustment (p > 0.05).

4. Discussion

We examined the competency and confidence levels of emergency residents in dealing with ocular cases that require emergency treatment. To our knowledge, this is the first study in Saudi Arabia to evaluate residents in such cases. Thus, the findings of this study are important, as they provide insights into whether Saudi emergency residents are sufficiently equipped to handle such cases. Our results revealed that the residents’ confidence in the management of ocular emergency cases was insufficient. Only 14.9% of the residents expressed confidence in handling emergency eye patients, 66.3% expressed little confidence, and 18.8% were not confident. Residents’ most common reason for a lack of confidence was being afraid to miss something important (40.9%), followed by a lack of confidence in the diagnostic procedure and management (24.0%). This is consistent with a previous study by Wang et al., who reported that most emergency medicine residents demonstrated a lack of confidence when asked about the diagnostic, examination, or management skills of specific ophthalmic conditions or symptoms. They reported several reasons why their comfort with ophthalmologic patients was limited, such as insufficient patients, insufficient time to talk to patients, and insufficient attendance of lectures [12]. These reasons may have been aggravated by the COVID-19 pandemic as there was a considerable decrease in the number of emergency department visits in Saudi Arabia during the pandemic [13,14], including the overall number of eye emergency department visits [15]. Over the years, other studies have reported that emergency doctors do not feel competent in managing patients with ocular disease [5,9,10,11]. However, little seems to have changed since then, and many emergency medicine physicians have reported being uncomfortable using ophthalmic equipment [16]. Therefore, extensive efforts are needed to address the lack of competence of EM residents in handling ocular cases. However, given the residents’ lack of time in developing their confidence in handling these cases, the fact that this gap will be addressed soon is unlikely. Multi-faceted efforts and innovative solutions are required to achieve an adequate level of confidence among emergency medicine residents.

In our univariate analysis, the region of practice, receiving formal training and instruction in the management of eye emergencies in the A&E department, availability of an ophthalmoscope and slit lamp, being taught how to use an ophthalmoscope and slit lamp, perceived confidence in the use of an ophthalmoscope and slit lamp, difficulties in referring a patient to a specialist, and the average number of eye cases seen per day were found to influence the level of confidence. However, in our multivariate estimates, the region of practice, availability of slit lamps, and difficulties in referring patients remained significant, and thus, were determined as the independent factors associated with the level of confidence. The analysis further suggested that a decreased confidence level was associated with practicing in the Eastern region, while an increased confidence level was associated with having access to slit lamps outside the A&E department and ease in referring patients to a specialist. Few studies have established the effect of residents’ characteristics on the confidence level. A study conducted among American physicians in internal, emergency, and family medicine departments reported that a greater number of hours of ophthalmic education in residency was associated with increased confidence in family (p < 0.001), emergency (p < 0.001), and internal (p = 0.005) medicine residents [17]. Further investigation is required to determine the factors influencing residents’ level of confidence.

Moreover, 28.2% of the residents reported that they received sufficient training and instructions in the management of ocular emergencies, while 26.5% indicated having no formal training. This was consistent with the results of Tan et al., who reported that 26% of emergency senior health officers received no training in the management of emergency ocular patients [14]. In another study conducted in the UK, 63% of emergency medicine physicians reported having no formal training in ophthalmology within the general A&E department, and 57% felt that their undergraduate teaching in ophthalmology was insufficient [16]. This was echoed by a study conducted in the US, in which 70.9% of EM physicians wished that they had received more ophthalmology courses and training during medical school [3]. The deficit in basic ophthalmic courses during undergraduate years was also discussed in a qualitative study by Ah-Kee et al., who mentioned that the deficiency in ophthalmologic training can be traced back to the undergraduate years [18].

The availability of ophthalmic equipment within the A&E department is an important factor in increasing confidence in managing emergency ocular cases. However, in our study, 48.6% of the residents stated that an ophthalmoscope was available in their A&E department, while the availability of slit lamps was only 21.5%. Furthermore, many residents indicated that they had been taught how to use an ophthalmoscope (63%), while only 30.9% had received training on how to use a slit lamp. Similarly, 18.2% of residents were confident in using an ophthalmoscope, while only 8.3% were confident in using a slit lamp. A lack of competency in using ophthalmic equipment was also observed by Murray et al. [16]. Based on their study, most EM doctors were uncomfortable using standard ophthalmic equipment, such as an ophthalmoscope (71%) and slit lamp (68%) [16]. By contrast, Wang et al., who believed that ophthalmology and examination skills are important to a future career, reported that residents exhibited greater competency levels as they became more comfortable with slit lamp examination during residency training, with an average comfort level of 6.9 on a scale of 1 to 10, which was frequently seen among residents at the third-year level [10].

One of the major limitations of this study was the small sample size owing to the lack of participation (n = 181). Hence, a better view of the level of confidence among emergency residents in the management of ocular cases is needed. Another limitation is that the questionnaire was distributed electronically, providing less accurate results and creating a demographic maldistribution. Additionally, the level of confidence was assessed using subjective questions, resulting in some bias in the residents’ responses. Finally, owing to the cross-sectional nature, this study is prone to certain disadvantages, including cause-and-effect relationships and other biases.

5. Conclusions

In this study, we highlight the need for teaching emergency residents ophthalmic skills. Different countries across the world have reported similar findings. Therefore, we advise integrating basic ophthalmic clinical skills into emergency resident training programs to help gain better insight, reduce the workload of ophthalmic services, and provide proper emergency eye care. Measures such as providing the appropriate instruments and facilitating the connection with specialists have a significant impact to enhance the training of residents. In addition, family physicians have recently begun providing emergency care at the primary care level in Saudi Arabia. Thus, further studies are recommended to determine the knowledge and practices of family physicians in evaluating eye-related diseases.