Otoscopic examination is an important audiological procedure that helps in identifying early signs of both outer and middle ear pathologies . In fact, research has indicated that otoscopic examination can identify middle ear pathologies much better than the conventional tympanometry with single probe tone  that is used by audiologists. It is therefore crucial that students are equipped with the necessary skills to be competent and confident in conducting otoscopic examination. This study therefore sought to determine if audiology students perceived themselves as competent and/or confident in conducting otoscopic examination following video otoscopic training.
Current findings suggest that approximately 50 % of the audiology students surveyed perceived themselves as competent and confident in conducting otoscopic examination, while the rest perceive themselves as less competent or/and confident. In terms of aspects of otoscopic examination that audiology students perceive themselves as less or more competent and confident in, majority of the students felt that they were less competent and confident in performing and interpreting otoscopic examination. The perceptions of audiology students in this study are inconsistent with previous studies that trained students [3, 13, 23]. Kaf and colleagues  found that majority of the audiology students (over 70 %) perceived themselves to be more confident after training; while You and colleagues  also found that the perception of medical students regarding confidence in otoscopic examination significantly improved following training.
The difference between the current findings and previous studies can be attributed to different training methods used. Kaf and colleagues  used Mannikin ears that reflected various statuses of the middle ear, while in the current study audiology students used University students mainly with normal middle ear function. The lack of exposure to various pathologies during training could have played a role in students’ perceptions. Students may be unsure on what they should be looking for when conducting otoscopic examination. Therefore, the findings of this study suggest a need for curriculum review for practical training of audiology students. Future training on otoscopic examination should consider incorporating patients with various middle ear pathologies.
In addition to video otoscopic training using volunteer patients, institution of higher learning, particularly in LMICs, should consider using simulations as part of clinical training as research suggests that simulations improve students’ confidence and competence [24, 25]. Wilson and colleagues  argue that simulations should support clinical training and not replace clinical training. Von Buchwald and colleagues  found that junior doctors scored low in identifying simulated middle ear pathologies. These authors argue that the difficulty in identifying pathologies may have been due to lack of case history accompanying the pathologic ears. Therefore, in LMICs, training programmes for audiology students should ensure inclusion of case history information as part of training to help students with the identification of outer and middle ear pathologies, and to make sure that the training is not in isolation.
Regarding specific pathologies that students can confidently and/or competently identify using otoscopy, 43 % of students felt that they can identify outer ear pathologies such as cerumen and foreign objects, while few indicated that they were able to identify outer and middle ear pathologies. These findings are also inconsistent with findings of a study conducted by Davies and colleagues  who found that 71 % of medical students perceived their confidence in diagnosing pathologies of the ear to have improved following training. Although audiology students are not expected to diagnose pathologies of the ear, it is within the scope of audiology for students to distinguish normal from abnormal outer and middle ear pathologies in order to be able to plan further testing as well as appropriate intervention and/or referral . Therefore, it is crucial that students’ confidence and competence be improved for clinical best-practice purposes. Davies and colleagues  argue that lack of confidence in diagnosing ear pathologies ultimately affects graduates in clinical practice.
Despite the students’ lack of confidence and competence in identifying outer and middle ear, it was assuring that 97 % of the students felt that video otoscopy should continue to be part of their clinical training. This means students feel that video otoscopic training may improve their confidence and competence if done properly. In studies by Kaf and colleagues  and Davies and colleagues , training included images of pathologic ears to help students distinguish between normal and abnormal. Therefore, further research in this area should ensure that pathologic ears are included in the training.
There is an increasing effort to develop mobile applications to facilitate identification and management of auditory and otolaryngological pathologies, including outer and middle ear pathologies . Given the documented demand versus capacity challenge in LMICs, mobile applications can be used to help with the training of students to identify outer and middle ear pathologies, where instructors other than those physically available in local training institutions can be utilised. Bhavana and colleagues  found a higher sensitivity and specificity of smartphone otoscopy in identifying outer and middle ear pathologies when compared with oto-endoscopy. Myburgh and colleagues  developed an automated cloud-based smartphone system which uses image analysis to diagnose outer and middle ear pathologies. These mobile applications are crucial in LMICs and can be used to teach audiology students to be able to identify early signs of outer and middle ear pathologies; and can also facilitate peer and/or supervisor support though asynchronous tele-audiology modalities.
Given that the COVID-19 pandemic has severely affected the traditional face-to-face audiological service provision , including student training in institutions of higher learning, Khoza-Shangase and colleagues  emphasise the need for innovative models of service delivery and student training to ensure the continuity of care and student training during and beyond this pandemic. Telepractice and teletraining have been at the forefront to ensure continuity of care and student training. Bhavana and colleagues  argue that smartphone otoscopy can be used as a teaching tool within the telemedicine approach, especially in LMICs. Sebothoma and Khoza-Shangase  and Binol and colleagues  indicate that video otoscopic images of the tympanic membrane can be used within the telemedicine approach. Given the high sensitivity and specificity of video/digital otoscopy, this has important training and practice implications, particularly during the COVID-19 pandemic.
While the current study provides important evidence about the use of video otoscopy as a teaching tool for outer and middle ear pathologies, it is worth noting that at the time of this study, there was 100 % female audiology students from third to fourth year at the University where the study was conducted. Although this gender profile may be slightly different in other universities, the predominant number of females in the cohort of students is not surprising given that the gender profile of the South African audiologists and speech therapists registered with the Health Professional Council of South Africa (HPCSA) is primarily (95 %) female . These professions are highly feminised in South Africa, with efforts to transform the gender, linguistic and racial demographic profile afoot in the country. Despite this, it is not believed that this profile had an impact in the current findings. In addition, the sample size for this study was very small, with a response rate of 38 % which is significantly lower than the ideal 60 %; and this certainly is believed to have had an impact on the current findings; and influences their generalizability. The impact of COVID-19 pandemic on data collection for this study highlighted the importance of enhancing tele-training and tele-data collection strategies in any training programme.
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