Optimizing teaching efficiency in the neuro-ophthalmology clinic

Introduction

The educational landscape for graduate medical education (GME) in ophthalmology is rapidly shifting with the integration of new teaching technologies (including artificial intelligence), novel teaching and learning platforms (internet), and changes in learning style (e.g., video, sound bites, YouTube). In response to this evolving and dynamic cultural shift in GME, as well as the specter of physician burnout, we believe that enhanced scholarly and academic measures should be incorporated into clinical training curricula and aligned with current educational theory for incorporation into the clinic and classroom learning environments (1). Implementing effective teaching techniques and strategies should ideally produce timely, precise, and actionable feedback. This approach creates a learning environment that promotes a growth mindset, increases efficiency and motivation, and reduces uncertainty (2). Although the basis of educational theory continues to apply to the learners of today, physician mentors and GME educators must meet novel challenges unique to the current landscape of medical training. The pressure to be clinically productive can make teaching and mentoring increasingly difficult and rising rates of physician burnout (including ophthalmology) emphasize the need for change and initiatives that promote well-being and improved efficiency (3).

In this manuscript, we aim to review current best practices for optimizing teaching efficiency in the neuro-ophthalmology clinic and to describe countermeasures to improve mentorship opportunities and potentially reduce physician burnout. In this study, we describe mentorship as an ongoing form of career development where mentors can guide learners through professional choices and career trajectory. Feedback, when given by mentors, can help guide learners in both the short-term and long-term setting. To conduct this study, we reviewed the existing literature on physician burnout, feedback in clinical education, and time-management strategies relevant to GME, with a particular focus on ophthalmology and neuro-ophthalmology. Sources were identified through a targeted search of PubMed, Scopus, and Google Scholar using keywords such as physician burnout, ophthalmology education, clinical teaching efficiency, mentorship, feedback in medical education, and time management in clinical practice. Articles published between 1980 and 2025 were considered, and reference lists of relevant publications were screened for additional studies. In addition to peer-reviewed literature, we included selected high-quality educational reviews and professional resources (e.g., clinical reasoning frameworks, time-management models) where empirical studies were limited. This narrative, selective review was designed not to be exhaustive but to synthesize practical best practices that can be feasibly applied within the neuro-ophthalmology clinic and more broadly across ophthalmology training environments.

Burnout

Physician educators must increasingly balance heavy clinical loads with mentoring. As a consequence of these demands, coupled with lack of time and opportunity, burnout has become more predominant in various clinical fields. A national large-sample study published in April 2025 on burnout and work-life satisfaction revealed that 45.2% of physicians reported at least one symptom of burnout (3). A 2022 article examining physician burnout within ophthalmology noted that while the burnout rate among ophthalmologists remains on the lower end (at 37%), a breakdown of subspecialty burnout rates reveals notable discrepancies (4). Burnout rates among ophthalmologists vary significantly by subspecialty, career stage, gender, and practice type. Studies have indicated that ophthalmologists employed in an academic setting were two times more likely to report symptoms of burnout than those in private practice (4).

Burnout reflects a constellation of factors including bureaucratic workload, decreased perceived impact, and a lack of professional fulfillment. The Maslach Burnout Inventory (MBI), a scientifically developed measure of burnout, has been widely applied to assess physician burnout across specialties (3,5,6). Burnout has been associated with increased risk for medical errors, decreased quality of care, and diminished professionalism (7,8). While physician burnout is often fueled by mental and emotional fatigue from work-related pressures such as scheduling difficulties and reimbursement issues, a lack of professional fulfillment remains one of the major causes of burnout (3) (see Appendix 1 for a breakdown of MBI subscales).

Mentorship participation can mitigate feelings of emotional exhaustion by providing new energy and renewed interest in academic pursuits; can decrease feelings of depersonalization by engaging both mentor and mentee in professional relationships that are invigorating and rejuvenating; and can increase professional satisfaction in novel and unique ways. One of the most powerful defenses to combat burnout is finding personal and professional fulfillment in mentorship. One study that investigated the impact of mentorship on burnout in cancer hospital employees showed that individuals, regardless of the type of work done, rank, or role, participating in a mentoring relationship were less likely to report burnout than individuals who were not a part of a mentoring relationship (9). This work suggests that the benefits of mentorship are reciprocal, providing meaningful value to both mentees and mentors. Incorporating effective and meaningful mentoring relationships within ophthalmology-related academic settings (where burnout rates tend to be higher) will serve as useful tools to help combat the discrepancies in work satisfaction within ophthalmology.

Contemporary coaching literature further frames effective clinical teaching as an ongoing process of guided performance, where the educator acts as a coach who supports skill development, fosters autonomy, and enhances professional growth (10,11). Within this model, strategies such as structured feedback, hypothesis generation, and time-management tools are viewed not as isolated fixes but as components of a coaching approach that benefits both faculty and trainees. This framing also helps avoid a deficit-oriented focus on burnout alone; instead, it positions mentorship and teaching efficiency as proactive strategies that cultivate resilience, fulfillment, and improved outcomes.

Feedback

Feedback is a critical element in the training process for medical professionals. The important role of feedback in clinical education is well established, but current feedback practices are often insufficient for learners and mentors. Some survey-based studies highlight discrepancies between learners’ self-assessments and teachers’ external evaluations, as well as short-comings related to unstructured and infrequent feedback (12). Effective feedback is an active process that should be timely, accurate, and actionable (13). The typical learner feedback session, however, is often not timely and feedback sessions may be put on the back burner and not prioritized without a regular, structured, and scheduled, ongoing feedback process (13).

Teaching and feedback in a clinical setting relies on appropriate structure, format, and content (13). We use a continuous feedback process as part of our mentoring program that is scheduled, structured, daily, clinical, and timely. Feedback must work for both the physician educator and the learner. One successful and practical framework for developing clinical reasoning that facilitates effective feedback is through systematic hypothesis generation (scientific method-based approach). Generating hypotheses enables the learner to form “educated guesses” and then test these hypotheses in an analytic study. Similarly, in the clinical setting, every new patient at their initial visit starts with hypothesis generation, followed by hypothesis testing (differential diagnoses). Follow-up patient visits use the previous hypothesis as a framework to perform hypothesis testing. If the null hypothesis is accepted, then the process starts over, and a new hypothesis is generated. This scientific method-based process is not only a helpful diagnostic tool, but also a cognitive tool in education that promotes active learning and clinical reasoning which emphasizes the dynamic nature of cases through cultivating a broad, multi-faceted perspective when approaching each patient (14). In addition, hypothesis generation and hypothesis testing provide a means of delivering effective feedback to learners in a clinical setting. Physician educators can gain valuable insight into a learner’s critical thinking and decision-making skills, pinpoint specific areas that need reinforcement or correction, and can effectively incorporate real-time feedback into the clinic each day. Strategies like timely feedback and systematic hypothesis generation (and testing) serve as practical methods to combat burnout and enhance overall teaching efficiency.

Optimizing teaching efficiency

Physician educators work under significant time pressure, balancing patient care, documentation, and teaching responsibilities in often unpredictable clinical environments. These competing demands limit opportunities for deliberate teaching and meaningful feedback, which are critical to both learner growth and faculty fulfillment (15,16). To address this challenge, preparation and intentional time management are essential.

One effective approach is “pre-charting with a purpose”. The night before clinic, learners review assigned patient encounters, generate hypotheses, and anticipate clinical findings. By arriving prepared, they enter the encounter with confidence, able to engage patients thoughtfully and demonstrate initiative to faculty. This strategy reflects principles of adult learning theory, in which learners thrive when they are self-directed and can immediately apply new knowledge in context (17). It also aligns with the framework of deliberate practice, where structured preparation and immediate application are central to skill acquisition (18).

These strategies are most impactful when embedded within a coaching framework. Coaching in medical education emphasizes longitudinal relationships characterized by feedback loops, reflection, and psychological safety (10-12). Within this framework, pre-charting becomes more than a time-saving tactic: it is a deliberate tool to prompt feedback and encourage coachee-driven reflection. Faculty can build on learner preparation to provide real-time coaching, reinforcing both medical knowledge and professional identity formation (19).

Another complementary strategy is the Eisenhower Decision Matrix (EDM) (Figure 1). Though originally designed for productivity, it can be reframed in medical education as a tool for self-regulated learning (21) and cognitive load management (22,23). By categorizing tasks into four quadrants (urgent/important, urgent/not important, not urgent/important, and not urgent/not important), educators can allocate their limited time and cognitive resources more intentionally.

Figure 1 The Eisenhower Decision Matrix (20).

For clinical educators, the most impactful quadrant is “not urgent but important”, which aligns with reflective practice, protected teaching time, and wellness activities, components known to reduce burnout and enhance professional identity formation. Rather than listing each quadrant as an isolated strategy, we advocate integrating the EDM with structured feedback and coaching principles. For example, urgent/important patient care needs can become opportunities for real-time teaching through live dictation; urgent/not important tasks may be delegated to learners as scaffolded responsibility; and not urgent/important activities, such as scholarly writing or mentoring meetings, can be time-blocked to safeguard against erosion by competing demands. This alignment grounds the EDM within established educational frameworks, positioning it not as a stand-alone productivity tactic but as a deliberate method to support learner autonomy, faculty resilience, and educational efficiency.

By combining pre-charting, structured coaching, and intentional time management strategies like the EDM and time blocking, educators can conserve space for teaching while addressing the drivers of burnout. These strategies may be especially beneficial in ophthalmology and other high-volume specialties, where the tension between productivity and education is acute (19,24). This combined approach of EDM and time blocking supports not only the workflow, but also the dynamic of teaching (and learning) in a clinical setting—incorporating pre-clinic preparation, in-clinic training, and post-clinic reflection.

Pre-clinic preparation

Pre-clinic preparation involves pre-charting with a purpose, where each learner is given 2–3 patients per day to thoroughly pre-chart each case, and prepare for the next day’s clinic. This encourages intentionality, depth of learning, and confidence, where they can then engage in peer-teaching with the other learners the following day. Each morning, the learners and educators hold a “morning report”, which discusses cases from the previous day. The other learners can then read about the patients discussed, allowing everyone on the team to become familiar with every case, ensuring shared learning as well as consistent knowledge throughout the team.

In-clinic training

During clinic, a physician educator can reserve teaching moments for quick observations or short demonstrations that do not disrupt the flow of clinic. By intentionally deferring more detailed discussions to the next day’s morning report, we can avoid disruptions to scheduling and also plan for the next day’s post-encounter teaching. During each patient encounter, feedback is integrated into the clinical care process, where learners receive feedback in real-time in the context of patient education and clinical care (e.g., aphorisms like “don’t do that” or using our teaching time to teach both the patient and the learner, “let us look at the algorithm for this clinical presentation”). This approach simultaneously educates both the patient and the learner, focusing on the care plan instead of learner-specific performance. One way that a physician educator can explicitly model clinical reasoning and rationale for their decisions is in the live dictation with the patient in the exam room at the end of the visit. This method serves as an effective educational tool for both the patient and the learner, elucidating the differential diagnosis, management, and treatment plan to the patient while also articulating structured clinical reasoning that benefits the learner.

Post-clinic reflection

The teaching and learning process continues the following day in the post-clinic review at morning report. This method of longitudinal teaching highlights academic and clinical integration and allows for discussion of case-follow-ups for the learners before clinic begins. Each learner can be given a case from the morning report meeting that they will then present at weekly ophthalmology grand rounds—attended by medical students, residents, and fellows. This repetition within an organized framework strengthens understanding of critical information, encourages peer learning and discussion, and fosters interdisciplinary engagement. Notably, this process serves as a practice for the learner who can then produce a scholarly outcome—such as a case report and/or Eye Wiki—that promotes academic development and supports future endeavors (such as mentorship) for the learner. One of the ways in which a physician educator may incorporate wellness and exercise into their routine is by post-charting on the treadmill for virtual daily morning report before clinic starts for the day. Learners also benefit from preparation time at home (after a break and dinner) and get to “sleep on it” to help consolidate learning from both the in-clinic setting and the at-home learning (homework in preparation for morning report the next day). Figure 2 visualizes the key challenges and countermeasures discussed in this manuscript.

Figure 2 Key challenges and countermeasures.

Inspiring the next generation

Studies have proven that mentorship and building meaningful connections in medicine benefits not only the mentee, but also the mentor (9). These relationships enhance the learner’s performance in the clinical setting, reduce burnout among mentors and mentees, and foster long-term engagement in future mentorship roles for former students. Either directly or indirectly from their mentors, students can learn these teaching strategies that will help support a sustainable legacy of teaching for the future. Through observation and structured feedback, mentees can be inspired to adopt these teaching practices and carry them forward, supporting future generations of learners. This legacy cultivates a sense of purpose in academic medicine and contributes to improved scholarly and clinical outcomes.

While actively making time for self-care—such as regular exercise, sufficient sleep, and maintaining work-life balance—can be difficult, it becomes far more manageable with thoughtful approaches like the EDM and time blocking. Delegating appropriately and incorporating high-quality teaching methods can simultaneously encourage learner engagement and alleviate physician educator workload. Finding a balance between the roles of physician, mentor, and educator can be both challenging and deeply fulfilling. We hope that these practical strategies (pre-chart with purpose, hypothesis generating/testing, closing the loop with post-charting and morning report) will empower physician educators to approach mentorship with more defined purpose, structure, and strategy. A strategic, deliberate, intentional, and planned approach to daily mentoring may allow us to contribute meaningfully to the future of medicine, shaping how the next generation of physicians will practice, teach, and lead.

Conclusions

In summary, optimizing teaching efficiency in the clinical environment requires a deliberate balance between mentorship, feedback, and structured time-management strategies. By incorporating practices such as purposeful pre-charting, hypothesis-driven clinical reasoning, and systematic reflection, physician educators can create sustainable learning environments that support both learner growth and mentor well-being. Practical tools like the EDM and time blocking not only protect against burnout but also safeguard time for academic and personal fulfillment. Investing in these approaches empowers clinical educators to foster the next generation of ophthalmologists, cultivate meaningful mentorship, and contribute to healthier, more resilient healthcare systems.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Eye Science for the series “Special Consideration for Teaching and Learning in Neuro-Ophthalmology”. The article has undergone external peer review.

Peer Review File: Available at https://aes.amegroups.com/article/view/10.21037/aes-25-34/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aes.amegroups.com/article/view/10.21037/aes-25-34/coif). The series “Special Consideration for Teaching and Learning in Neuro-Ophthalmology” was commissioned by the editorial office without any funding or sponsorship. A.G.L. served as the unpaid Guest Editor of the series and serves as an unpaid editorial board member of Annals of Eye Science from June 2024 to December 2026. A.G.L. received consulting fees from National Aeronautics and Space Administration (NASA), the National Football League (NFL), Amgen, AstraZeneca, Bristol-Myers Squibb, Alexion, Stoke, Ethyreal, Catalyst, Dompe, and Viridian, and received payment to his institution for expert testimony from Lawyers. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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