Rcophth Essay Prize for Foundation Doctors

RCOphth Essay Prize for Foundation Doctors

‘Which elements of ophthalmology would you embed in the Foundation Curriculum?’

William Foulsham

October 2015

The Academy of Medical Royal Colleges’ curriculum document emphasises that the Foundation Programme is the only period of medical training ‘which is common to all United Kingdom medical students and doctors’.(1)The two-yearscheme represents a vital period of clinical and personal development in which trainees are exposed to a wide range of clinical environments, and make key decisions about their future careers. When considering the elements of ophthalmology that should be embedded with the Foundation curriculum, we must first answer a more fundamental question – we must define what we want the Foundation Programme to achieve for ophthalmology.

This paper proposes two objectives for the curriculum with respect to ophthalmology:

i.)Train recently graduated doctors to develop the skills necessary to safely diagnose and manage acute and long-term ophthalmological conditions in a primary care setting

ii.)Increase exposure to ophthalmology in order to inform career choice

This first objective recognises that the majority of doctors progressing through the Foundation Programme will not become ophthalmologists. The largest proportion will become general practitioners (GPs); many others will work in hospital in medical and surgical specialties. For this reason, it is crucial that the Foundation Programme equips trainee doctors with the ophthalmological skills and knowledge that are necessary to practice safely in a primary care setting. This will involve an understanding of common chronic ophthalmological conditions and their management, and also how to recognise ‘red flag’ signs and symptoms requiring urgent specialist referral.

The second objective acknowledges that medical students often receive minimal exposure to ophthalmology during their undergraduate careers - usually about two weeks’ clinical teaching.(2) The Foundation Programme curriculum provides an opportunity to increase trainee doctors’ exposure to ophthalmology, and potentially to excite and inspire them about thebroad range of medical knowledge and surgical skill involved in ophthalmology.By these means, it may be possible to encourage a broader group of Foundation doctors to apply for specialty training, thereby promoting greater diversity within the profession.

Much of the curriculum document describes good practice in general, and these outcomes are as applicable to ophthalmology as they are to all clinical specialties. Ophthalmologists should behave appropriately in the workplace, develop time management skills, work as a team, become leaders, cultivate good communication skills, engage in lifelong learning etc. Let us consider some of these generic competencies in more detail, in order to understand how they might specifically relate to ophthalmology. Outcome 10.1 of the document states that Foundation doctors should ‘accurately re-prescribe long-term medications checking for side-effects and significant interactions in the context of the current illness’. Furthermore, it states that doctors should ‘manage long-term conditions during episodes of acute care’.(1)Studies have demonstrated that inpatients on non-ophthalmic wards with regular eye drop medications often have these medications overlooked or incorrectly prescribed. At a tertiary referral centre in the West Midlands, Masri and Robinson found that 18 of 31 identified glaucoma patients (58%) did not have their glaucoma drops prescribed.(3)In a prospective study of 55 inpatients in two teaching hospitals in Glasgow, Chong and Murdoch found that 40 of 55 patients (73%) with regular eye drops had their ocular treatment either inaccurately prescribed or not prescribed at all.(4)These results highlight a need for improvement – a need that might be addressed by explicating the importance of ophthalmic medications in the curriculum. In the age of electronic medical records, the most likely reason for the omission or incorrect prescription of eye drops is a lack of familiarity of the trainee doctor with the drops, and a lack of awareness of the importance of drops in a chronic condition such as glaucoma. The unique opportunity to educate doctors regarding these points during the Foundation Programme should not be missed – otherwise we risk perpetuating bad prescribing habits in both the hospital and primary care settings.

Outcome 10.5 states that the Foundation trainee should ‘recognise and use opportunities to prevent diseases and promote heath’.(1) The examples of breast, cervical and bowel screening programs are given. With an eligible population of all people with either Type 1 or Type 2 diabetes over the age of 12, the NHS diabetic eye-screening (DES) programme should also be noted in this list. In 2014 Liew, Michaelides and Bunce demonstrated that, for the first time in at least five decades, diabetic retinopathy/maculopathy is no longer the leading cause of certifiable blindness among working age adults in England and Wales.(5) Inherited retinal disorders are now the main cause of blindness certifications. With the prevalence of diabetes increasing, we may have expected to see similar increases in blindness secondary to diabetic eye disease. The divergence of the prevalence of diabetes and diabetic retinopathy/maculopathy is explained by the NHS DES programme and by improved glycaemic control. An awareness of the target population and an understanding of the preventative action that can be taken to stop diabetic eye disease progressing is relevant to the majority of doctors practicing in the UK.

There are 224,000 people with severe sight loss in the UK. Furthermore, there are almost 2 million people with sight loss that has a significant impact on their daily lives.(6) Visual impairment presents significant challenges to the provision of medical care in both hospital and community settings. In hospitals, visual impairment has been shown to be a significant risk factor for falls amongst elderly inpatients.(7)Visually impaired inpatients have specific nursing needs, often requiring greater assistance with eating, drinking and mobilising about the wards. These patients are often disorientated having been placed in an unfamiliar environment. Activities of daily living present challenges for visually impaired people, who report greater difficulty with these tasks than individuals with no sensory impairment.(8) In the community, people who experience sight loss have reduced psychological wellbeing and greater social withdrawal.(9) Visually impaired individuals are at greater risk of cognitive and functional decline.(10) Healthcare professionals need to develop an awareness and anticipation of the needs of visually impaired individuals in order to provide care that is tailored to their needs.Outcome 10.1 of the Foundation Curriculum states the importance of ‘recognising co-morbidity and its effects on in-patient and community care’.(1)In a population in which the prevalence of visual impairment is increasing, we should take every opportunity to increase the awareness of the specific needs of this population.

One in fifty GP consultations relates to eye, equating to about four cases seen by a GP each week.(11)Despite the high volume of presentations, a survey of more than eight thousand general practitioners revealed that 10% of respondents were ‘scared stiff’ of the eye.(12) The majority (68%) admitted that they had ‘some uncertainties’ about the eye. A lack of confidence has also been highlighted amongst doctors working in Emergency departments, with over two thirds of doctors reporting little to no confidence in dealing with eye emergencies.(13)Direct ophthalmoscopy is an important physical examination tool that can be used to identify pathological optic cupping, optic disc oedema, AV nicking, cotton wool spots, emboli and infarcts. Direct ophthalmoscopy allows GPs and emergency physicians to identify signs of potentially life-threatening conditions such as papilloedema due to a cerebral space-occupying lesion. Furthermore, it empowers these doctors to differentiate between those causes of acute, painless loss of vision that need expert care immediately (e.g. central retinal artery occlusion) from those do not (e.g. central retinal vein occlusion). Ophthalmologists have expressed concerns about witnessing ‘mistakes in referral or assessment by non-specialists – errors whose root cause is the inadequate training at the undergraduate level, where an irretrievable attitude of passivity to ophthalmology is ingrained’.(14)It is encouraging to see some evidence of resistance to this trend. For example, direct ophthalmoscopy was included as one of the ‘Stanford 25’ – a selection of general medical examination skills essential to physical diagnosis and promoted globally.(15) In the interest of upholding basic ophthalmic knowledge and skills amongst Foundation doctors, direct ophthalmoscopy should be included as one of the procedures listed in Section 12 of the curriculum.Funduscopy also provides a mechanism for trainees to reacquaint themselves with the diverse range of ophthalmic pathology, and the notion of the retina being a window to the brain – these are ideas that may excite the trainee doctor and promote the consideration of ophthalmology as a career choice.

The Foundation Programme curriculum provides a unique opportunity to shape the professional development of trainee doctors in the UK. I have argued that the curriculum should achieve two goals with respect to ophthalmology, and I have suggested specific strategies as to how they might be achieved.

References

1. NHS. The Foundation Programme Curriculum [Internet]. 2012 [cited 2015 Feb 25]. Available from:

2. Shuttleworth GN, Marsh GW. How effective is undergraduate and postgraduate teaching in ophthalmology? Eye. 1997 Sep;11(5):744–50.

3. Masri I, Robinson R. Glaucoma medication ignored in general medical and surgical patients. JRSM Short Rep. 2010 Jan;1(1):16.

4. Chong NH, Murdoch JR. Is ophthalmic therapy often overlooked in hospital wards? J R Soc Med. 1993 Oct;86(10):569–70.

5. Liew G, Michaelides M, Bunce C. A comparison of the causes of blindness certifications in England and Wales in working age adults (16-64 years), 1999-2000 with 2009-2010. BMJ Open. 2014 Jan;4(2):e004015.

6. Economics A. Future sight loss UK 1: Economic Impact of Partial Sight and Blindness in the UK adult population. RNIB. 2009. Available from:

7. Oliver D, Britton M, Seed P, Martin FC, Hopper AH. Development and evaluation of evidence based risk assessment tool (STRATIFY) to predict which elderly inpatients will fall: case-control and cohort studies. BMJ. 1997 Oct 25;315(7115):1049–53.

8. Crews JE, Campbell VA. Vision impairment and hearing loss among community-dwelling older Americans: implications for health and functioning. Am J Public Health. 2004 May;94(5):823–9.

9. Thurston M, Thurston A, McLeod J. Socio-emotional effects of the transition from sight to blindness. Br J Vis Impair. 2010 May 17;28(2):90–112.

10. Lin MY, Gutierrez PR, Stone KL, Yaffe K, Ensrud KE, Fink HA, et al. Vision impairment and combined vision and hearing impairment predict cognitive and functional decline in older women. J Am Geriatr Soc. 2004 Dec;52(12):1996–2002.

11. Morrell DC. Expressions of morbidity in general practice. Br Med J. 1971 May 22;2(5759):454–8.

12. Wilson A. The red eye: a general practice survey. J R Coll Gen Pract. 1987 Feb;37(295):62–4.

13. Tan MM, Driscoll PA, Marsden JE. Management of eye emergencies in the accident and emergency department by senior house officers: a national survey. Emerg Med J. 1997 May 1;14(3):157–8.

14. Yusuf IH, Salmon JF, Patel CK. Direct ophthalmoscopy should be taught to undergraduate medical students—yes. Eye. Royal College of Ophthalmologists; 2015 Jun 5;29(8):987–9.

15. Verghese A, Horwitz RI. In praise of the physical examination. BMJ. 2009 Jan;339:b5448. Available from:

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William Foulsham