All
ophthalmologists are medical practicioners. Their name appears on the
register of the GMC and they are subject to annual registration and
disciplinary procedures. The GMC recently also began to record
specialist, but not subspecialist training in the register.
Confusion
can arise due to differences in title. A medical student graduates with
a bachelors degree. He is “a doctor” in the public meaning of the term,
but has no academic right to this title unless he goes on to obtain an
MD or a PhD, which are both primarily research qualifications. An
optometrist graduates with a bachelor’s degree in science. He may go on
to obtain a PhD and be academically more entitled to use the term
“doctor” than a medical practicioner. In this situation he is called
“doctor” but is not a doctor in the public’s sense of the term.
The
ophthalmologist will go on to a period of higher surgical training and
become a Fellow of a Royal College (of Surgeons, or, more recently, of
Ophthalmologists). He will then have the right to revert to the term
“Mister”. This dates from the historical membership of surgeons to the
guild of barber surgeons, the Hippocratic oath expressely forbidding
physicians from participating in the barbarous practice of cutting a
patient. At some stage after passing the postgraduate exam he will be
awarded the CCST, or Certificate of Completion of Specialist Training,
and be eligible for appointment as an NHS consultant.
A
plethora of paramedical staff are involved in eye care. These are not
medical practicioners. They may work independently in the community,
where they are a valuable source of referrals to the ophthalmologist,
or as support workers in hospital-based services.
Not all
patients realise that an ophthalmologist is a medical practicioner, and
many patients believe that the paramedics are medically qualified.
There have been instances of the paramedics encouraging this belief.
Ophthalmic nurses. An
ophthalmic nurse is an RGN (Registered General Nurse) who has undergone
a six-month period of further specialist training (English Nursing
Board) in an approved eye unit. This training entitles her to carry out
certain tasks at the discretion of her employer, traditionally under
the supervision of the medical staff, but increasingly in an autonomous
capacity. In most modern eye units the nursing staff will carry out
triage of casualty patients, assess and counsel pre-operative patients,
carry out ophthalmic photography, ultrasound, clinical measurement and
sometimes fluorescein angiography.
Ophthalmic theatre nurses
undergo an additional period of training to assist and act as
technicians in the operating theatre environment.
In the USA,
the realisation that many of the skills of the general nurse are
redundant in ophthalmology has led to the development of the ophthalmic
assistant who have their own de novo training schemes. It remains to be
seen whether this trend will be adopted on this side of the Atlantic.
Optometrists and opticians. In
the UK there were traditionally two types of optician. The dispensing
optician was skilled in the trade of grinding lenses and making
spectacles. These have gradually declined in number as the
manufacturing process has become automated. The ophthalmic optician
could carry out an eye exam, refer patients to the GP when he detected
pathology, prescribe and fit contact lenses and spectacles. Many
ophthalmic opticians in this country prefer the American term
optometrist in order to avoid confusion with dispensing opticians.
There has been a trend in the USA for optometrists to become licensed
to prescribe medication and even carry out laser treatment, and there
are some optometrists in this country who would like their profession
to be granted the same privileges. While optometrists are not medically
trained, it has to be said that in general they are more informed about
eye disease than general medical practicioners. Nevertheless,
optometrists are required by law to refer any pathology that they
detect to the GP (9). The GP will almost always refer these patients to
the hospital eye services. This is a cumbersome system, which has the
dual effect of flooding clinics with insignificant conditions, and
introducing delays where a genuine situation of urgency exists.
Anecdotally, there are many optometrists, GP’s and ophthalmologists who
feel that optometrists should be able to refer directly ot the hospital
eye services..
Orthoptists Orthoptists were invented in
wartime, when it was believed that they could enhance pilots’ vision.
Nowadays they function in two roles. In the community they carry out
visual screening of children and in the hospital eye service they treat
children with amblyopia (lazy eye) and adults with double vision. They
are generally excellent at the complex business of assessing the visual
function of children; they function semi-autonomously and generally
know when the patient needs the attention of the ophthalmologist.
How does ophthalmology relate to primary care and other medical specialties? The
patient with an eye complaint will usually present to their optometrist
or general practicioner. A few present to accident and emergency or to
eye casualty services. The fate of the patient depends on the
knowledge and ability of the professional to whom they present and the
provision of ophthalmic expertise available locally.
For reasons
discussed in Part 1, GP’s often feel uncomfortable in the diagnosis of
eye disorders. This is very variable, some medical schools having a
more exhaustive undergraduate emphasis on training in ophthalmology and
some GP’s having spent a period in training as a junior doctor in an
eye department. GP’s will often lack the equipment necessary to
adequately examine the eyes (3). One would hope that on the basis of
serious symptoms (sudden loss of vision, painful red eye) urgent
referral to an ophthalmologist would take place. Problems arise when
loss of vision is more gradual and less dramatic, yet underlying eye
disease is still present.
Optometrists are generally very
conscientious in eliciting signs of eye disease, and problems generally
arise when delay occurs because they cannot refer directly to the
hospital eye service.
In some areas, eye casualty provides a
self-referral service for patients with eye symptoms. Problems have
arisen in recent years because emergency services are not remunerated
to the same extent as elective GP referrals and therefore have tended
to suffer attrition of resources by hospital managers.
Finally,
a number of patients are referred by other hospital specialists such as
the diabetic physician, the endocrinologist or the neurologist.
Political factors affecting the provision of subspecialised eye services. The
realisation of the ideal that all eye units have staff who are trained
in all the subspecialties is constrained by resourcing issues. This is
particularly true in small one, two or three man eye units, where the
problem may be solved by doubling-up of special interests or the
formation of partnerships between neighbouring eye units with
complimentary special interests. It is important that clear
arrangements for emergency care are made when staff with the relevant
expertise are absent on leave and that remaining staff do not feel
pressurised to “have a go”. Before the formation of NHS Trusts it was
not uncommon for patients to be sent the length of the country to a
consultant with the necessary expertise to advise on their treatment.
This is seen less nowadays, partly because trusts are emphasising the
importance of having the relevant subspecialties represented “in
house”, but partly because there are financial or performance factors
which deter referral for second opinions. It must be remembered that
there are some conditions, such as ocular tumours, which are so rare
that there are only a handful of consultants in the country who are
experienced in their management.
What should the legal professional look for in an ophthalmological negligence case?
As
in all cases of potential negligence, the first step is to examine the
chronology and the chain of events, looking for delays, misdirections
and actions inappropriate to the training of the individuals involved.
Applying the Bolam principle to the players involved in the
ophthalmology scene, an optometrist would be expected to carry out a
full examination and refer immediately to the GP. The GP might not be
expected to conduct a full eye exam, but would be expected to recognise
the significance of key symptoms and make appropriate referral. The
availability of ophthalmic emergency services locally would influence
the fate of the referral. In the past this might shift responsibility
for an incident to the local provider, but the recent White Paper may
shift the responsibility to the purchaser of services (PCG) to ensure
that such areas are adequately covered (10).
Once the patient
arrives in the hospital sector, it is worth examining in detail who
dealt with them – nurse, trainee doctor, orthoptist, consultant etc.
Was the first point of contact adequately trained and supervised? Was
the consultant (11) involved in the surgery? Was the consultant
adequately trained in the subspecialty area of the patient’s complaint?
Was he adequately supported in the provision of those services? If the
patient came to surgery, was the anaesthetic administered by a member
of staff trained in ophthalmic anaesthesia? Were eye-trained theatre
staff available to assist? There is now some evidence, for example,
that outcome is not adversely affected by delaying retinal surgery (12)
until appropriate facilities are available. Could better care have been
provided by transferring the patient to another more specialised unit,
or would transfer or delay have prejudiced the outcome?
What should the legal professional look for in obtaining an ophthalmological opinion?
An
ophthalmological opinion will as a bare minimum be a registered medical
practicioner, whose name is on the specialist register and who is a
Fellow of the Royal College of Ophthalmologists (FRCOphth) or one of
the Royal Colleges of Surgeons (FRCS).
The most crucial step in
obtaining an appropriate opinion is to identify the subspecialty within
which the patient’s complaint lies.
A subspecialist will have
undergone a period of training of at least one and possibly two years
in an approved fellowship programme. Fellowship programmes are approved
by the Royal College of Ophthalmologists and the American Academy of
Ophthalmology.
He will be employed in a department which
recognises subspecialisation and will be actively involved in treating
patients with disorders falling within his area of expertise. A
doubling up of areas of subspecialty is credible, particularly in
smaller departments, but expertise claimed in several subspecialties
should be regarded as highly suspect. All practicioners in training are
required by the college to maintain a logbook of surgical procedures.
Many consultants maintain their logbooks throughout their professional
careers and with the advent of revalidation this is likely to become
compulsory. It is worth asking to see the logbook and determining to
what extent the witness is experienced in the procedure which has
allegedly gone wrong. Finally, it is worth checking that the witness
understands the importance of being totally objective and not using the
case to score points in situations of academic or personal rivalry.
Ophthalmology is a very small community, and there are opposing views
on how conditions should be treated in just about every area of
ophthalmology – even in cataract surgery one can find those who believe
that the modern technique of phacoemulsification is experimental
surgery, or those who believe that its alternative, extracapsular
surgery, is positively archaic.
There are organisations of
subspecialists which exist, often informally, to promote advances in
the field and the sharing of knowledge, and not primarily to provide
lists of expert witnesses. One reliable way of finding an expert is to
carry out a literature search through Medline and find the authors of
publications in the relevant subspecialties.
References (9) Opticians Act 1989. (10) Malpractice litigation 1: the law. Chapter 7 in Montgomery J. Health Care Law. Oxford University Press, 1997 p 181. (11) Snead MP, Scott JD. Results of primary retinal detachment surgery: a prospective audit. Eye 1998; 12: 750-751. (12) Hartz
AJ, Burton TC, Gottlieb MS, Mc Carty DJ, Williams DF, Prescott A, Klein
P. Outcome and cost analysis of scheduled versus emergency scleral
buckling surgery. Ophthalmology 1992; 99:1358-1363.
