Jennifer Utting MBChB, PGCert Clinical Education¹

¹Leeds Teaching Hospital Trust, West Yorkshire, UK

Introduction

Clinicians working in emergency medicine (EM), general practice (GP) and general medicine are frequently expected to review, assess and manage those presenting with ophthalmic complaints. They are in many instances the gatekeepers to accessing secondary ophthalmological care services. Often these clinicians have received only undergraduate teaching on ophthalmology and infrequently utilise their skills with ophthalmological equipment such as fundoscopes and rarely a slit lamp. Due to this, clinician confidence in managing ophthalmological issues is often poor (1,2).

Discussion

There is limited formal post-graduate ophthalmology teaching within existing training programmes including the UK foundation programme. For GPs, the Royal College of General Practitioners provides advice on e-learning only and Royal College of Emergency Medicine advises trainees to seek experiential learning for broader topics such as ophthalmology (3,4).  This leaves clinicians to rely upon knowledge and experiences gained through undergraduate training or seeking out additional self-directed study to inform their clinical practice. Despite the Royal College of Ophthalmology (RCOphth) setting out clear guidance on the knowledge and skills that undergraduates should leave their medical school education with, it is well known that this undergraduate training is varied and limited due to changing curriculum priorities (5,6). Increasing work-place pressures on clinicians also diminishes the experiential learning of clinical placement for many undergraduates.

Working in emergency medicine (EM), I witnessed first-hand that particularly junior clinicians lacked confidence in managing those presenting with ophthalmic conditions.  With support from EM and Ophthalmology seniors a teaching program was developed to tackle the discrepancy in desired versus held knowledge on relevant ophthalmology.

The teaching covered emergent aspects of the RCOphth curriculum and RCEM guidance focussing on common complaints seen in emergency departments:

• The red eye
• The painful eye (including acute close angle glaucoma)
• Sudden vision loss (including temporal arteritis)
• Pre-septal and orbital cellulitis
• Diplopia (including cranial nerve palsies)

Additionally, the session encouraged discussion on how to differentiate benign from emergent complaints with similar presentations, how to best undertake a thorough assessment with limited ophthalmological tools and the most beneficial initial management within the scope of the emergency department.

The aim was to improve clinician knowledge and thus confidence for those likely to see ocular issues in their daily practice. Qualitative data at the time of teaching indicated all participants felt lower levels of confidence in dealing with eye issues compared with other more mainstream elements of medicine and the post-teaching survey indicated an increase in knowledge and confidence.

With limited organised post-graduate teaching on ophthalmology, training centres are failing to prepare trainees to confidently and competently manage a key demographic attending primary and emergency care. It may be unrealistic to expect training programmes to introduce formal teaching on ophthalmology into training days but local ophthalmology and emergency departments could feasibly collaborate to deliver similar sessions, to that described above, on a cyclical basis to bridge the gap in knowledge and help improve clinician confidence and competence in ophthalmology.

Conclusion

There is a growing consensus that undergraduate ophthalmology teaching is not adequately preparing clinicians for managing patients with ophthalmic complaints. Although this would be best managed at university level by creating realistic and manageable curricula for medical students complimented by engaging and positive clinical attachments (7), this is a large-scale and time-consuming undertaking and would not mitigate the cohort of doctors who require input now to remedy their lacking undergraduate education. To address this, resources could be generated and collaboration sought from ophthalmologists to enhance the knowledge, confidence and competence of their EM, GP and general medical colleagues. This would be beneficial to ophthalmology departments as clinicians with better knowledge and skills are likely to generate better quality and fewer referrals, thus reducing the burden on ophthalmology services. 

References

1. Uhr JH, Governatori NJ, Zhang QE, et al. Training in and comfort with diagnosis and management of ophthalmic emergencies among emergency medicine physicians in the United States. [published online April 29, 2020] Eye (Lond). doi: 10.1038/s41433-020-0889-x. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7609324/  (Accessed January 24, 2023)
2. Gelston CD, Patnaik JL. Ophthalmology training and competency levels in care of patients with ophthalmic complaints in United States internal medicine, emergency medicine and family medicine residents. [published online August 29, 2019] J Educ Eval Health Prof. doi: 10.3352/jeehp.2019.16.25. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6748877/ (Accessed January 24, 2023)
3. Royal College of General Practitioners. GP Curriculum, Clinical topic guides. https://www.rcgp.org.uk/mrcgp-exams/gp-curriculum/clinical-topic-guides#eyes. Accessed January 23, 2023.
4. Royal College of Emergency Medicine. Curriculum. https://rcem.ac.uk/curriculum/. Accessed January 23, 2023.
5. Royal College of Ophthalmologist. Medical Students and Foundation Doctors. https://www.rcophth.ac.uk/our-work/ophthalmology-careers/medical-students-and-foundation-doctors/. Accessed January 23, 2023.
6. Scantling-Birch, Y., Naveed, H., Tollemache, N. et al. Is undergraduate ophthalmology teaching in the United Kingdom still fit for purpose?. [published online August 30, 2021] Eye (Lond) https://doi.org/10.1038/s41433-021-01756-y (Accessed January 24, 2023)
7. Utting J. Response to: ‘Is undergraduate ophthalmology teaching in the United Kingdom still fit for purpose?’. (published online August 24, 2023) Eye (Lond). doi: 10.1038/s41433-022-02212-1. https://www.nature.com/articles/s41433-022-02212-1 (Accessed January 25, 2023)