Elinor Jones

Published statistics estimate that 6% of Emergency Department (ED) attendances and up to 2% of all General Practice (GP) consultations are eye-related (1). The majority of complaints are minor and can be managed by a non-ophthalmologist (2). Given the frequency of ophthalmic presentations, suboptimal care of these patients is unacceptable (3). In addition to this, eye complaints are often a presentation of disease in other body systems, further contributing to why patients present to general care services such as GP or ED (4). This stresses the need for junior doctors working in any department to have basic competence in the assessment and management of some ophthalmic conditions. Furthermore, many common eye pathologies such as macular degeneration, cataracts and glaucoma increase with age so doctors will be seeing these increasingly frequently in line with our ageing population (5).

UK medical schools are no longer required to include ophthalmology rotations in clinical attachments (4). The current state of ophthalmic education has sadly seen little improvement over the last few decades with studies 25 years ago also reflecting an inadequate system, resulting in general practitioners with poor confidence in looking after patients presenting to them (6). Scantling-Birch and colleagues go as far as to say that we have a current crisis in ophthalmic education (7), where we may be seeing non-ophthalmologists in medico-legally indefensible positions, unable to complete a basic examination (8). Declining exposure to ophthalmology and the issues relating to its undergraduate education are not limited to the UK; Mottow-Lippa discusses the similar decline in the United States and stresses that efforts from the profession are needed if we want to preserve doctors who are competent in basic ophthalmic examination (9).

Whilst most eye complaints presenting to non-ophthalmologists are benign, common presentations such as the red eye can also indicate a serious, sight-threatening pathology such as keratitis or acute glaucoma. Misdiagnosis or mismanagement can cause patient harm through delayed referral to ophthalmology. It’s recognised that the time and equipment needed to make certain ophthalmic diagnoses may not be available in primary care and therefore adequate knowledge of red flag symptoms is crucial (10), in addition to basic competence in ophthalmoscopy.

Direct ophthalmoscopy can indicate disease in other body systems, triage the urgency of ophthalmology referral and detect both sight and life-threatening pathology. Yusuf and colleagues argue that failing to prioritise the teaching of this skill to undergraduates could amount to negligence when considering the impact on patient care and suggest that a similar attitude would not be found to clinical skills in other specialties (8). The lack of undergraduate experience translates to postgraduate competence, where we are seeing 90% of junior doctors in ED reporting a lack of confidence in performing direct ophthalmoscopy (2).  The FOTO-ED study (11) found that only 14% of patients in which direct ophthalmoscopy was indicated had it carried out on presentation to ED. In patients where pathology was identified instead via fundus photography (33 patients), only 5 had direct ophthalmoscopy performed and, in all cases, it was incorrectly reported as normal. Junior doctors want more teaching in ophthalmoscopy and studies have shown nearly all doctors citing it as an important skill (12).

A contrasting view of some authors is that greater ophthalmic education should be prioritised over attempts to teach direct ophthalmoscopy to medical students, which may be unrealistic given the limited exposure to ophthalmology and lack of opportunities to maintain the skill through practice. Alternative approaches to identifying pathology may be suitable, such as utilising fundus photography rather than relying on direct ophthalmoscopy (13). Some suggest this would not solve the issue, however, as access to such equipment is not guaranteed in all areas and hours (14).  Furthermore, many doctors now work abroad for periods during their careers and therefore direct ophthalmoscopy may be more of a transferable skill due to its global use (15). 

There is suggestion in the literature that medical students are unsatisfied with their current exposure to the specialty. There are currently doctors graduating having had no exposure to ophthalmology (16). A survey of medical students who were allocated a clinical attachment (5 days on average) in the specialty shows that even then, the majority hope for greater exposure and a staggering 75% feel their undergraduate experience was inadequate. Competing pressures on arranging clinical placements may mean that integrating ophthalmology into other clinical attachments may be appropriate (4). Removing the specialty from undergraduate curricula threatens awareness of the specialty and teamworking and collaboration between specialists (15).

Not only is there a lack of undergraduate exposure but postgraduates are not afforded suitable education within settings such as ED due to irregular shift patterns and time pressures (3). A survey in 2003 found that 63.9% of Senior House Officers had little or no confidence in managing eye complaints (17). Unfortunately, this has deteriorated further, with a more recent survey of junior doctors working in ED in London finding that over 90% had little or no confidence in managing ophthalmic emergencies (2). Whilst there is a lack of data relating to diagnostic error of doctors working in ophthalmic emergencies (18), making objective assessment of quality of care challenging, the aforementioned literature suggests that the current system is not providing doctors with the level of education that they need or desire. Yusuf and colleagues summarise this, suggesting that that an “attitude of passivity to ophthalmology is ingrained” within our system, and we must strive for better (8). Whilst controversy exists on how to solve the issue, it is clear that further educational initiatives are needed (14).

References

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