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Are junior doctors in today's NHS competent in managing ophthalmic cases in the emergency department?

Sir,

In a 2003 national survey of the management of eye emergencies in the accident and emergency department, Sim et al1 found that 63.9% of senior house officers in the UK had little or no confidence in dealing with ophthalmic cases. Surprisingly, this proportion was unchanged from a previous similar national survey conducted by Tan et al2 in 1993, despite the significantly higher availability of slit lamps in the departments and increased training on their use. Furthermore, there was no significant difference in the prevalence of training in the management of eye emergencies between the two studies. Hence, Sim et al rightly pointed out that the shift to a more competency-based training brought about by Modernising Medical Careers (MMC) could serve as a platform to enhance confidence and competence in managing ophthalmic emergencies. However, to our knowledge, there is no recent national survey similar to the aforementioned surveys, which begs the question: has anything changed over a decade on?

The introduction of MMC and the European Working Time Directive (EWTD) has lead to many inexperienced foundation year 2 trainees having to deal with ophthalmic cases.3 Given the relative frequency of ophthalmic presentations to the emergency department, this points to the fact that suboptimal care is unacceptable, just like it would be for an acute cardiac presentation. Several identified issues have contributed to the poor confidence of junior doctors in dealing with eye emergencies. First, the deficit in basic ophthalmic training can be traced back to the undergraduate years where ophthalmology education is very limited owing to increased emphasis on core specialties and soft skills such as communication skills. Second, there is a lack of formal structured teaching of junior doctors in managing ophthalmic presentations to the emergency department, including the use of slit lamps or fluorescein staining, owing to time constraints and variable shift patterns. Third, there is no general consensus on the baseline core ophthalmic competencies expected of junior doctors allocated to a four month A&E rotation. Furthermore, there is no clear national guidance or protocol on the management of ophthalmic presentations in the different departments across the country.

In conclusion, we believe that a national survey is required to assess the current state of ophthalmic care delivered by junior doctors in the emergency department. Findings from the survey would form a basis for the need for a higher investment in resources, including finances and manpower, and organizational changes on a national level to improve ophthalmology training and supervision in the emergency department. This will ultimately ensure optimal ophthalmic care but also reduce out-of-hours ophthalmic workload in the department.

References

  1. Sim D, Hussain A, Tebbal A, Daly S, Pringle E, Ionides A . National survey of the management of eye emergencies in the accident and emergency departments by senior house officers: 10 years on—has anything changed? Emerg Med J 2008; 25: 76–77.

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  2. Tan MM, Driscoll PA, Marsden JE . Management of eye emergencies in the accident and emergency department by senior house officers: A national survey. J Accid Emerg Med 1997; 14 (3): 157–158.

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  3. Patel N, Zia R, Dewitd D, Morris S, Ionides A . Early structured core training of junior trainees in ophthalmology. Postgrad Med J 2007; 83 (986): 738.

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Correspondence to E Y Ah-kee.

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Ah-kee, E., Scott, R., Shafi, A. et al. Are junior doctors in today's NHS competent in managing ophthalmic cases in the emergency department?. Eye 30, 164 (2016). https://doi.org/10.1038/eye.2015.193

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