Introduction

Ophthalmic emergencies comprise of a significant portion of the workload in general accident and emergency (A&E) departments [1,2,3], accounting for about 6% of new casualty attendances [4]. Most of these (~69%) are minor in nature and can be managed adequately by non-ophthalmic doctors [4]. With annual attendance numbers for emergency eye care only set to increase in the future [5], the effective management of ophthalmic emergencies by non-ophthalmologists in general A&E departments plays a major role in reducing pressure on dedicated ophthalmic A&E departments and hospital eye services.

Due to the ever-increasing demands on A&E departments in the UK, most patients with eye problems are often seen by junior doctors [6, 7], a significant proportion of which consists of foundation year two doctors [FY2s, previously known as senior house officers (SHOs)] [8]. Despite the importance of junior doctors in this regard, two previous national surveys (1993 and 2003) have demonstrated a concerning lack of training and confidence in the management of eye emergencies amongst this cohort [9, 10].

A number of changes have been introduced since, perhaps most notably Modernising Medical Careers (MMC), a nationwide system introduced in 2005 to facilitate a more competency-based training programme for junior doctors [11]. It was hoped that these changes would serve as a platform to improve ophthalmic training and confidence for future generations of A&E doctors [10]. However, to date, there has been no study assessing the change in ophthalmic training and competence amongst A&E junior doctors since the most recent survey in 2003. The need for a national survey has also been echoed by the ophthalmology community in recent years [8, 12]. The main aim of this study was therefore to investigate if any changes have occurred over the last 15 years.

Methods

A prospective, combined online and telephone survey of all the A&E departments in the UK listed on the official National Health Service (NHS) directory was conducted [13,14,15,16]. This project was deemed exempt from NHS Research Ethics Committee review by the Imperial College London Joint Research Compliance Office. FY2s who were currently working in A&E departments were contacted for participation via social media and e-mail through foundation programme coordinators of individual UK foundation schools. Following this, two follow-up reminders were sent at a fortnightly interval to non-responding A&E departments. Remaining non-responding departments despite online reminders were subsequently contacted by telephone up to four times to improve response rate. Telephone surveys were conducted using a standardised interview script and participants were asked to provide answers over the phone. No additional assistance was provided. This survey was conducted over a 2-month period (October and November 2018) to ensure that all the FY2s had been in their A&E post for at least a month following the national annual changeover in August.

A 14-item questionnaire, adapted with slight modifications from a previously published version, was used (see Appendix 1) [9]. In brief, questions served to ascertain the level of training A&E FY2s receive with regard to management of ophthalmic emergencies, their self-perceived level of confidence in managing such cases and the availability of appropriate diagnostic equipment in A&E departments. Three additional questions about direct ophthalmoscopy were also added to the original questionnaire to explore its availability, training and FY2s’ confidence in its use. The main exclusion criteria were: (1) paediatric A&E departments, (2) A&E departments with a separate, dedicated eye casualty and (3) those that did not offer training posts for foundation doctors at the time of the survey. Data analysis was performed using IBM SPSS Statistics for Windows, version 23 (IBM Corp., Armonk, NY, USA). Data comparison with that of previous surveys was done using χ2 tests, with Bonferroni correction where appropriate.

Results

Two hundred and forty-seven A&E departments were identified from the official online NHS directory. After application of the exclusion criteria, 210 were contacted and 202 responded (response rate of 96.2%).

A total of 346 FY2s participated in the national survey, with a minimum of one FY2 per A&E department. Of these, 310 (87.6%) responded to the online survey and 36 (13.4%) to the follow-up telephone survey. Table 1 gives the full details and the results of the questionnaire used.

Table 1 Questionnaire and responses (n = 346)
Full size table

To allow comparison with the results of the previous surveys in 1993 and 2003 [9, 10], the response of one FY2 from each A&E department was chosen by selecting the first responder for each hospital (n = 202). Table 2 provides a summary and comparison of the main results from the 1993, 2003 and 2018 surveys.

Table 2 Summary and post hoc comparison of the main results between the surveys in 1993, 2003 and 2018
Full size table

Significant differences were detected for all the main results between the three surveys (Table 2). Post hoc analysis showed a significant reduction in the prevalence of training in the management of eye emergencies [45.5% in 2018 vs 77.4% in 2003 (p < 0.001) and 74% in 1993 (p < 0.001)] and proportion of A&E SHOs/FY2s who felt confident in the management of eye emergencies [6% in 2018 vs 36.1% in 2003 (p < 0.001) and 31.2% in 1993 (p < 0.001).

Although there was a significant increase in the availability of slit lamps since 1993 (79.7% in 2018 vs 57.8% in 1993; p < 0.001), no similar change was detected for the last 15 years (79.7% in 2018 vs 74.4% in 2003; p = 0.26). The prevalence of slit lamp teaching has significantly reduced since 2003 (52% in 2018 vs 68.4% in 2003; p = 0.003), approaching the level of that in 1993 (52% in 2018 vs 47.4% in 1993; p = 0.36). The proportion of A&E SHOs/FY2s who felt confident using the slit lamp has also seen a significant reduction [10.4% in 2018 vs 39.1% in 2003 (p < 0.001) and 27.6% in 1993 (p < 0.001)]. There was also a significant, stepwise decline in the proportion of A&E SHOs/FY2s who saw ≥3 eye cases on an average working day [31.2% in 2018 vs 45.1% in 2003 (p = 0.01) and 59.9% in 1993 (p < 0.001)].

Discussion

The demand for general A&E services have been rising steadily—by nearly half a million annually—for more than a decade since 2004 [17]. In addition to a growing and ageing population, the increasing demand for A&E services has also been attributed to a change in health seeking behaviour that occurred around the time [18]. The latter was mainly blamed on the change in the general practice (GP) out-of-hours contract in 2004 from which 90% of GP practices opted to sacrifice £6000 salary in order to give up responsibility for out-of-hours services, leading to the axing of a crucial provider of emergency care outside general A&E departments.

As ophthalmic emergencies account for a significant proportion (~6%) of the general A&E workload, the rise in the numbers of patients with such conditions will inevitably mirror that of general A&E attendances. This is indirectly corroborated by the increase in the numbers attending large dedicated walk-in eye casualty units over the last decade [5]. Based on first-hand anecdotal and published evidence, most patients with eye problems in general A&E departments in the UK are seen and managed by junior doctors, of which FY2s account for a significant proportion of the workforce [8].

Our follow-up survey in 2018 has demonstrated a worrying decline since 2003. In the 15 years that have passed, there has been a considerable reduction in the level of training that FY2s receive in the management of eye emergencies, with only less than half receiving some form of training during their time in A&E. Perhaps even more alarmingly is the drastic drop in confidence in the management of eye emergencies among this cohort, with more than 90% of FY2s reporting little or no confidence.

Despite the specific changes introduced by MMC in 2005, notably a competency-based Foundation Programme, these have not resulted in any improvement in the training and management of ophthalmic emergencies by A&E FY2s. Indeed, concerns have been raised about the inflexibility of MMC, with it being criticised as being a more rigid training system that often conflicted with the programme’s stated aims [19]. Nonetheless, the observed decline in our study is likely to be complex and multifactorial, involving local, regional and nationwide factors.

An important factor at a local level is undoubtedly the lack of exposure in medical school. Multiple studies have shown that medical students in the UK receive variable and often inadequate ophthalmic training, most of which does not meet the recommended International Council of Ophthalmologists standard [20,21,22,23]. At a regional level, this is further compounded by the lack of formal structured teaching for A&E junior doctors (as corroborated by our results), often owing to time constraints and fragmentation of rotas [12]. In addition, there is no clear definition of the baseline core ophthalmic competencies required of junior doctors in foundation training [12]. On a national level, there is evidence to suggest that the reduction of working hours and transition to a shift system via the implementation of European Working Time Directive in 2004 has impeded training for doctors [24,25,26]. This is also exacerbated by the increasing pressures on NHS services, which have been shown to have negatively impact junior doctors’ education and training [27].

There appears to be a gradual decline over the last 25 years in the number of eye cases seen by A&E junior doctors, as corroborated by the observed stepwise decline in the proportion of A&E FY2s/SHOs who saw ≥3 eye cases on an average working day in our study. Interestingly, a similar trend for non-ophthalmological conditions in general A&E has been demonstrated, with junior A&E doctors being recorded as seeing 17% fewer patients per hour over a 3-year period [28]. Reasons for this are likely to be multifold, with previous studies reporting factors such as general A&E junior doctors being slower and more cautious than before [28] and higher proportions of patients being managed entirely by nurse practitioners [29].

Although this study found an overall good access to and training in the use of direct ophthalmoscopy (a topic not explored by previous surveys), there was a concerning lack of confidence in its use with about 90% of FY2s reporting such an issue. This is not surprising given a similar climate reported in undergraduates [30, 31]. Given the fact that direct ophthalmoscopy is considered a fundamental competency of the Foundation Programme [32], our results may further attest the need for more strategic emphasis on direct ophthalmoscopy training for foundation doctors. Nonetheless, it should be recognised that there is still ongoing debate with mixed views from the ophthalmology community on the value of teaching direct ophthalmoscopy to non-ophthalmologists [33,34,35,36,37,38].

The main limitation of this study is the risk of overestimation of the scale of the problem. The comparison between SHOs previously and FY2s presently is likely to be unfair as the previous “SHO” definition likely included a wider range of training grade doctors who might feel more confident managing eye emergencies due to greater experience and more time in A&E. A&E experience for FY2s, by contrast, will commonly be limited to a single 4 month placement. Conversely, it is also possible that our findings have merely captured the “tip of the iceberg” and underestimate the true scale of the problem as other grades of A&E junior doctors were excluded. Future studies could administer the same survey to investigate if similar issues exist within other groups of primary care practitioners (e.g. GPs and community optometrists) at the forefront of emergency eye care. Given the emergence of nurse practitioners as independent frontline staff, it would be of interest to explore the scale of the shift from doctors to this cohort in the provision of emergency eye care in general A&E departments over the last few decades. Qualitative approaches via focus group interviews could also be employed to provide an in-depth understanding about junior doctors’ perception of the management of ophthalmic emergencies.

A continuation of this state of decline among A&E FY2s will have major implications for both general and dedicated ophthalmic A&E departments and may well perpetuate the decrease in training efforts, under-confidence in managing patients with eye conditions and lack of resources needed to support the real-world burden of eye disease looming just over the horizon. There is an urgent need for concerted and sustained efforts at a local, regional and national level to improve the situation. This should begin at the level of undergraduate education, for instance by embedding critical ophthalmic material and skills (e.g. slit lamp use) into the popular integrative multidisciplinary outcomes-based teaching model, thus complementing other disciplines and positively impacting patient care. On a wider scale, there is a need to push forward an agenda of higher investment in resources and innovative organisational changes to improve ophthalmic training for junior doctors in the UK.

Summary

What was known before

  • Ophthalmic conditions are generally approached with much apprehension by junior doctors in the A&E department.

  • This is corroborated by previous national surveys that have demonstrated a consistent lack of confidence and training in the management of ophthalmic emergencies among this cohort.

What this study adds

  • There has been a worrying decline since the last national survey; only less than half of FY2s in A&E received training in the management of eye emergencies.

  • But perhaps more concerning is the alarmingly low confidence in the management of eye emergencies among this cohort, with more than 90% A&E FY2s reporting little or no confidence.