Professionalism in Ophthalmology - PowerPoint Presentation

Slide1

Professionalism in Ophthalmology

Dr

Michael Williams

Slide2

Professionalism session

Why have this session on professionalism?

Hopefully

this session is…

- something

on which you can reflect

-

eportfolios

are here to stay in your lives!

- something of interest

- hopefully!

- something of

relevance

- touching on issues you’ll encounter with patients, relatives and your friends every week

Slide3

Is your role merely to provide technically competent care?

- What is professionalism?

- Should professionalism be taught to medical students?- How should professionalism be taught to medical students?Please discuss!

Slide4

What

is professionalism

?A pithy definition is always a good start!“The total of values, behaviours and relationships which justifies and supportsthe trust of people in doctors”Dutch Medical Association

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What

is professionalism

?How you relate to patientsHow you relate to yourselves- e.g. do you maintain a good work-life balance, with outside interests?How you relate to taskse.g. do you get your eportfolio filled in to the satisfaction of the NIMDTA Training Committee?

e

.g. do you turn up on time for CESC sessions?

Slide6

Communication is an aspect of being professional

Who is this in the photo?

He wrote the book “Blink”, which refers to the study belowThe Relationship With Malpractice Claims Among Primary Care Physicians and Surgeons. Wendy Levinson et al. JAMA.

1997;277(7):553-

559

Investigators were played content neutral

audioclips

of doctor-patient consultations. Half the doctors had been sued, half hadn’t.

Could the investigators predict who?

Slide7

Orientating the patient as to what to expect

Inviting the patient’s opinions

Checking understandingEncouraging patient to contributeUsing humour

Taking more time

Of course they could!

Below are features of the communications styles associated with

not

being sued.

This gives us an idea of what patients value in a consultation.

Slide8

So – what a

spects

of vision are important for driving?Four needed from the group before we move on!

Slide9

Aspects of vision important for driving

- visual acuity - visual fields - contrast sensitivity - glare - twilight vision

Slide10

Driving standards for vision

- defined in law - this takes the decision away from the doctor, which helps maintain the doctor-patient relationship - good vision essential for driving - obviously! - given the visual standards, most accidents are caused by age (young or old), alcohol, distraction, inexperience - difficult to

study

- can’t do a prospective trial of crash risk comparing those with poor vision and those with good vision…

- in most countries RTA data can’t be linked with medical records for administrative reasons, which hampers research on this

- driving simulators are the best method

Slide11

Who is responsible for what

with regard to vision and driving…

?If your patient doesn’t meet the visual standards for driving, should you tell the driving authorities?If so, when?Speaker notes: students often disagree with the position the law takes on this – that’s interesting, as its today’s students who will be making the law / advising the government in 20 years

Slide12

Who is responsible for what?

-

drivers should self-report and that means: - any health issue which may affect their ability to drive - as soon as they can, not at the time of license renewal - doctors

-

should

keep

up with legal standards / guidance

- be prepared to advise patients clearly

- and document clearly and at the time

- but patient confidentiality should be respected

Slide13

What happens when a patient refuses

to accept advice being given?

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What happens when a patient refuses

to accept advice being given?

- be open and straightforward - try hard to persuade - warn the patient you may have to inform the DVLNI - and if needed after several warnings – inform the authorities

-

but be open: copy

the patient into any

correspondance

Slide15

The GMC’s guidance on confidentiality.

“Personal

information may, therefore, be disclosed in the public interest, without patients’ consent, and in exceptional cases where patients have withheld consent, if the benefits to an individual or to society of the disclosure outweigh both the public and the patient’s interest in keeping the information confidential. “

Slide16

Conundrums:

can you drive…

- with an eye pad on? - eg been gardening – soil in the eye – removed at Casualty – eye pad on overnight - after pupillary

dilatation?

Slide17

Conundrums

- driving with an eye pad onStrictly speaking no – as there’s been no time for monocular adaptation - after pupillary dilatationMost will be within legal limits, but wise not to drive as glare and dazzle likely to be a problem

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Driving standards –

G

roup One drivers (car / motorcycle)Visual acuity“…the visual acuity (with the aid of glasses or contact lenses if worn) must be at least 6/12 (Snellen decimal 0.5) with both eyes open, or in the only eye if

monocular”

Slide19

Driving standards –

Group One drivers

(car / motorcycle)Visual fields“Must have a visual field of at least120 on the horizontal;

the

extension should be at least 50 left and

right.

In

addition, there should be no significant defect in the binocular field which encroaches within 20° of fixation above or below the horizontal

meridian.”

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How would you describe these visual field (VF) defects?

To describe any VF defect, there is a small bank of words you just need to slot into position

Are these patients likely to meet the VF driving criteria?While we’re at it, what causes these VF defects?

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Driving - unlikely to meet the criteria for driving

- exceptionality may occur,

eg an adult with a lifelong VF defect from childhood brain surgery, to which the patient has adapted On your left is a

homonymous hemianopia

- these are due to a lesion of the posterior visual pathway

- depending on the clinical picture, think demyelination in a younger patient, stroke in an older patient and “SOL” (doesn’t just mean

tumour – other SOLs exist) at any ageOn your right is

a

bitemporal

hemianopia

- like a primitive reflex, this should make you think…

“optic chiasm compression – most common cause is pituitary adenoma –

investigation of choice is CT or MRI of head”

Slide22

Esterman

binocular visual

field- The DVLNI specifies this VF test as the legally acceptable test- Acceptable central loss is: scattered missed points or a cluster of up to three points missed- The width measurement can ignore a cluster of up to three points, or a vertical defect one point wide that happens to cross the vertical meridian- Its OK to repeat the test if the patient ‘fails’, and wants a retest

Slide23

Driving standards – group one vehicles (car / motorcycle

)

Can someone drive legally in the following circumstances?Monocular visionCataractDiplopiaNight blindnessColour blindnessBlepharospasm

– what is this?

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Monocular vision

- must a) inform the authorities, b) meet the legal standards, & c) had sufficient time to adapt – but yesCataract - must meet the legal standards, but yes though care is warranted as glare with oncoming car headlights a common symptom of cataractDiplopia - must cease driving till the diplopia is adequately controlled with a prism or glasses that must be worn when drivingNight blindness

-

eg

RP, advanced glaucoma, lots of PRP

(speaker’s notes: explain!)

, must meet the legal standards but cases are considered on an individual basis

Colour blindness

- this is no bar to drive and the authorities need not be informed

Blepharospasm

- yes if mild & treated with

BoTox

, but if severe, even if treated – usually no

Slide25

Motorcycle and car

drivers

Bus, coach, lorry and taxi driversJust so you know, different standards apply ifyou’re ferrying members of the public - Visual acuity (Snellen):

At least 6/7.5 in best eye

At least 6/60 in other eye

Glasses no stronger than +8D

- Visual fields: Horizontal visual field of at least 160 degrees

E

xtension

should be at least

70

0

left

and right and

30

0

up

and

down

No

defects should be present within a radius of the central

30

0

Slide26

Now for something completely

different

Consent – does the patient know what they’re in for?

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Consent – does the patient know what they’re in for

?

Note:Treating someone without their consent may be seen as assualt and battery even if they were helped by your actionsThe four principles of consent are: - what?

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Consent – does the patient know what they’re in for

?

The four principles are:AutonomyBeneficenceNon-maleficenceEquality

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Consent – does the patient know what they’re in for?

Consent should be given…

- voluntarily - i.e. without deceit or coercion - by someone who - has capacity - i.e. the patient a) can comprehend the info, b) can retain the info, c) can weigh up the info and d) can communicate their decision (by any means, even by blinking)

- and is fully

informed

- i.e. knows a) how necessary the procedure is, b) what alternatives exist and c) what common or serious complications can occur

Slide30

Can you name s

ituations

when examination can proceed even if a patient refuses consent…?Speaker’s notes: bet the students won’t be able to name these,but they are quite interesting

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Situations when examination can proceed even if a patient refuses consent

:

- psychiatric examination / treatment - examination of patients with a psychiatric disorder can occur without their consent under the Mental Health Act 2007 - patients with a notifiable disease - with a Magistrate’s

O

rder, such a patient can be examined

- new

prisoners

- can be examined to exclude an infectious disease

- members of the armed

forces

- can undergo routine medical examination without their consent

- immigrants

- can be examined by port and airport medical staff in the UK without the patient’s consent

Slide32

The patient on your left is 15 years old, and refuses treatment.

What is the legal position?

The patient whose photo is on the right presents to you acute painless loss of vision. He is 80 years old.What is the diagnosis? What is the legal position?

Slide33

- The law defines anyone under 18y as a child

- In practice anyone aged 16 or more can be assumed to have capacity

- Below 16y, they can be judged to have capacity if they are “Gillick competent”, although historically this refers specifically to the patient’s ability to understand the moral aspects of a situation- If not Gillick

competent, the decision can be made by the legal guardian, though this can be overruled by a court.

Any examples of when this might occur?

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Patients can refuse to consent for treatment, but they need to have capacity. Their reasons can be logical, non-logical or they can have no reason at all, as long as they are judged to be competent.

So the 80yo with

…..what diagnosis was that…..? can refuse likely sight-saving treatment if he is judged to be competent

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Patients can refuse to consent for treatment, but they need to have capacity. Their reasons can be logical, non-logical or they can have no reason at all, as long as they are judged to be competent.

So the 80yo with acute angle closure glaucoma can refuse likely sight-saving treatment if he is judged to be competent

Slide36

Many

thanks for listening / reading.