Retinal Screener

Taking a Look Behind the Screens

Q. How many Retinal Screeners does it take to change a lightbulb?

A. Two. One to change the lightbulb, and one to move it to the side for the nasal view.

But that aside, here's a little anecdote I was lucky enough to hear today...

A small boy walks into his parents' bedroom late one night and finds them making love. He sees what they're doing, but decides to keep quiet, and creeps back out of the room without saying a word. The next morning at breakfast, his father calls him over and says "Son, I saw you come into the bedroom last night, and I was proud of your tact and discretion. As a reward, I'm giving you a pocket watch that my father gave to me". He hands his son a beautiful gold watch.

The next day at school, the boy shows the watch to his best friend, and recounts the story of how he got it. The friend is naturally impressed, and says "I'm going to try that myself!"

So the next night, the friend gets up and walks ino his parents' bedroom, where they too are making love. His father sees the boy at the foot of the bed and says "What do you want, son?". The boy replies "I want a watch". So his Dad says "Well, pull up a chair, but shut the door - there's a draught going straight up my backside".

I've cleaned that up considerably. The original was so fruity it would count as one of your five a day. But here's the real punchline:

That joke was told to me today by one of my patients, shortly after I'd administered the eye drops. I think he was trying to put me through as much pain as I'd put him through. I wouldn't mind, but he made the story last a good five minutes, and performed it as though he was doing an open mic slot at the Comedy Store. He even did the whole routine on his feet. I've never seen anyone take stand-up comedy so literally. I kept looking around for a red buzzer like they have on Britain's Got Talent.

But here's the second punchline:

The chap was 87, and my oldest patient of the day.

I don't know what they're putting in the water around here, but they need to stop before the man gets an agent. Whatever happened to pensioners who just sit quietly in a corner, dribbling?

It's interesting the things people choose to complain about. I had a patient today who was outraged that hospital transport had refused, for the third year running, to bring him to his retinopathy screening appointment. And why? Because he's perfectly able-bodied.

The man was only in his sixties, lived less than two miles from the hospital, and had the use of both legs. But that wasn't the issue. The issue, so he told me, was that he couldn't get a direct bus from his house to the hospital, and for us to expect him to change buses en route was completely unacceptable. So he'd been forced to get a taxi. The cost of which was an outrage. So every year, he'd tried to request hospital transport, they'd asked him about his mobility, he'd said he's fine thank you very much, and they'd put the phone down.

This was a man who wanted answers. As he said to me, "Why shouldn't I get hospital transport, just because I can walk?". It's a good question. I felt like offering to push him back to the waiting room in a wheelchair, just to save him the effort. But being a helpful sort of person, I chose instead to politely explain our policy on transport and travel expenses (which was essentially that you're not getting either), before offering some alternatives. I suggested that maybe next year he could ask a friend to drive him to the appointment. He looked at me stony-faced and said "I don't have any friends".

I didn't know quite what to say to that. The obvious reply was "I'm not surprised, the way you keep moaning", but I felt that wouldn't be professional. So instead I asked him to start reading from the top of the eye chart. The complaining continued right through the VA, the drops and the photos. If the man was being sponsored to moan, he'd have raised enough money to hire a chauffeur driven limo. Personally I was tempted to phone Travis Bickle.

To be honest, I don't think the chap would have been happy unless I'd offered him a lift home or given him a tenner for the taxi. And frankly I was tempted, just to shut him up. I think I'll arrange to pick him up myself next year.

Mr AngrySometimes I think my patients are being referred to me by Roger Hargreaves. In the past I've had Mr Happy, Mr Noisy, Mr Bump (complete with bandages) and Little Miss Awkward. In fact the only one I haven't met is Mr Tickle. Which is something of a relief. Today, however, I screened Mr Angry.

At the time, I was unaware of the drama which was unfolding in the waiting room. The first I knew was when I waved goodbye to a patient, and emerged from the consulting room to call my next victim. One of the receptionists promptly came running (literally) up to me, and took me straight back inside, where she told me what was going on. Apparently one of my patients, a man in his sixties, had arrived ten minutes late for his appointment, and immediately been abusive to one of the ladies on reception.

There were three different clinics taking place there this morning, so having established the patient's name, the receptionist asked him what he was there for. He'd taken offence at this request for personal information, refused to say, and ended up shouting and throwing the appointment letter at her. He'd then proceeded to the waiting room where he'd apparently upset a couple of other patients with his complaining.

The question is how to deal with someone like that. I've talked to other screeners who take the line that if a patient treats others (whether they be healthcare profesionals or fellow patients) in an unacceptable manner, then they don't deserve friendliness and helpfulness from the screener. As a result they receive a cool and curt service, possibly with an admonishment for their behaviour.

I take a slightly different line. I agree that they don't deserve to get service with a smile, but I give it to them anyway. In bucketloads. When I called this gentleman into the room, he was exuding silent rage from every pore, his body language screamed anger, and he was clearly spoiling for a verbal fight. So I greeted him like a friend, turned on the charm, and took niceness to new heights. By the time he left, I'd killed him with kindness and turned him into Mr Happy.

Morally, this is a bit of a dilemma. The receptionist in question is a lovely lady, and she was genuinely upset by this man's conduct. As was one of her colleagues. I would have been within my rights to refuse to see him, and have him removed from the building for unacceptable behaviour. So to choose instead to reward that behaviour by being extra nice to him seems somehow morally wrong. But the thing is, it works.

I began the appointment with a man so angry that both a receptionist and another patient had felt the need to warn me about him, and express concerns for my safety. Twenty-five minutes later, he and I were such good friends that I couldn't get rid of the man. He was so enjoying telling me anecdotes about his life, swapping tips about superfoods, and even making me laugh with his jokes, that he didn't want to leave. He told me he's such a coward about eye drops that if he was fighting in Afghanistan, the Taliban would only need to arm themselves with Tropicamide and he'd surrender immediately.

To be honest, I think that joke speaks volumes. A lot of anger comes from fear, and I think this was a man driven to rage by his fear of the appointment. That doesn't excuse his behaviour, of course, but it did enable me to solve the problem. By responding to his stress with compassion, treating him with respect, and showing him that he had nothing to fear, the man's anger was dissipated within minutes. He left with a smile on his face, and even said a cheerful "Bye bye!" to the receptionist he'd abused.

The receptionist didn't deserve the treatment she'd received from Mr Angry, and Mr Angry didn't deserve the treatment he received from me. But two wrongs don't make a right. I could have treated this patient the same way he'd treated our staff - it would have been no more than he deserved - but I'd have got exactly the same treatment back, probably tenfold. By ignoring what he'd done and letting it go unpunished, I got the best out of a potentially difficult patient, and he left relaxed and happy, with a positive experience of retinal screening. It might seem morally wrong, and I feel bad for the receptionist who suffered, but it's the only way I can work.

British Association of Retinal ScreenersAccording to my moles working undercover in the higher echelons of the British Association of Retinal Screeners, the 2010 BARS Conference will be held in... [drum roll please]... Manchester.

Rumours that the keynote speakers will include Wayne Rooney and Liam Gallagher are, as yet, unconfirmed, but at the very least I'm hoping for a tour around the Cadbury's factory with a group of type 2 diabetics.

Personally I'm still wrestling with my 2009 Conference Evaluation Form, and working out how I can give a minus score to the 'Modernising Scientific Careers' lecture. It's a difficult thing to rate though. On the one hand, it bored me to tears, had very little relevance to my job, and couldn't have been more dry if we'd heard it in Death Valley, but on the other, it was delivered by a man called Mr Mody. And you've got to admire anyone named after a type of diabetes. I might give him a 10 for commitment alone.

Just occasionally in this job, I manage to reach the parts of a patient that other healthcare professionals just can't reach. And sure enough, this week a gentleman dropped his trousers in front of me.

I knew there was something up when he suddenly began to waddle as he entered the consulting room, and said "I think I'm going to embarrass myself here...". The chap was in his eighties, and for a moment I thought he was about to wet himself, but as I closed the door behind him, he clarified the situation by adding "I think my underpants are falling down", before asking "Do you mind if I adjust them?"

For some reason, despite his use of the word 'underpants', I assumed he was talking about his trousers, which looked a bit baggy and ill-fitting, so I cheerfully replied "That's fine" and stepped back, expecting him to hoik them up over his hips, and sit down.

Instead, he undid his belt and dropped them to the floor. Which might have been ok, were it not for the fact that he was right about the underpants. They were fast approaching his knees.

It was at that precise moment that I decided I had something extremely important to examine on my clipboard. Something which needed my full and undivided attention for... well, for about the same amount of time that he was standing semi-naked in front of me. I must admit, as I stared intently downwards, it did cross my mind that he was some kind of serial flasher, and that his whole intention was to get me to look at him. Something I had no intention of doing. I had visions of the two of us stuck forever in a permanent impasse of nudity: me refusing to look up, and him refusing to get dressed.

But as it turned out, he was just an innocent old man with dodgy pant elastic. Having fiddled with his ill-fitting underwear for thirty seconds, he successfully redressed himself, tightened his belt, and took a seat. I've never been so relieved to start a VA.

They do say that you don't realise what you've got until it's gone. And for all its faults, I'll never moan about our computer system again. Well, not for the rest of this week, anyway. We had a major server crash at work overnight, resulting in the temporary loss of three of the hospital's computer systems. Two were restored within the hour, but the third was out of action for the rest of the day. And that system was ours. Every bit of software used by the Diabetic Retinopathy Screening Programme was unavailable until late afternoon.

No appointments could be booked or rearranged, no grading could be done, and out in the field, I had to get through a clinic using Photoshop and a few sheets of paper. Capturing the images was frustratingly time-consuming, but what I missed most were the little things: the ability to check past results, to see a patient's eye history, and even just the computer's ability to tell me how long a patient had been waiting since I administered the eye drops. I had to take addresses, GP details and medical records by hand, and ended up with pages of scrawled notes that only a doctor with a graphology degree could read.

I had patients asking me if their retinopathy was any worse than last year, or if their vision had changed, and I simply couldn't tell them. I didn't have access to their previous results, let alone past images or treatment records. Conversely, I had a lady who could barely see the top line of the eye chart, yet claimed her vision had not deteriorated in any way. I had no way of checking if this was true, and was unable to challenge anything she said. A lot of my working life is spent in low-level lighting, but today I was completely in the dark. And I didn't like it.

Our computer system may not be perfect, but when you're suddenly forced to work without it, you realise just how much we take the thing for granted. We have a wealth of information at our fingertips - in fact we know more about the patients than most of them do - and when that information's not accessible, you realise what diabetic blindness is all about. It's obvious that we couldn't do retinal screening without state of the art camera equipment, but in many ways our computer system is just as priceless. The thought of having all that information printed on cards and sitting in filing cabinets sends a shiver down my spine. We might moan about IT issues and technical breakdowns, but we should be damn grateful that we live in an age of computers and digital photography. The alternative doesn't bear thinking about.

About this blog

I'm a Retinal Screener and Grader currently working for the NHS as part of a Diabetic Retinopathy Screening Programme somewhere in England.
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