When I first started this blog, I had virtually no idea what I wanted to do with it. Anyone who's read it will know that I still don't. I think I was just shocked to discover that the domain name describing my profession was still unregistered, so I wanted to claim it and put up some flowers. Possibly with the intention of selling it on to Specsavers for a six figure sum.
But having planted a few seeds (mostly daisies), and watched things grow over the past few months, it's been brought to my attention by certain shadowy figures within the NHS (although they're only shadowy because we're trying to save on the lighting bill) that I could be on slightly dodgy ground when it comes to information governance. Apparently if just one 95-year-old diabetic gets herself a computer, manages to find her glasses, and enters 'Retinal Screener' into Google, I could be in trouble.
Fortunately I've completed the NHS 'Handling Complaints Positively' course, which included surprisingly little advice on sulking, and after much thought, I've decided to draw things to a close, in the hope of steering clear of the justice system. Harriet Harman's Court of Public Opinion might let me off, but the Old Bailey won't.
So this will be my last post for the time being. I'd just like to thank all the people who have e-mailed me over the past few months, in particular: the chap who used this site to prepare for an interview (and got the job); the person who told me that if I want to speak at the next BARS conference, I only have to ask (I'm still not sure I believe that); the man who stays in the grading room until 9pm to read this stuff; the people who claim they've fallen off chairs laughing at it; and above all, the lady who told me that her friend thought she was a rectal screener. Your compliments have been greatly appreciated. Maybe we should all start using the BARS Forum now.
I'd just like to finish this blog in the same way I started it: by saying that I love my job, the people I work with, and even most of the patients. I've only ever trodden on one person's toes (and he had neuropathy, so he didn't notice), but that's one person too many, and it was never my intention to risk making anyone feel uncomfortable. So I'll stop before I do.
But in the meantime, join me over at my new site - www.RetinalScreeningDiploma.com - where I'll be posting the answers to all nine City & Guilds units.
(Just kidding).
RS
I don’t know who came up with the idea of February, but frankly they deserve to be fired. It’s not the month I object to, it’s the fact that it’s exactly four weeks long. It means the days of the week are the same as for March. And that means all my patients turn up a month early.
I had an 84-year-old lady this afternoon who sat outside in the waiting room for almost an hour before complaining that she hadn’t been called. Having checked her appointment letter, I had to break the news to her that she was unlikely to be called for another four weeks. Needless to say I added her to my list and screened her anyway, so ultimately there was no harm done, but on top of giving me extra work, it caused a lot of embarrassment for the lady when she realised her mistake (she turned redder than a retinal haemorrhage), and that was in addition to her being kept waiting for an hour.
As for the chap I saw yesterday, let’s just say he had form. I was barely an hour into the new working month, when he turned up insisting that he had an appointment for 10:20 that morning. Needless to say he hadn’t bothered to bring his appointment letter, but that didn’t stop him being adamant that he was there on the right day. It’s always the ones with no proof who are the most confident of being right.
Anyway, the moment he complained about the short notice of his appointment, it was pretty obvious what had happened. And sure enough, a quick check on the computer told me that he’d arrived a month early. But as they used to say on all good 70s cop shows, the man had previous. When I got him back in for the photos, he admitted to me that he’d done it before, “only worse”. When I questioned how much worse you can get than arriving four weeks early for your retinal screening, he said “I once turned up for a hospital appointment in the wrong year”.
I admitted that was slightly worse.
It's not unusual for patients to turn up for their retinal screening appointments with a long list of all the medication they're taking, their latest glasses prescription, or a copy of the medical report they received in 1972 when they were booted out of the army. And they always expect me to read them. I've perfected the art of completely ignoring anything they show me, whilst simultaneously looking interested so as not to offend them. But today I had a patient who took the concept one stage further. She turned up with all her press cuttings.
It transpires that at some point (I'm not sure when - I didn't read the date on the first newspaper she gave me) she'd slipped into a diabetic coma, and had lain unconscious on her kitchen floor for two hours until being discovered by...
... her dog. Who licked her face and revived the lady sufficiently for her to phone 999. As she said to me this afternoon, "I'm lucky to be alive. The paramedics said it was a miracle".
I said "Being brought out of a diabetic coma by your dog? Yep, I'd say that was pretty miraculous".
Naturally the local paper were all over it. And having been forced to flick through paparazzi shots of the heroic pooch for a good five minutes before his owner would agree to do the VA, I can honestly say that he takes a good photo. I'm considering recommending him to NICE. Let's face it, he's got to be cheaper than glucagon.
Breaking news from the DRSEQA website...
“The EQA System will be unavailable until Monday Feb 1st. Please DO NOT attempt to og on before this time - your details will not be recognised”
Hmmm... methinks they have a few quality assurance issues of their own there. Not least in their ability to spell ‘log’. I wonder if their website would pass an EQA visit..?
And talking of quality assurance, I thought I'd failed a visit myself this afternoon, when I discovered to my horror that I’d kept a 93-year-old lady waiting for an hour and a half. One sniff of a no-win-no-fee lawyer and I’d have been sued to high heaven for mental cruelty. But I swear it wasn’t my fault, your honour.
We’d actually received a phone call from the lady’s surgery first thing that morning to say that they’d been unable to arrange hospital transport for her that day, and she’d therefore be unable to make it. So the office cancelled her appointment and made her a new one for March. The surgery said they’d let her know.
Well, not only did they not let her know, but they managed to organise transport for her after all. And they didn’t bother to tell us that either. So shortly before 2pm, the hospital transport guys picked her up, brought her over, dumped her in the communal waiting room, and left without saying a word. Having been told she wasn’t coming, I naturally didn’t bother calling her by name, but as luck would have it, I did go out and make a general call for anyone waiting for retinopathy screening.
Unfortunately she was as deaf as a post and didn’t hear me. It wasn’t until 3:30pm when she managed to wave at a nurse that we finally realised she was there. The irony is, she didn’t complain at all. In fact she kept apologising to me for being a nuisance. I suppose when you’ve lived through two world wars and are three months short of your 94th birthday, a ninety-minute wait for retinopathy screening is nothing.
One of the debates which seems to rear its pretty little head in our screening programme from time to time is the issue of how much information we pass on to patients in the clinic. Needless to say, we don’t give out results on the day, but most of my colleagues, myself included, like to show patients their photos and give them an initial impression.
On occasion, however, this causes problems. The most common complaint comes from patients who were told by the screener that there were no obvious problems, but then receive the results letter stating that they have background retinopathy. In reality, this can happen very easily: a set of photos which appear clear at first glance may very well hide a single microaneurysm which is only visible upon close inspection and/or manipulation of the images. To a screener, that’s not a big deal, but to a patient who was expecting the all-clear, it’s a disaster and an outrage. And they’re straight on the phone to tell us so.
As a result, we go to great lengths to stress to patients that we can’t be certain of anything until the photos are studied in more detail. My personal modus operandi when faced with a set of pictures which look clear, is to tell the patient that I don’t see any immediately obvious problems, but that the changes we’re looking for can be very tiny, and are not always visible until we study the images more closely. I then go on to tell them that if we do find anything, in all probability it will just be a bit of background retinopathy. I then explain what the term means.
For me, that last bit is key. A lot of our complaints come from people who lack the basic facts about retinopathy, and see any positive result as the death knell for their sight. Our standard results letter for R1 actually includes a line informing the patient that it doesn’t mean they’re going blind. That might seem like overkill, but it came about because we were getting regular phone calls from patients with background retinopathy who were asking just that. When you look at it in that context, therefore, it’s not surprising that someone who was expecting the all-clear immediately panics when told they have R1.
So my tactic is to pre-empt any bad news by explaining what background retinopathy is. If a patient understands the nature of the condition, they’re not going to suffer a panic attack when told they have it. It occasionally seems laborious to go through the ins and outs of R1 whilst looking at the flawless pictures of a patient with perfect diabetic control who’s had the all-clear for three years running, but if it spares them a bit of stress in the future (and saves us from an irate phone call), it’s well worth the effort.
In addition, on those rarer occasions when I spot something which is likely to lead to a referral, I like to prepare the patient for that eventuality. It can be a fine line between preparing a patient and panicking them, so we need to tread carefully, but we’ve had instances in the past where patients with R2 and even R3 have failed to turn up for appointments at the local eye hospital because the screener said nothing to them at the time, and they assumed it wasn’t important. I feel, therefore, that we should be emphasising the importance of attending any future appointment that might be sent to them, whilst at the same time reassuring the patient that their condition is treatable, so as not to cause worry.
Unfortunately, there will always be a small percentage of people who only hear what they want to hear. Selective memory is the bane of the healthcare professional. And no matter how carefully worded your information is, there will always be patients who swear blind a few weeks later that the screener gave them a cast iron guarantee of R0/M0 with no possibility of error.
Which is why I think we should ignore them. Every time we receive a complaint, we have another programme-wide debate in which someone proposes that we stop showing patients their photos and refuse to comment on any likely outcome. It’s been said that a patient going for breast-screening or a cervical smear wouldn’t expect the nurse to give them an idea of the result on the day - they accept that they wait for a letter. So why should retinopathy screening be any different?
Well, I’ll tell you. It’s because for 99% of people it’s the most beneficial part of screening. I don’t know who’s to blame for people’s ignorance about diabetes – GPs, nurses or the patients themselves – but I see patients all the time who have no idea what they’re being screened for. Some even say to me “I don’t know if you need to know, but I’m diabetic”. Others react with surprise when I tell them that their diabetic control (or lack of it) can actually affect their eyes.
By telling the patients nothing, we might stop the odd complaint, but we’ll also lose a golden opportunity for education. Those five minutes with a screener can make all the difference to a patient’s knowledge of their own condition, and many of my most satisfied customers have been those who learned something of interest during the appointment. I’ve seen countless patients who sheepishly ask “So what are you actually looking for..?”, and leave enlightened, reassured and, above all, grateful for the information they receive. It would be a tragedy to lose that for the sake of the few who like to complain.
In this case, ignorance isn’t bliss and it’s knowledge that makes people happy. If we stop showing patients their photos and giving feedback on what we can see, that’s when they’ll really have something to complain about.
I found out today that Diabetes UK, the diabetes charity founded by H.G. Wells, is now producing leaflets about diabetic retinopathy in a variety of languages. Oddly for an organisation started by the author of The War of the Worlds, they're not yet producing one in Martian, but as luck would have it, only a small percentage of my patients act like they're on another planet.
For the rest, this is fantastic news. It means I can stop doing the British thing of simply raising my voice and pointing furiously whenever I'm faced with a patient who doesn't speak English.
That might look like the sort of thing David Beckham would have tattooed on his arm, but it's actually the Bengali for retinopathy.
And on the right there is the word maculopathy in Gujarati. That means something to 46 million people worldwide. Although I haven't screened them all yet. I do think other languages are far more pretty to look at than English though. I'd be happy if I'd produced that in art class.
Anyway, the leaflets are available for download by clicking here. I'll be printing out a supply and keeping them with me at all times. It'll give me something different to point at when I'm struggling to make myself understood.
I knew it was tempting fate to say that the weather had improved enough for us to start running clinics again. After another download of snow on Tuesday night, the only thing we're currently running is short of appointments. We've been forced to reschedule so many patients that we're now booking up clinics for March. Patients keep telling me that they don't want to make a new appointment until they know what the weather's doing, and I have to tell them it's not a problem - we've got nothing available till the spring. Although now I've said that, we'll probably get a monsoon in April.
So after two days back at the retinal screening coalface, I spent yesterday in the office, phoning patients to rearrange their appointments. It provided me with a couple of interesting moments...
Firstly I phoned a man half an hour before his appointment time to tell him we were having to cancel. His wife said he wasn't there. I said "Oh, has he already left for the appointment?". She said "No, he's out of the country".
I was a little annoyed that they hadn't bothered to tell us, but as my colleague pointed out, maybe he was flying back in in the next twenty minutes. I'll give him the benefit of the doubt.
I followed that with a call to an elderly female patient, whose phone was answered by a much younger voice. I asked if I could speak to the lady in question, and she said "No, she died a few days ago". You can't really argue with that. Her appointment had obviously been cancelled by someone a lot higher than me.
Southern Australia is currently in the grip of a heatwave, with night-time temperatures in Melbourne reaching as high as 37C. I thought of that yesterday morning as I was attempting to dig my car out of the snow in a hospital car park. I also spent a lot of time wondering if Tropicamide would still work at sub-zero temperatures, and trying to calculate the freezing point of alcohol hand gel.
Conditions have improved sufficiently in my neck of the woods for us to start running clinics again, which meant I was back on the road yesterday morning and heading for a hospital 8 miles away. Or 10 miles if you're trying to avoid the snowdrifts. Despite taking a route more circinate that a bit of exudate near the macula, I made it to the clinic without too much difficulty. Which is more than I can say for my patients. By the middle of the morning, half of them had cancelled, and the ones who did turn up made their journeys sound like something undertaken by Scott of the Antarctic.
One chap arrived in wellies with a walking stick, and when I congratulated him on making it, he said "Well I only live around the corner". I said "Oh good, so it was walkable then?". He replied "No. I slid all the way here and fell over twice". I suppose I should be grateful he didn't sue us for having invited him. But hey, if you're going to break a leg, you might as well do it on your way to hospital.
So I had a pretty quiet day, but the patients I did screen seemed grateful that I'd made it. One took particular interest in the fact that I'd eschewed my usual smart pair of shoes for some more sensible footwear. As he said to me, "We know the weather must be bad when doctors like you are wearing walking boots instead of shoes!"
I was going to point out to the man that there are very few doctors like me, but that when I graduated from medical school many years ago and took the Hippocratic Oath, I vowed to save lives and heal the sick come rain, shine or heavy snow. And if that means striding up and down a hospital corridor in a pair of walking boots like an arctic explorer with an eye chart, then so be it.
But then I remembered I'm not a doctor. So I just agreed with him and said I was trying to promote cardiovascular exercise.
Just a quickie to say that if anyone else has been struggling to get onto the EQA System website this week, then try updating your bookmarks and replacing the old address of 'http://www.drseqa.org/site' with http://www.drseqa.org/index.html. That should do the trick.
It's 2010! Or 6/3 if you're using the Snellen chart. And I don't know if it's my imagination, but there seems to be a bit of snow out there. I've spent Wednesday and Thursday of this week on the phone to patients, cancelling their appointments and rebooking them for February. We did manage to get out to a couple of clinics yesterday, but very few people turned up, and to be honest, even if they're willing to brave the frozen wastes, I'm not sure it's a good idea to make patients walk home through a snow drift with dilated pupils. One shaft of sunlight and they'll be dazzled for life.
Most people have been relieved to hear that we don't expect them to haul their walking frames through a blizzard for the sake of a retinopathy screening appointment, and are only too pleased to be rebooked. But there's always one who has to be different. And I spoke to him today.
He was a chap in his 60s, and he had an appointment for tomorrow morning at a clinic 25 miles from our base. The roads between here and there are treacherous, and the decision was made first thing this morning to cancel tomorrow's appointments. Not only was it impossible for our screener to make the trip, but a number of patients had already cancelled for exactly the same reason. And they only live around the corner. Not this guy, though. He informed me on the phone that he lives four miles from the clinic, and would be walking to his appointment.
When I broke the news to him that there'd be no one there if he did, he began a lengthy rant which included the following little gems:
Screeners are just lazy and want to stay in bed all day.
If I can walk 4 miles, you should be able to drive 25.
The roads aren't that bad anyway.
It's only a bit of snow.
I hope the screeners won't get paid for tomorrow.
I said that if we can't get into work, we may be forced to take the day as annual leave, and he replied "Well that's some consolation I suppose". I should have added that we'll also be flogged in the street, and he might have been happy.
I mentioned this caller to my manager, and he told me that during a previous episode of bad weather, he'd spoken to a man who was outraged that we'd cancelled his appointment, and claimed that the 15 mile distance between our base and the health centre was, and I quote, "walkable". So my boss told him we were holding a clinic here, and said he was welcome to come.
