Why Tom and Jerry Need to Talk

Why do optometrists and ophthalmologists fail to communicate? Is it age-old prejudices? Is it fear of losing control of one’s patch? Is it an ignorance of each other’s skill sets? Is it because we just do not bother? Are we like Tom and Jerry?

In truth, it is probably a combination of these factors. But the bottom line is that this lack of communication must change—and change fast—because the world is changing faster. If we do not start communicating more efficiently, we will become a parody, like Tom and Jerry. (I will let the reader decide who is the cat and who is his sworn enemy, the mouse, in this analogy to the famous cartoon series.)

IN IRELAND

Consider as an example my home country, Ireland. As in many areas of the world, the demographic profile of Ireland is changing rapidly, and, with this, the health needs of the population are growing at an unprecedented rate. People’s expectations of what health care can deliver are also growing.

However, the current system of eye care provision in Ireland is failing to cope with the realities of increased demands and expectations. There are more of us, we are getting older, and we want healthy vision to help us maintain our independent way of living.

The Vision 2020 initiative of the World Health Organization and its international partners seeks to eliminate the main causes of preventable and treatable blindness by 2020. Unfortunately, we are nowhere near that target as things stand. The health and bioscience technologies are there. Why are we so far behind?

The need to meet the demands on the eye care service requires a paradigm shift in the way we look at health care delivery and the roles of the professionals involved. Along with this shift in thinking, improved and more effective communication methods between the professionals involved in this service are called for. We need to park prejudice and begin communicating on all levels.

Traditionally, in Ireland, communication between optometrists working in the community and ophthalmologists has been poor. In some areas, the relationship between ophthalmologists and optometrists is reasonably good, but in more areas it is not. Long-standing bias, the fact that optometrists are not employed in the public health system, and a lack of evidence-based referral pathways in Ireland do nothing to promote and encourage communication between the two professions.

The public system. Currently, within the public system, optometrists are required to refer patients through their general practitioner, resulting in inconvenience, delays, and additional costs to the patient or the national health system. There is a complete absence of communication between the referring optometrist and the receiving ophthalmologist. A referral letter may be provided by the optometrist, but this can go missing or can be misinterpreted in the trail of referral stages.

Once the referral is made, the referring optometrist may have no idea of the diagnosis or treatment received by the patient he or she has referred. Additionally, when the patient is discharged, the onus is on the patient to return to the care of his or her optometrist, and no information on diagnosis or treatment is made available to either party.

The private system. On the other hand, the private system allows direct referral of patients to ophthalmology. There is regular communication between the ophthalmologist and the optometrist, including letters of diagnosis, progress reports, and safe discharge back to the care of the community optometrist when appropriate.

This situation results in two different levels of communication in the two systems: (1) In the public sector, effective communication between optometry and ophthalmology does not exist, resulting in a practice that compromises care and outcomes; (2) in the private sector, communication exemplifies best practice principles. It is much easier to enjoy good interprofessional communications in the private arena. In the public arena, personally, I feel like a nuisance. Tom and Jerry, anyone?

LONG WAITING LISTS

One major problem area in the Irish eye care system is the long waiting lists for cataract surgery. With the aging of the population, lists for cataract surgery are growing by the day, resulting in 3-year (and, in some cases, longer) waits for surgery. I was recently contacted by a member of the public who was seeking the services of the National Council for the Blind because he had been waiting so long for cataract surgery that he could no longer see, and there was no prospect of surgery any time soon. To complicate the issue, he and his wife live in a remote area, and, because she does not know how to drive, they rely on him to get around. His wife explained to me that she calls out the directions to him when they are on the road.

A SUCCESSFUL SCHEME

The potential for change exists. In 2011, Paul Mullaney, FRCOphth, a Consultant Ophthalmologist at Sligo General Hospital in Ireland, decided to address the lack of patient-friendly referral pathways and the strain on resources within the hospital. He changed the way things were done in his cataract clinic. He approached the Association of Optometrists Ireland to explore the viability of referring his postoperative cataract surgery patients directly into the community, where the postoperative ophthalmic examination could be completed by the optometrist, rather than sending the patient back to the hospital when it was not deemed necessary.

Although all elements of the examination were within the legal scope of practice of optometrists, protocols and guidelines had to be set in place so that the optometrists could replicate what was being done in the hospital clinic. This entailed ensuring that all optometrists equipped their practices with Goldmann tonometers and 75.00 D Volk lenses and were competent in the use of the equipment. Additionally, accreditation required training in the use of the Medisoft patient management software system (eMDs), which was in use in the hospital, so that the community optometrists could upload patient examination records to the hospital system. The clinical nurse manager on the hospital surgical team and the information technology manager for the hospital communicated directly with me as the clinical lead for the optometrists.

The scheme quickly demonstrated a high level of success, in terms of both meeting clinical targets and achieving patient satisfaction. Regular audits were carried out to monitor the scheme’s progress, and key performance indicators were regularly examined.

The program was an overwhelming success. The scheme was begun in 2011, and, 5 years later, it has been expanded to cover six adjoining counties. More than 60 community optometrists have been trained and accredited to carry out postoperative cataract examinations. At the hospital, waiting lists were reduced significantly, a postoperative cataract outpatient clinic is no longer required, and the hospital resources employed in this clinic have now been redirected elsewhere within the hospital to speed up access to cataract clinics and to shorten waiting lists.

In short, it is a win-win: Optometrists are getting to hone their skill sets, ophthalmology is saving more sight, and patients are getting their vision back sooner.

The scheme has received several awards for innovation, excellence, and use of technology. Above all, the success of the scheme is an excellent example of how communication can function well on two levels: (1) Communication between ophthalmologists and optometrists led to development of the program, and (2) the e-communication platform facilitated communication between the hospital and the community optometrists.

CONCLUSION

There are some excellent examples of shared care and comanagement schemes employing optometrists in the community to work alongside ophthalmologists in hospital eye services (see Inside the Practice: London Vision Clinic and Inside the Practice: Wellington Eye Clinic). The one vital factor underpinning the success of all these schemes is good communication between optometrists and ophthalmologists, encouraged by a healthy and mutual respect for each profession.

The health care challenges in Ireland are not unique. Globally, the population is increasing and aging. New approaches are required to meet the demands on health care services and the provision of eye care. There is a need for a reallocation of resources and redistribution of clinical interventions, particularly for primary care. To make eye care more efficient and improve outcomes, a primary care system must embrace the complete skill sets of all eye care professionals. However, none of this can be achieved without good interprofessional communication, and good communication cannot be achieved without trust and respect.

Many hands make light work, as the saying goes. Having the right hands in the right places doing the work they are qualified to do—and communicating efficiently and effectively about it—is really something worth talking about.