Critical Incident Reflection

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Critical Incident

This is a particularly difficult reflection for me to write as I feel I am supposed to relate it to “teaching” as it is a pedagogy module. Since I do not teach yet, I haven’t encountered a student-demonstrator or student-facilitator incident upon which to reflect.

So if I may, I will tentatively report on an “incident” that relates to my profession as an optometrist instead of as a prospective facilitator.

A brief background is required for full understanding of this “incident”. The event in question was a brief conversation that I had over lunch one afternoon two weeks ago with my clinic manager. The topic of the conversation would ultimately change the way I practice optometry forever and change my view on my role and the role of optometrists as a whole. Furthermore as I look to expand my career into teaching future optometrists, I firmly believe that this incident will have a subsequent impact on how I teach my students.

The World Council of Optometry defines optometrists as the “primary healthcare practitioners of the eye and visual system” [World Council of Optometry,Who is an optometrist]. Primary eyecare is a frontline activity, providing eye care and identifying disease before it becomes a serious medical condition [Vision2020, 2012, Primary Eye Care]. The main role people think of when they think optician or optometrist is eye examinations to check for the need for spectacles. While this is a big part of the profession there are far more important jobs that and optometrist must do. For example an eye examination will detect eye diseases that can potentially lead to blindness if not managed appropriately. It is possible to detect ocular signs of systemic conditions such as multiple sclerosis, high blood pressure and diabetes in an eye examination.

But I will admit that the ‘interesting’ cases (those ones you learn about in college but never actually see) are a rarity and in this day and age, working in busy multiples who are just interested in churning out the tests and the conversion rates and average sale value, you sometimes forget that you are not a glorified sales person and that you actually have a very important medical role to play…. Well not anymore.

Description:

The conversation took place one lunchtime in the staff room in the National Optometry Centre. The topic being an ongoing case in the UK involving negligence and breach of duty of care by an optometrist. The consequences of this negligence have resulted in the optometrist being charged with manslaughter for missing an underlying medical condition in a child. Ultimately as a result the child died.

Full details of the case have not yet been made public, but what is known so far; an eight-year old boy attended for an eye examination and he had a swelling at the back of his eye. This is a sign of a build-up of pressure and swelling in the brain. It is an emergency referral to have the pressure and swelling reduced back to normal and to investigate the underlying cause of such occurrence. It appears that the optometrist in question was negligent in her role that day, she missed this sign and now could face a prison sentence for it.

Feelings:

To be frank, I’m not going to lie this scared the hell out of me. We have obviously had lectures on law and ethics, professional ethics and negligence in college and from time to time at CPD events. We have a professional code of conduct and ethics that we must follow set out by the Opticians Board, now Coru. (http://www.coru.ie/uploads/documents/OPTICAL_REGISTRATION_BOARD_CODE_OF_PROFESSIONAL_CONDUCT_AND_ETHICS_FOR_OPTOMETRISTS_BYE-LAW_2015.pdf). Always until now the worst case scenario (and this was still really bad) was you could lose your licence to practice optometry (so now you’re unemployed with a useless qualification). But for the first known time you could actually face a prison sentence on top of that - for having an ‘off day’.

Evaluation:

One of the scariest things about this is that it is virtually impossible to be on you’re A-game 100% of the time. It’s natural, it’s human, and we all have our off days. But it only takes one person… in your whole career, to take it all away.

To put this in perspective, when an optometrist works in a multiple they will do an eye test on average every 20 minutes. This will probably average at 20 tests a day. If you work full-time, 5 days a week you could potentially see 100 patients a week - 400 patients a month - 5200 patients a year. If the average person works for 40 years of their lives, that equates to 208,000 patients. That is a lot of 20 min sight tests that you have the potential to miss something extremely important.

Again we are all human, we all make mistakes, and it is a very real possibility. It only takes one. I don’t know the ins and outs of the case, none of those details have been released, but I feel so sorry for the poor girl whose whole world must feel upside down right now. I can completely see myself in her shoes, which is terrifying. It could just as easily have been me or any of my friends. Of course the family involved must be absolutely devastated and it’s hard not to see things from their point of view too.

All in all it feels too close, too real. But maybe it’s a good thing. Maybe it will scare us into being more vigilant as opticians, remind us that we have a very important, responsible job. Optometrists should learn from this experience; learn to stand up for ourselves, if we need more time when examining a patient, if we want to bring a patient back for further tests. We cannot allow ourselves be coerced into leaving things out because we don’t have time, or dispensing contact lenses without prescription just to get a patient by. I must admit I am speaking very generally here. In my experience nine times out of ten an employer won’t force you to do something you aren’t comfortable with, but I have seen it happen, to me and to others. And at the end of the day it is our name on the dotted line so if someone is going to get hung out to dry it won’t be the employer or optical assistant, that’s for sure.

Analysis:

The implications for me following this incident I would say are positive. As I mentioned if anything I think it makes me more cautious as a practitioner which can only be good for my patients’. For example a couple of days later I had a patient who was just in for a normal eye exam. We did the full test, visions were perfect and then I had a look at the back of the eye and I noticed a dark spot near the macula (part at the centre of the retina that we use to see detailed vision). Similar to having a freckle on your skin it was just a spot that was a different colour to the surrounding retina. Depending on what they look like the management protocol differs. For a small flat well defined freckle that doesn’t have any yellow spots on it you would tend to just monitor it by photographing it for change every couple of months. If it was raised, had ill-defined borders and yellow spots on the top, you would refer to check for a potential malignant growth. My patient’s freckle was flat, didn’t have any yellow spots but it was quite big, and I didn’t like how close it was too the macula. I advised the patient that I would check with the former practitioner if the freckle had been there at her eye exam two years previous and that we would photograph the freckle in three months again. They wouldn’t actually give me a conclusive yes or no answer. So I hummed and hawed for a couple of days and discussed the patient with a couple of colleagues.

Luckily the National Optometry Centre has a machine that can scan the layers of the retina. I referred my patient to have a scan done which would give a better indication than a photo for any underlying fluid or malignant changes. It can measure the depth and width of the freckle which allows us to better monitor any changes.

I know that “freckles” at the back of the eye can be malignant melanomas, which is cancer, which can result in death but I truly believe that had I not heard about the incident in the UK I would probably have just left it three-six months before taking another picture. As a result of the case in the UK I acted quicker and sooner. I wasn’t happy with just monitoring a picture. It may just be a freckle, I haven’t had any results back yet, but when I know it’s not the norm I think it warrants more detailed investigation rather than just leaving it to chance.

Optometry as a profession is changing. It’s exciting times for us all. We are entering into conversations with ophthalmologists, the eye hospitals, the HSE to allow us more responsibility in treating common causes of red eye, monitoring slowly progressive conditions like diabetes, glaucoma and macular degeneration. Optometrists provide a valuable resource to the HSE and hospital eye service that is not utilised to its full potential. We can help to reduce the burden on the hospitals and ophthalmology departments at present. News like this bodes nothing for us trying to show case our skills, knowledge and abilities.

Action Plan:

On reflection I look at this conversation as a positive experience. It has certainly made me a more attentive practitioner which cannot be a bad thing when other peoples’ lives are literally in your hands. As I outlined above my patient management routine is more cautious while still within the guidelines. We think of the GP or nurses and doctors in hospitals as the people who pick up and diagnose serious illnesses – not the optician. Reflecting upon this incident I have highlighted to myself how uncertain I am about certain situations at work and now having evaluated the situation feel competent and confident to continue to practice in chaotic clinics where things rarely happen by the book. [Ghaye, 2000].

In Law and Ethics students learn about the Professional Code of Conduct, the responsibilities of being an Optician and the consequences for being negligent. While this is an unfortunate situation for the optometrist in question, and at the risk of sounding harsh, it will make for an excellent case study to use as an example to try and show or explain to students the importance of being consistently thorough. My area of study centres around abnormal ocular conditions so I could use it as an example of the importance of knowing the different conditions and what to do in each case so as to avoid landing in a similar situation themselves. Especially as these are going to be the future of optometry and as I mentioned our responsibilities are likely to increase. With these responsibilities come risks and consequences. It is important that the students are fully aware of the consequences.

Conclusion:

Reflective practice is a relatively new concept in Optometry, and it makes sense that reflective practice for one discipline does not necessarily match another [Fook et al, 2006]. With the end of the Opticians Board and amalgamation of several healthcare professions under the one banner -CORU, comes a new era where reflection is going to become a major part of life-long learning for optometrists (Finlay, Reflecting on reflective practice). Taking our clinical experiences we will gain new insights and self-awareness of ourselves as individual practitioners [Boud et al 1985; Boud and Fales, 1983; Mezirow, 1981, Jarvis, 1992]. As one would naturally expect this change in CPD is met with some resilience by the older optometrists, they’ve spent the majority of their professional careers not having to do anything other than attend the odd lecture here and there. The newly qualified optometry students on the other hand will be coming out with developed reflective writing skills as it becomes a more and more integral part of learning.

I believe that in the future I can transfer my learning from this to my students. Help them to understand their role as optometrists, their responsibilities, the penalties and consequences of negligence are no longer that you lose your job.

Boud, D. and Fales, A. (1983) Reflective learning: key to learning from experience. Journal of Humanistic Psychology, 23(2), 99-117.

Boud, D., Keogh, R. and Walker, D. (1985) Promoting reflection in learning: a model. In D. Boud, R. Keogh and D. Walker (eds.) Reflection: turning experience into learning. London: Kogan Page.

Ghaye, T. (2000) Into the reflective mode: bridging the stagnant moat. Reflective Practice, 1(1) 5-9

Fook, J., White, S. and Gardner, F. (2006) Critical reflection: a review of contemporary literature and understandings. In S.White, J.Fook and F.Gardner (eds.) Critical reflection in health and social care. Maidenhead, Berks: Open University Press.

Jarvis, P. (1992) Reflective practice and nursing. Nurse Education Today, 12(3), 174-181.

Mezirow, J. (1981) A critical theory of adult learning and education. Adult Education, 32(1), 3-24.