- Email: [email protected]
Harmonisation of eye care training
Contact Lens and Anterior Eye 39 (2016) 175–176
Contents lists available at ScienceDirect
Contact Lens and Anterior Eye journal homepage: www.elsevier.com/locate/clae
Editorial
Harmonisation of eye care training
When it comes to eye care, especially primary eye care, like many health care disciplines, there exists some overlap between the various professions. A patient with an eye problem may present first to an optician, an optometrist, an ophthalmic surgeon or a medical practitioner. Who sees the patient first may depend on the type of eye problem, or the accessibility to a particular clinic, costs involved, local beliefs and even where the patient is in the world. In a field such as contact lenses, if the patient presented in Brazil then they would probably be fitted by an ophthalmologist, in Italy they may be fitted by an optician and in Australia they would probably be fitted by an optometrist. It is worth remembering that these professions, although overlapping, do have different origins. Opticians can trace their origins back to the various European Guilds that stemmed from vocations such as jewellery makers or watch makers. The Worshipful Company of Spectacle Makers was granted Royal Charter in 1629 by King Charles I. This Company and the British Optical Association are the precursors to the current Association of British Dispensing Opticians and the College of Optometrists. Surgeons can trace their origins back to medieval times too, in Europe we had barber-surgeons. They had the characteristic red and white diagonally striped poles outside their premises. Interesting modern day barbers still use the same symbol outside their shops. Surgery of other types does pre-date this era of course, with bone resetting, or blood-letting and cauterisation in ancient Mesoptania, Babylon, Assyria, India, China, Egypt and Greece. You will be forgiven if you have not heard about trepanation, an ancient technique of drilling or scraping holes in the skull, used for treating disorders like epilepsy, intracranial pressure, mental disorders and even migraines. You will not be surprised to learn that many died from infection but the survival rate was above 50% although what the success rate of the actual procedure was is not known. Early cataract extraction was performed with a technique known as couching where a blunt instrument was used to dislodge the hard crystalline lens and push it back and downwards to allow light to enter the eye again. The patient would be left aphakic and thus require high positive lens corrections but interestingly spectacles (eyeglasses) were not invented until the late thirteenth century in Italy. Although early evidence of lenses does exist in ancient cultures such as the Nimrud lens, which dates back to around 750BCE, or the Aristophanes’ magnifying lenses of around 400BCE. The medical profession also has roots in ancient cultures and through the middle-ages became more regulated until surgery became a branch of medicine. As times have changed, cultures developed, people migrated, countries were invaded or colonised the spread of clinical skills has
become more global. Many developing countries will base their scope of clinical practice on that from established models. I was at an international congress recently where a speaker said that in his country there was a need to establish optometry and they wanted to base it on the best model which he said was that of the UK. My reply was that the UK was not necessarily the best model but it worked in the UK, and the model in the UK is evolving too. Furthermore, any country should first measure its need and then decide what ratio of the various ophthalmic professions would serve it best. There are cultural and institutional beliefs which can be hard to break and thereby the availability of services need to take this into account. It may be that a country has more need for eye surgery or more need for dispensing opticians. Optometrists offer a middle ground, they can be a self-sufficient profession where their costs are paid by direct payment for services offered or the service cost is subsidised by the retail side of the practice. Optometrists are cheaper and quicker to train than ophthalmologists. It could be argued that the United States and Canada offer the most advanced optometry model since therapeutic work is more commonplace. In reality a lot of optometrists in North America are also working with a model that relies on regular eye examinations followed by dispensing of spectacles. However, in places where optometry does not exist it would be difficult to establish a North American style scope of optometry practice as this would impinge on ophthalmology practice too heavily and may be resisted by others. Maybe in that regard the UK model could work as in the UK the roles of opticians, optometrists and ophthalmologists do have less overlap. UK opticians do not refract, UK optometrists do not provide medical treatment or surgery and UK ophthalmologists do not sell spectacles or contact lenses. Most UK optometrists do not have therapeutics licenses, although that is on the increase too, especially with more specialist services and shared care being taken on by optometrists in the UK due to the overburdening of the National Health Service hospital eye services. The question that always makes me think is what if there were no optical technicians, no opticians, no orthoptists, no optometrists, and no ophthalmologists and we were starting again. If we were designing eye care clinicians starting with a blank piece of paper, would we have all these professions? Would ophthalmologists need full medical training before specialising in ophthalmology. In the UK a student can study a law degree but that does not make them a lawyer. In fact lawyers in the UK are either solicitors or barristers. The UK society uses the services of solicitors more than that of barristers so it is not surprising that after the initial training of a law degree more of the graduates engage in further training to become solicitors and a smaller number
http://dx.doi.org/10.1016/j.clae.2016.04.007 1367-0484/ ã 2016 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.
176
Editorial / Contact Lens & Anterior Eye 39 (2016) 175–176
undertake the training to become barristers. Some do not engage in the further training and may use their law degree to enter other fields including legal clerks or assistants. Nurses do something similar, they have the same initial training and then some will specialise in areas where there is a need and others may train further to enter management or sub-speciality fields or become nurse-practitioners. The additional specialisation and training is not sought by all and the priority is to offer an essential nursing provision for patients. Could this work in eye care practice? Could there be a basic body of training that would allow the person to enter into one profession, followed by optional further training programmes that allowed the individual to practice at a different or more specialist level? Could this be a more cost effective way of training? I don’t think this is the complete answer because we are not starting with a blank sheet of paper and we are working with what already exists. Furthermore, in countries that lack even basic
eye care practitioners or have insufficient provision it is more important to get people trained quickly so that some level of service can be offered immediately. In some developing countries basic ophthalmic training is given to health visitors, nurses or even teachers. This may not be ideal but is better than nothing. Furthermore, these countries are often reliant on non-government organisations to help whilst trying to increase training and raise standards to a level that allows adequate patient care. There is still a lot to do to try and harmonise professions, but the priority still remains to be ensuring basic eye care provision globally based upon the needs of each country. Shehzad A. Naroo School of Life and Health Sciences, Aston University, Birmingham, United Kingdom E-mail address: [email protected]
Contents lists available at ScienceDirect
Contact Lens and Anterior Eye journal homepage: www.elsevier.com/locate/clae
Editorial
Harmonisation of eye care training
When it comes to eye care, especially primary eye care, like many health care disciplines, there exists some overlap between the various professions. A patient with an eye problem may present first to an optician, an optometrist, an ophthalmic surgeon or a medical practitioner. Who sees the patient first may depend on the type of eye problem, or the accessibility to a particular clinic, costs involved, local beliefs and even where the patient is in the world. In a field such as contact lenses, if the patient presented in Brazil then they would probably be fitted by an ophthalmologist, in Italy they may be fitted by an optician and in Australia they would probably be fitted by an optometrist. It is worth remembering that these professions, although overlapping, do have different origins. Opticians can trace their origins back to the various European Guilds that stemmed from vocations such as jewellery makers or watch makers. The Worshipful Company of Spectacle Makers was granted Royal Charter in 1629 by King Charles I. This Company and the British Optical Association are the precursors to the current Association of British Dispensing Opticians and the College of Optometrists. Surgeons can trace their origins back to medieval times too, in Europe we had barber-surgeons. They had the characteristic red and white diagonally striped poles outside their premises. Interesting modern day barbers still use the same symbol outside their shops. Surgery of other types does pre-date this era of course, with bone resetting, or blood-letting and cauterisation in ancient Mesoptania, Babylon, Assyria, India, China, Egypt and Greece. You will be forgiven if you have not heard about trepanation, an ancient technique of drilling or scraping holes in the skull, used for treating disorders like epilepsy, intracranial pressure, mental disorders and even migraines. You will not be surprised to learn that many died from infection but the survival rate was above 50% although what the success rate of the actual procedure was is not known. Early cataract extraction was performed with a technique known as couching where a blunt instrument was used to dislodge the hard crystalline lens and push it back and downwards to allow light to enter the eye again. The patient would be left aphakic and thus require high positive lens corrections but interestingly spectacles (eyeglasses) were not invented until the late thirteenth century in Italy. Although early evidence of lenses does exist in ancient cultures such as the Nimrud lens, which dates back to around 750BCE, or the Aristophanes’ magnifying lenses of around 400BCE. The medical profession also has roots in ancient cultures and through the middle-ages became more regulated until surgery became a branch of medicine. As times have changed, cultures developed, people migrated, countries were invaded or colonised the spread of clinical skills has
become more global. Many developing countries will base their scope of clinical practice on that from established models. I was at an international congress recently where a speaker said that in his country there was a need to establish optometry and they wanted to base it on the best model which he said was that of the UK. My reply was that the UK was not necessarily the best model but it worked in the UK, and the model in the UK is evolving too. Furthermore, any country should first measure its need and then decide what ratio of the various ophthalmic professions would serve it best. There are cultural and institutional beliefs which can be hard to break and thereby the availability of services need to take this into account. It may be that a country has more need for eye surgery or more need for dispensing opticians. Optometrists offer a middle ground, they can be a self-sufficient profession where their costs are paid by direct payment for services offered or the service cost is subsidised by the retail side of the practice. Optometrists are cheaper and quicker to train than ophthalmologists. It could be argued that the United States and Canada offer the most advanced optometry model since therapeutic work is more commonplace. In reality a lot of optometrists in North America are also working with a model that relies on regular eye examinations followed by dispensing of spectacles. However, in places where optometry does not exist it would be difficult to establish a North American style scope of optometry practice as this would impinge on ophthalmology practice too heavily and may be resisted by others. Maybe in that regard the UK model could work as in the UK the roles of opticians, optometrists and ophthalmologists do have less overlap. UK opticians do not refract, UK optometrists do not provide medical treatment or surgery and UK ophthalmologists do not sell spectacles or contact lenses. Most UK optometrists do not have therapeutics licenses, although that is on the increase too, especially with more specialist services and shared care being taken on by optometrists in the UK due to the overburdening of the National Health Service hospital eye services. The question that always makes me think is what if there were no optical technicians, no opticians, no orthoptists, no optometrists, and no ophthalmologists and we were starting again. If we were designing eye care clinicians starting with a blank piece of paper, would we have all these professions? Would ophthalmologists need full medical training before specialising in ophthalmology. In the UK a student can study a law degree but that does not make them a lawyer. In fact lawyers in the UK are either solicitors or barristers. The UK society uses the services of solicitors more than that of barristers so it is not surprising that after the initial training of a law degree more of the graduates engage in further training to become solicitors and a smaller number
http://dx.doi.org/10.1016/j.clae.2016.04.007 1367-0484/ ã 2016 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.
176
Editorial / Contact Lens & Anterior Eye 39 (2016) 175–176
undertake the training to become barristers. Some do not engage in the further training and may use their law degree to enter other fields including legal clerks or assistants. Nurses do something similar, they have the same initial training and then some will specialise in areas where there is a need and others may train further to enter management or sub-speciality fields or become nurse-practitioners. The additional specialisation and training is not sought by all and the priority is to offer an essential nursing provision for patients. Could this work in eye care practice? Could there be a basic body of training that would allow the person to enter into one profession, followed by optional further training programmes that allowed the individual to practice at a different or more specialist level? Could this be a more cost effective way of training? I don’t think this is the complete answer because we are not starting with a blank sheet of paper and we are working with what already exists. Furthermore, in countries that lack even basic
eye care practitioners or have insufficient provision it is more important to get people trained quickly so that some level of service can be offered immediately. In some developing countries basic ophthalmic training is given to health visitors, nurses or even teachers. This may not be ideal but is better than nothing. Furthermore, these countries are often reliant on non-government organisations to help whilst trying to increase training and raise standards to a level that allows adequate patient care. There is still a lot to do to try and harmonise professions, but the priority still remains to be ensuring basic eye care provision globally based upon the needs of each country. Shehzad A. Naroo School of Life and Health Sciences, Aston University, Birmingham, United Kingdom E-mail address: [email protected]