Download Study Guide - Curriculum for Ophthalmic Specialist Training

Summary of changes to OST curriculum study guide
July 2010
http://curriculum.rcophth.ac.uk/study-guide/clinical_assessment
Key:
Additions in red support changes made in response to stakeholder feedback
Additions in green support medical leadership enhancements
Additions in orange support Common Competencies Framework
enhancements
CLINICAL ASSESSMENT (CA) STUDY GUIDE
CA1 Take a directed clinical history
Think:




Many of your history taking and communication skills will have been acquired
in your foundation training. How do these skills apply to an ophthalmic
history?
How should I proceed when there is conflict between the history from the
patient and that from relatives and carers?
In what situations may it be helpful to revisit the history with the patient?
What aids to history-taking can be used? (e.g. Questionnaires etc.?)
Activity:


Observe senior colleagues.
See as many patients as you can and practice presenting cases to senior
colleagues
Self Assessment:

Clinical Rating Form. Ask a colleague to observe your technique, complete a
clinical rating form and give you feedback
CA2 Assess vision
Think:



What is meant by 'visual acuity'?
How do you assess vision in children or people with learning difficulties?
How do you assess vision away from the eye clinic?
Activity:

Ask your orthoptist if you can participate in an orthoptist clinic assessing
childrens vision
Resources:


Broadway DC, Tufnail A, Khaw PT. Assessment of Colour Vision.
Ophthalmology Examination Techniques Questions and Answers. 1st ed.
Oxford: Butterworth-Heinemann; 1999: 9-10.
Easty DL, Sparrow JM. Ophthalmic Clinical Examination. Oxford Textbook of
Ophthalmology. Oxford; 1999.
1
Summary of changes to OST curriculum study guide
July 2010


Rowe F. Clinical Orthoptics. Blackwell; 2004.
Broadway DC, Tufnail A, Khaw PT. Assessment of Visual Acuity.
Ophthalmology- Examination Techniques Questions and Answers. 1st ed.
Oxford: Butterworth-Heinemann; 1999: 5-8.
CA3 Assessment and interpretation of visual fields by confrontation
Think:

What neuroanatomical sites give rise to detectable field defects on clinical
examination?
Resources:


Trobe JD, Acosta PC, Krischer JP, Trick GL. Confrontation Visial Field
Techniques in the Detection of Anterior Visual Pathway Lesions. Annals of
Neurology 10, 28-34. 1981. Ref Type: Journal (Full)
Visual Fields Examination and Interpretation. American academy of
Ophthalmology; 1990.
Self Assessment:


Field defects can be simulated! Try practicing on other trainees.
Clinical Rating Form. Ask a colleague to observe your technique, complete a
clinical rating form and give you feedback.
CA4 Demonstrate and teach the appropriate use of the Amsler chart to patients
Resources:

http://www.macular.org/chart.html
CA5 Performance of a complete external eye examination
Resources:

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
Leatherbarrow B. Blepharoptosis. Martin Dunitz; 2002: 29-33.
Broadway DC, Tufnail A, Khaw PT. Assessment of the orbit and proptosis.
Ophthalmology Examination Techniques Questions and Answers. 1st ed.
Oxford: Butterworth-Heinemann; 1999: 28-32.
Easty DL, Sparrow JM. Ophthalmic Clinical Examination. Oxford Textbook of
Ophthalmology. Oxford; 1999.
Self Assessment:

Clinical Rating Form. Ask a colleague to observe your technique, complete a
clinical rating form and give you feedback.
CA6 Examination of the pupils and perform diagnostic pharmacological tests
Think:

What are the pupillary pathways?
2
Summary of changes to OST curriculum study guide
July 2010
Resources:


Kline LB, Bajandas FJ. The Pupil. Neuro-ophthalmology Review Manual. 5th
ed. 2004
American Academy of Ophthalmology. Pupil. Neuro-ophthalmology. 1997.
Self Assessment:

Clinical Rating Form. Ask a colleague to observe your technique, complete a
clinical rating form and give you feedback.
CA7 Perform a cover test and assess ocular motility
Think:


What are the actions of the extraocular muscles?
This is an examination technique that requires a lot of practice
Activity:

Spend time with your orthoptist and ask to participate in their clinics
Resources:



Rowe F. Clinical Orthoptics. Blackwell; 2004.
MacEwen CJ, Gregson RMC. Manual of Strabismus Surgery. 1st ed.
Butterworth Heinemann; 2001.
http://www.mrcophth.com/videosonclinicalexamination
Self Assessment:

Clinical Rating Form. Ask a colleague to observe your technique, complete a
clinical rating form and give you feedback.
CA8 Measure intraocular pressure using applanation tonometry
Resources:

http://www.opt.indiana.edu/riley/HomePage/new_Goldmann_tonometry/2Gold
mann_Tonometry.html
CA9 Perform slit lamp biomicroscopy of the anterior segment using appropriate
illumination techniques and stains, and diagnostic contact lenses
Think:

It is important to know exactly how the slit lamp and its accessories work
Activity:

Get a senior colleague to show you and the instruction manuals are a useful
resource!
3
Summary of changes to OST curriculum study guide
July 2010
Resources:


Easty DL, Sparrow JM. Ophthalmic Clinical Examination. Oxford Textbook of
Ophthalmology. Oxford; 1999
Elkington AR, Frank HJ, Greaney MJ. Instruments. Clinical Optics. 3rd ed.
Blackwell Science; 1999: 165-215.
Self Assessment:

Clinical Rating Form. Ask a colleague to observe your technique, complete a
clinical rating form and give you feedback
CA10 Examine the fundus using appropriate techniques
Think:

Scleral indentation is a skill that takes a lot of practice
Activity:

Take as many opportunities as you can to practise
Resources:

Rosenthal ML. The Technique of Binocular Indirect Ophthalmoscopy. In:
Hilton GF, McLean EB, Chuang EL, editors. Retinal Detachment. 5th ed. San
Francisco: American Academy of Ophthalmology; 1989: 160-203.
Self Assessment:

Clinical Rating Form. Ask a colleague to observe your technique, complete a
clinical rating form and give you feedback
CA11 Perform a directed general medical examination taking into account the
associations between systemic and ophthalmic disease
Think:

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Many of your general medical examination skills will have been developed
during your foundation years. Which ophthalmological problems would prompt
you to use these skills as an ophthalmologist?
When should I request a chaperone?
Resources:

MacLeod's Clinical Examination 11th Edition. ISBN 0443074046. April 2005.
Editors: Douglas,G. Nicol,F. Robertson,C.
CA12 Perform a basic paediatric and developmental examination taking into account
the associations between systemic and ophthalmic diseases
4
Summary of changes to OST curriculum study guide
July 2010
Think:

What developmental milestones would you expect a two year old to be
capabable of?
Resources:

MacLeod's Clinical Examination 11th Edition. ISBN 0443074046. April 2005.
Editors: Douglas,G. Nicol,F. Robertson,C.
CA13 Perform a directed neurological examination taking into account the
associations between systemic and ophthalmic diseases
Think:

Many neurological problems present to the ophthalmologist and a competent
neurological assessment of patients is required
Activity:

Arrange sessions with your local neurology/neurosurgical department in their
clinics or ward rounds to develop your examination skills
Resources:

MacLeod's Clinical Examination 11th Edition. ISBN 0443074046. April 2005.
Editors: Douglas,G. Nicol,F. Robertson,C.
CA14 Examine the neck taking into account associations between systemic and
ophthalmic diseases
Resources:

MacLeod's Clinical Examination 11th Edition. ISBN 0443074046. April 2005.
Editors: Douglas,G. Nicol,F. Robertson,C.
CA15 Examine the skin and joints taking into account the associations between
systemic and ophthalmic diseases
Resources:

MacLeod's Clinical Examination 11th Edition. ISBN 0443074046. April 2005.
Editors: Douglas,G. Nicol,F. Robertson,C.
CA16 Formulate a differential diagnosis
Activity:

Make it routine at the end of a consultation to document a differential
diagnosis.
5
Summary of changes to OST curriculum study guide
July 2010
http://curriculum.rcophth.ac.uk/study-guide/patient_investigation
Key:
Additions in red support changes made in response to stakeholder feedback
Additions in green support medical leadership enhancements
PATIENT INVESTIGATION (PI) STUDY GUIDE
PI1 Orthoptic assessment
Think:



An orthoptic assessment is essential for the proper diagnosis of ocular motility
disorders
What does an orthoptic report mean and how can I interpret it?
What is a Hess chart/Lees screen and how do I interpret it?
Activity:
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Attend orthoptic clinics regularly
Learn from the orthoptists how they perform a cover test and practice this with
them watching you. Learn to talk to your patient, especially children and make
them cooperate with your instructions
Learn how to handle a prism bar effectively
Read an orthoptic report and learn what the notation means
Watch the orthoptist performing a Hess/Lees screen examination
Interpret the results
Become familiar with the Hess chart pattern of common oculomotor disorders
Resources:



MRCOphth.com
Easty DL, Sparrow JM. Ophthalmic Clinical Examination. Oxford Textbook of
Ophthalmology. Oxford; 1999
Rowe F. Clinical Orthoptics. Blackwell; 2004.
Assessments:




Clinical Rating Form. Ask a colleague to observe your technique, complete a
clinical rating form and give feedback.
Case based discussions
Part 1 FRCOphth, OSE
Part 2 FRCOphth, OSCE
PI2 Assessment of corneal shape, structure and thickness
Think:

Investigations for these parameters are very useful for determining refractive
problems as well as managing glaucoma.
6
Summary of changes to OST curriculum study guide
July 2010
Activity:
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
Watch senior colleagues perform these investigations and then ask if they
can watch you doing it. Try and practice on the two standard keratometers
(Javal-Schiotz and Von Helmholtz). Also use a corneal topographer and
interpret the printout obtained. Have the technique done on yourself to
appreciate what the patient has to do.
Some instruments such as specular microscopy and pachymetry may not be
available in your hospital. If this is the case try and find out as much as you
can about those instruments you are unable to lay your hands on from
sources such as manufacturers websites. Make sure you know what the
printout of such machines looks like and how you would interpret it.
Resources:


MRCOphth.com
Easty DL, Sparrow JM. Ophthalmic Clinical Examination. Oxford Textbook of
Ophthalmology. Oxford; 1999
Assessment:




Clinical Rating Form. Ask a colleague to observe your technique, complete a
clinical rating form and give you feedback.
Case based discussions
Part 1 FRCOphth. OSE
Part 2 FRCOphth. OSCE
PI3 Retinal and optic nerve imaging techniques
Think:

These are common investigations done by all eye departments. What
techniques are utilised and what structures are imaged by these methods?
Activity:
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Participate in as many photographic imaging sessions as you can
Attend a diabetic screening programme
Try and use the instruments available yourself
Be experienced in interpreting the pictures obtained
Attend workshops and clinical forums when these topics are discussed
Be aware that there are many instruments which may not be widely available
in every eye unit. If this is the case try and find out as much as you can about
those instruments you are unable to lay your hands on from sources such as
manufacturers websites.
Resources:


MRCOphth.com
Easty DL, Sparrow JM. Ophthalmic Clinical Examination. Oxford Textbook of
Ophthalmology. Oxford; 1999
7
Summary of changes to OST curriculum study guide
July 2010
Assessment:




Clinical Rating Form. Ask a colleague to observe your technique, complete a
clinical rating form and give you feedback.
Case based discussions
Part 1 FRCOphth. OSE
Part 2 FRCOphth. OSCE
PI4 Ocular angiography
Think:

This is a common technique employed by all eye units. What are the
techniques involved and what structures are being imaged
Activity:


Participate in as many Fluorescein angiography sessions as you can. Talk to
the photographer taking the pictures. Be involved in taking the photographs
and understand the techniques of the particular retinal camera used.
Understand the nature of the filters used. Become experienced in interpreting
the images obtained.
Indocyanine green angiography may not be available in your hospital. Try and
find out the indications for its use and its limitations. Try and attend
workshops and study days for angiography.
Resources:


MRCOphth.com
Easty DL, Sparrow JM. Ophthalmic Clinical Examination. Oxford Textbook of
Ophthalmology. Oxford; 1999
Assessment:




Clinical Rating Form. Ask a colleague to observe your technique, complete a
clinical rating form and give you feedback.
Case Based discussions
Part 1 FRCOphth. OSE
Part 2 FRCOphth. OSCE
PI5 Ultrasonography
Think:
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


What structures are imaged by these techniques?
What is the difference between an A-scan and a B-scan?
What are the physical principles employed?
What are the newer techniques of ultrasound imaging?
8
Summary of changes to OST curriculum study guide
July 2010
Activity:
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

Watch senior colleagues perform these investigations. Ask them to take you
through what they are doing and why. Ask them to watch you doing the same
thing.
Use any opportunity to perform a B-scan - eg. a vitreous haemorrhage you
may see in the Casualty clinic.
Ask the technician or nurse in charge of the cataract pre-operative
assessment clinic to allow you to perform the biometry. Be aware of the
differing printouts of the machines and learn how to interpret them accurately.
Resources:


MRCOphth.com
Easty DL, Sparrow JM. Ophthalmic Clinical Examination. Oxford Textbook of
Ophthalmology. Oxford; 1999
Assessment:




Clinical Rating Form. Ask a colleague to observe your technique, complete a
clinical rating form and give you feedback.
Case Based discussions
Part 1 FRCOphth. OSE
Part 2 FRCOphth. OSCE
PI6 Radiology and other neuro- imaging
Think:
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What are the structures identified in X-rays, CT scans and MRI scans?
What are the differences between the techniques?
Be aware of the physical principles of the investigations.
What contrast media are used to enhance the images obtained?
What are the newer investigations that are coming into common practice e.g.
PET scans?
Activity:
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
Observe as many images as you can and read the associated report. Ask a
senior colleague to go through the findings with you.
Try and visit the radiology department and ask questions of the clinicians and
technicians there.
Try and attend seminars and workshops of relevant radiology.
Resources:


MRCOphth.com
Easty DL, Sparrow JM. Ophthalmic Clinical Examination. Oxford Textbook of
Ophthalmology. Oxford; 1999
9
Summary of changes to OST curriculum study guide
July 2010
Assessment:




Clinical Rating Form. Ask a colleague to observe your technique, complete a
clinical rating form and give you feedback.
Case Based discussions
Part 1 FRCOphth. OSE
Part 2 FRCOphth. OSCE
PI7 Ocular and neuro-electrophysiology
Think:
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

Why are these techniques useful?
What are the principles involved?
Which investigation is appropriate for what ocular pathology?
Activity:


Many hospitals do not have direct access to these techniques and rely on a
larger department for them. If you can gain access to a neurophysiology
department go and observe the techniques in action. Otherwise read the
principles involved and make yourself aware of the various printouts and
parameters of each technique.
If you see a patient in the clinic who needs electrodiagnostic tests try and
accompany them to the investigation.
Resources:



MRCOphth.com
Easty DL, Sparrow JM. Ophthalmic Clinical Examination. Oxford Textbook of
Ophthalmology. Oxford; 1999
Adler. Physiology of the Eye, Clinical Application. Mosby 1999
Assessment:



Case Based discussions
Part 1 FRCOphth. OSE
Part 2 FRCOphth. OSCE
PI8 Biochemistry
Think:

What biochemical tests are relevant to ophthalmology?
Activity:

Study any biochemistry form that arises from your clinical management. Know
the relevance of any variance from the normal values. Talk to a senior
colleague about the relevance of each parameter.
10
Summary of changes to OST curriculum study guide
July 2010
Resources:


Biochemistry of the Eye. Whikehart R. Butterworth-Heinemann
The Eye: Basic Sciences and Practice. Forrester JV, Dick AD,McMenamin P,
Lee WR, WB Saunders Ltd, London
Assessment:



Case based discussion
Part 1 FRCOphth
OSE
PI9 Haematology
Think:

What haematological tests are relevant to ophthalmology?
Activity:

Study any haematology form that arises from your clinical management.
Know the relevance of any variance from the normal values. Talk to a senior
colleague about the relevance of each parameter.
Resources:

The Eye: Basic Sciences and Practice. Forrester JV, Dick AD,McMenamin P,
Lee WR, WB Saunders Ltd, London
Assessment:


Case based discussion
Part 1 FRCOphth. OSE
PI10 Pathology
Think:
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


Pathology, especially histopathology, is an important part of ophthalmology.
How does the pathologist help the ophthalmologist in diagnosing an eye
condition?
How do ocular conditions appear on a cellular level and macroscopically?
How to you transport pathological specimens to the laboratory?
What staining techniques are available for diagnosis?
Activity:
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

Attend clinico-pathological conferences and teaching sessions when
pathologists show and discuss relevant slides.
Find out how to obtain pathological specimens by biopsy or excision.
Whenever you send a specimen to a pathologist for diagnosis, try and attend
the laboratory to look at the specimen under a microscope and discuss the
case with the pathologist.
11
Summary of changes to OST curriculum study guide
July 2010
Resources:



Ocular Pathology: A Text and Atlas. Yanoff M, Fine BS. JB Lippincott Co,
Philadelphia.
Atlas of Ocular Pathology. Yanoff M, Fine BS. Mosby-Wolfe
The Eye: Basic Sciences and Practice. Forrester JV, Dick AD,McMenamin P,
Lee WR, WB Saunders Ltd, London
Assessments:



Case Based discussions
Part 1 FRCOphth. CRQ
Part 2 FRCOphth. CRQ
PI11 Microbiology
Think:

Infection is a common problem in ophthalmology. What organisms are
responsible for ocular infections? How are they isolated and identified?
Activity:




Make yourself aware of the various methods to collect microbiological
specimens.
Become familiar with the techniques to obtain swabs and scrapes of the
ocular tissues.
Learn which transport medium is required for optimal isolation of the
organism.
Learn how to perform a Gram stain out of hours in order to get a preliminary
diagnosis and to initiate treatment of a severe ocular infection.
Resources:



Coster DJ. Procedures. Cornea. BMJ; 2002.
Ocular Pathology: A Text and Atlas. Yanoff M, Fine BS. JB Lippincott Co,
Philadelphia The Eye:
Basic Sciences and Practice. Forrester JV, Dick AD,McMenamin P, Lee WR,
WB Saunders Ltd, London
Assessments:



Case based discussions
Part 1 FRCOphth. CRQ
Part 2 FRCOphth. CRQ
PI12 Biometry
Think:

The commonest cause of patient dissatisfaction in ophthalmology is the
implantation of an incorrect power intraocular lens. How do you accurately
assess the power of an intraocular lens?
12
Summary of changes to OST curriculum study guide
July 2010
Activity:



Attend the pre-operative assessment clinic, often run by nurse practitioners.
Become familiar with the biometry apparatus in your department including
ultrasound A-scans and partial coherence interferometers. Know what the
printout looks like and the relevance of the A-constants of each individual
implant/surgeon.
Always predict a particular power for the intraocular lens and then compare
your estimate with the surgeon who is in charge of the patient.
Perform a continuous audit of the refractive outcome of your cataract surgery
to refine your own A-constant.
Resources:

Cataract Guidelines pp25 - 30: Royal College of Ophthalmologists 2004
Assessment:



Case Based discussions
Part 1 FRCOphth. OSE
Part 2 FRCOphth. OSCE
PI13 Fields (automated, manual)
Think:

Visual field analysis is a vital part of an ophthalmic examination. What
instruments are available to analyse the visual field? How do they function?
What are their limitations? What are the different programmes and which one
should be chosen for what condition?
Activity:

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

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
All eye units should have an automated visual field analyser. Ensure you
observe a technician performing such a test.
Have a test performed on yourself to appreciate the problems that patients
may have whilst doing the test.
Learn how to set up the instrument properly including the provision of the
refractive error in the eyepieces.
Find out about the fixation monitoring protocols and the meaning of the
reliability indices.
Know which programme to select for glaucoma monitoring, neurological
assessment and driving standards.
If there is a Goldmann perimeter in the department, take the opportunity to
watch a field analysis being done using this instrument. Know the differing
nomenclature for the spot size, illumination of the target etc.
Resources:


Automated visual field analysis - J Sowka. 2005
http://www.nova.edu/~jsowka/Course_Notes/Glaucoma%20Visual
%20Fields.doc
13
Summary of changes to OST curriculum study guide
July 2010

Visual Fields Examination and Interpretation. American Academy of
Ophthalmology; 1990.
Assessment:




Clinical Rating Form. Ask a colleague to observe your technique, complete a
clinical rating form and give you feedback.
Case Based Discussions
Part 1 FRCOphth. OSE
Part 2 FRCOphth. OSCE
PI14 Immunology and allergy testing
Think:

What are the immunological processes involved in ophthalmic conditions?
What investigations can be performed by ophthalmologists in the clinic?
Activity:




Study any immunological form that arises from your clinical management.
Learn the relevance of any variance from the normal values.
Be aware of allergy testing such as the patch test.
Talk to a senior colleague about the relevance of each parameter.
Resources:

The Eye: Basic Sciences and Practice. Forrester JV, Dick AD,McMenamin P,
Lee WR, WB Saunders Ltd, London
Assessment:


Case based discussion
Part 1 FRCOphth. OSE
PI15 Urinalysis
Think:

Urine testing is simple and can be revealing. What conditions relevant to
ophthalmology can be revealed by testing the urine?
Activity:


Observe a colleague testing urine with clinical diagnostic sticks.
Learn the variety of biochemical abnormalities that can be detected with the
sticks
Resources:

MacLeod's Clinical Examination 11th Edition. ISBN 0443074046. April 2005.
Editors: Douglas,G. Nicol,F. Robertson,C.
14
Summary of changes to OST curriculum study guide
July 2010
Assessment:

Case based discussions
PI16 Bone scans
Think:

Bone scans are relevant to ophthalmic patients on long term steroid therapy
Activity:


Remember that bone scans may need to be ordered for patients who are on
long term steroid therapy. Look at the report and if possible the image of a
bone scan.
Revise the relevant abnormalities that may be expected in patients with
osteoporosis.
Resources:

http://www.medicinenet.com/bone_density_scan/article.htm
Assessment:



Case Based Discussions
Part 1 FRCOphth
Part 2 FRCOphth
15
Summary of changes to OST curriculum study guide
July 2010
http://curriculum.rcophth.ac.uk/study-guide/patient_management
Key:
Additions in red support changes made in response to stakeholder feedback
Additions in green support medical leadership enhancements
Additions in brown support Common Competencies Framework
enhancements
Additions in grey support ethics curriculum enhancements
PATIENT MANAGEMENT (PM) STUDY GUIDE
PM1 To formulate and agree with the patient a management plan based upon clinical
assessment and investigations, with reference to established protocols and
guidelines
Think:









How can I best develop my personal patient management skills?
What are the gaps in my knowledge and competencies which I need to
address? - and in particular which will I attempt to fill in the next 6 months?
Can I organise my thoughts appropriately, or do I need to improve my powers
of logic and decision-making?
Am I aware of published guidelines to help me take an evidence-based
approach?
Can I communicate my suggested management plan clearly and be sure I
have correctly interpreted my patients’ understanding, motivation and ability
to carry out the management plan?
Do I ensure my patients feel comfortable to discuss or question my
management plan without anxiety of compromising their future care?
Can I improve my patients’ ability to administer treatment with advice, devices
or referral to other staff or agencies?
How can I best involve and support the patient in the management of their
condition (“self-care”) and help their family, friends and carers to assist them?
What are the risks and benefits of the management options and how can I
best communicate these to the patient?
Activity:




Ensure that your Programme Director and local trainer have planned your
timetable to provide wide exposure to range of cases in a supportive,
supervised environment
Observe senior colleagues as they formulate management plans, and ask
questions - even "stupid" ones!
Ask senior colleagues to discuss your management plans for your patients
and criticise constructively
Take time to present cases (particularly new or difficult cases) both in the
clinic situation and in meetings ("Case-based Discussions")
Resources:

Case based discussions, Ophthalmology Fact Fixer (MCQ revision) CN Chua,
Voon and Goel Radcliffe medical Press 2002
16
Summary of changes to OST curriculum study guide
July 2010



Royal College Ophthalmologists guidelines on common problems: e.g.
management of glaucoma, retinal vein occlusion, cataract, diabetic
retinopathy (http://www.rcophth.ac.uk/about/publications/)
The Wills Eye Manual : Office and Emergency Room Diagnosis and treatment
of Eye Disease. Kunimoto et al. Lippincott Williams and Wilkins (2004)
Oxford Textbook of Ophthalmology. Easty and Sparrow. Oxford Medical
Publications (1999)
PM2 To make appropriate use of triage and prioritise or refer patients when indicated
Think:


How do I decide which is the most urgent case?
Which patient has a condition which will respond to rapid intervention?
Activity:





Participate in weekly casualty sessions
Participate in on call sessions
Get involved in accepting acute referrals from GPs and A and E Departments
Develop an algorithm for priorities : preserve life, preserve sight, relieve pain
Maintain life support skills annually
Resources:



Access to above with correctly equipped eye exam room, working alongside
nurse practitioners and with access at all times to more senior opinion
Wills Eye Manual
Oxford Textbook of Ophthalmology. Sparrow and Easty. Oxford (1999)
PM3 Prescribe and administer appropriate local and systemic therapy
Think:










What is the anatomy of eye/ orbit?
What needle should I use?
What are the actions and side effects of drugs I am giving?
What are the actions, side effects and interactions of drugs my patient is
receiving and what monitoring may be necessary?
What special considerations should be taken when prescribing in pregnancy
and lactation?
In what situations may a dose adjustment be required?
How can I best minimize use of drugs?
How often should a drug regime be reviewed?
What do I need to tell my patient/carer about the drugs?
How can I monitor and improve concordance with treatment?
Activity:

Administration of :


topical drops
subconjunctival injections
17
Summary of changes to OST curriculum study guide
July 2010



intravenous steroid
acetazolamide and other agents
antibiotics topically, orally and IV, and intravitreally (year 5)
Resources:






Sessions in casualty and in operating theatre so techniques can be learned
under supervision
Access to and use of hospital pharmacy advice, BNF, Drug company
information
Education on long term effects of steroids (e.g. from rheumatologist)
Wills Eye Manual
Clinical Ophthalmologyl, 5th ed. Kanski, J.
The Pharmacological Basis of Therapeutics, 9th ed. Goodman and Gilman.
McGraw Hill (1996)
PM4 To select appropriate cases for surgery
Think:

What is the purpose of consent?
Activity:






Attendance at clinics where decisions to offer surgery are made e.g. one stop
cataract clinics, cyst clinics
Observation and training in taking informed consent
Pre-operative rounds with senior colleagues
Observation and practical experience in surgical procedures and post
operative management
Video analysis of taking informed consent
Case based discussions with trainers
Resources:






Time for training in above issues
Written information leaflets on specific procedures
GMC guidelines on informed consent, consent taking for children and those
patients with reduced ability to give consent
Royal College Ophthalmologists information on consent, eg information and
consent document on cataract surgery
Local Trust and departmental guidance on consent, forms to be used etc
Essential ophthalmic surgery Foss, A. Butterworth (2000)
PM5 To prepare patients for surgery
Activity:




Attendance at and participation in pre-op assessment clinics
Attendance and participation in administration of local anaesthesia for
ophthalmic procedures
Experience in preparation of patients of all ages for general anaesthesia
Pre-op assessment following local protocols
18
Summary of changes to OST curriculum study guide
July 2010

Recognition of patients with conditions which render either local or general
anaesthesia hazardous in that individual
Resources:






Formal lecture from anaesthetic colleagues on aspects of general
anaesthesia and sedation
Attendance at courses on practical aspects of local anaesthesia for
ophthalmic operations
Royal College of Ophthalmologist and Anaesthetists joint document on
Guidelines for Anaesthesia for Cataract Surgery
American Society of Anaesthesiologists ASA Standards, Guidelines and
Statements 1999 American Society of Anaesthesiologists, Park Ridge (2000)
The pharmacological Basis of Therapeutics, edition 9. Goodman and Gilman.
McGraw Hill (1996)
Chapters on anaesthesia in Phacoemulsification Principles and Techniques,
Buratto et al. (2003) (ISBN 1- 55642-604-6)
PM6 To assess the progress of disease and response to treatment or surgery
Activity:


Opportunity to attend contact lens/corneal clinics awareness of various
contact lens types and associated risks
Experience management of complications of contact lens wear
Resources:



Courses on contact lenses and or corneal diseases (e.g.Institute of
Optometry course)
Ocular Infection investigation and treatment in practice. Seal, Bron and Hay.
Dunitz (1999)
Institute of Optometry website (www.ioo.org.uk)
PM7 To recognise and manage local and systemic complications of treatment
Think:


What are potential benefits and side effects from the treatment I am
recommending?
What was last serious clinical incident in the department and how was it
handled?
Activity:




Look up side effects of any treatment you are proposing, whether
pharmacological, surgical or other intervention
Look up average complication rates of procedures and be alert for these
being exceeded
Take every opportunity to examine patients pre and post intervention and
follow their progress
Take time to discuss progress with senior colleagues and modify
management in light of response or complications
19
Summary of changes to OST curriculum study guide
July 2010




Observe and seek practical experience of the recognition and management of
complications of treatment
Seek training at induction and later in what constitutes a serious clinical
incident and how it is reported
Observe the management of clusters of infectious incidents and how these
are reported and managed
Participate in clinical audit and governance at local, regional and national
levels
Resources:


RCOphth.ac.uk/scientific/audit
http://www.dh.gov.uk/en/Publicationsandstatistics/Statistics/DH_077094
PM8 To apply emergency management of medical problems and first aid
Think:

What are vital signs and can I assess deterioration in these signs?
Activity:


Attendance in Accident and Emergency Department or on acute Medical Firm
Practice BLS on mannekins
Resources:


Basic Life support courses
http://www.resus.org/
PM9 To manage anaphylaxis and cardiopulmonary resuscitation (basic life support)
Think:

How would I act if a patient collapsed after fluorescein injection in the Eye
Clinic?
Activity:




Attend the Accident and Emergency, acute Medical firms and/or Intensive
Care Unit.
Check resuscitation trolleys in Eye Department
Attend Basic life support course with refresher course regularly
Practice techniques on mannekins
Resources:




British Heart Foundation guidelines
Local Trust information packs on BLS
Departmental protocols on management of anaphylaxis
http://www.resus.org/
20
Summary of changes to OST curriculum study guide
July 2010
PM10 To interpret and apply visual standards for driving and occupational visual
standards
Think:



Do I know about the visual standards for employment and driving?
What do I say to a patient about driving if he/she does not meet occupational
or driving standards?
What techniques are involved in assessing vision for these purposes?
Activity:




Look up and learn the DVLA driving standards for all types of vehicle
Find out how to access visual standards for a variety of occupations, e.g.
pilots, police etc
Learn the principles and interpretation of the visual tests involved, eg
Ishihara, Estermann visual fields
Find out the practical difficulties of these tests by performing them yourself
and having them done on yourself!
Resources:


http://www.dvla.gov.uk/media/pdf/medical/aagv1.pdf
http://www.caa.co.uk/docs/49/SRG_MED_JARClass2InitialVisStds%5B538%
5D.pdf
PM11 To refer patients, when appropriate, for provision of low vision aids and
rehabilitation services for the visually impaired, and interpret and apply the criteria for
registration with visual impairment
Think:



Do I know the criteria for registration of partial and severe visual impairment?
Do I know about local and national organisations which support visually
impaired people?
Patients involved in a support group can contribute to helping others as well
as benefiting themselves
Activity:





Take part in the completion of the CVI form (Certificate of Visual Impairment)
Attend Low Visual Aid and Visual Rehabilitation clinics
Practice the assessment of low visual aids appropriate to the condition
Go out with a social services support worker on the home assessment of a
person with vision problems
Go out with an educational support officer working with visually impaired
children
Resources:


http://www.rnib.org/
Clinical Optics. Elkington and Frank
21
Summary of changes to OST curriculum study guide
July 2010

Sinclair A, and Ryan B. Low Vision: The Essential Guide for
Ophthalmologists. The Guide Dogs for the Blind Association, Reading, (2008)
ISBN 978-0-9559268-0-8
PM12 To involve, and make appropriate referrals to, medical and non-medical
colleagues
Think:



Do I know about systemic conditions caused by or linked to ophthalmic
problems?
When can another professional help or add to the management of a patient?
Do I know the urgency with which onwards referrals should be made to other
professionals?
Activity:



Attend general practice, medical, neurological and genetics clinics
Ask to work with allied medical professions (dieticians, orthoptists,
optometrists, social services staff) to develop an appreciation of their roles
Observe those involved in providing visual support services
Resources:




Clinical Ophthalmology, 5th Ed. Kanski J
http://www.rnib.org/
Local Social services for visual impairment
NICE.org.uk for clinical guidelines on various conditions
PM13 To recognise and act upon ocular findings and treatments that have
implications for the general health and well-being of patients
Think:


Do I know, and can I recognise, the associations between ophthalmic
conditions and systemic diseases?
Do I understand to when and to whom it is appropriate to refer a patient for
further investigation or management of systemic problem?
Activity:


Attend joint/special clinics e.g relating to diabetes, neurology, rheumatology,
paediatric and genetic clinics
Ensure that you routinely assess the whole patient rather than their
ophthalmic problem alone
Resources:




MRCOphth.com CN Chua website
Clinical Ophthalmology, 5th Ed. Kanski J.
Eye in Systemic Disease Kanski J, et al Butterworth Heinemann
American Academy Ophthalmology BCSC
22
Summary of changes to OST curriculum study guide
July 2010
PM14 To use spectacle lenses and prisms when indicated
Think:



In what situations should I advise correction of a refractive error, and when
should it be left uncorrected?
What are the different forms of spectacle lens, and what are their advantages
and disadvantages?
What forms of prism correction are available and when should I advise their
use?
Activity:



Read up on the optics of refractive correction
Talk to a local optometrist about the spectacle correction of refractive errors
Arrange to sit in with an optometrist and a dispensing optician for one or two
sessions
Resources:

Duane's Clinical Ophthalmology, Ed Tasman W and Jaeger EA. Lippincott,
Williams & Wilkins. 2002. Volume 1, Chapters 42-53.
PM15 To use contact lenses when indicated
Think:






Do I understand the optics of contact lenses?
Do I understand the basic principles of fitting of hard and soft lenses?
What are the indications for refractive and therapeutic uses of contact lenses?
What rules and procedures should a practitioner and a patient follow for safe
contact lens wear?
What complications can arise and how do they present?
How should I manage contact lens complications?
Activity:




Read up on the necessary basic sciences (optics, microbiology, properties of
the various lens materials and care solutions)
Attend contact lens clinics, discuss cases with the practitioner and observe
practice
Ask to be involved in inserting and removing bandage contact lenses
Get involved in recognising and managing acute complications as they
present to the ophthalmic department
Resources:


Clinical Optics. Elkington and Frank
American Academy Ophthalmology BCSC section on contact lenses
23
Summary of changes to OST curriculum study guide
July 2010
PM16 To advise on the benefits and limitations of refractive surgery
Think:




What alternative corrective techniques are available to a patient with a
refractive error? (spectacles, contact lenses, forms of refractive surgery)
What are the pros and cons of all of these?
What are the relative risks?
What are the indications for refractive surgery?
Activity:




Attend assessment , counselling, treatment and follow-up sessions for
refractive surgery
Attend refractive surgery sessions at postgraduate meetings (eg UKISCRS,
ESCRS)
Attend a refractive surgery training course (eg ESCRS Residents programme
1 day course)
Try to get involved with the management of refractive surgery complications
as they present to eye casualty
Resources:




http://www.rcophth.ac.uk/about/publications/ section on refractive surgery and
laser standards
American Academy BCSC refractive module
Standards for laser refractive surgery Dec 2004
Excimer Laser PRK - Best clinical practice guidelines 1998
PM17 To select patients for laser treatment when indicated
Think:


Do I understand the different types of laser techniques used to treat
ophthalmic diseases?
Do I understand the risks and benefits associated with each treatment?
Activity:




Read up the basic physics of lasers
Assess and discuss cases in clinic which could benefit from laser treatments
Attend dedicated laser sessions to observe and perform procedures
Ensure you see patients for follow-up post laser therapy
Resources:



Phacoemulsification principles and techniques, 2003, Buratto et al chapter
43.1,43.2, 43.7
Guidelines for diabetic retinopathy, Royal College Ophthalmologists 2004
Terminology and Guidelines for Glaucoma, European Glaucoma Society,2nd
ed. 2003. www.eugs.org
24
Summary of changes to OST curriculum study guide
July 2010
PM18 To understand and promote the importance of diet and nutrition in ophthalmic
disease
Think:





Do I remember my generic nutrition training from medical school?
Do I know which systemic diseases with a link to nutrition have ophthalmic
manifestations?
Do I know which specific ophthalmic diseases are linked to nutrition?
Do I understand the links between poverty/affluence and nutrition?
What might my patients know about this subject which I might not know?
Activity:




Revise general nutrition
Look up links between nutrition and ophthalmic disease
Consider nutritional status when assessing future ophthalmic patients (eg
diabetics, macular degeneration patients)
Arrange to speak to a nutritionist in your Trust about these issues, and/or ask
for a session on nutrition in your local postgraduate programme
Resources:




General medical textbooks
http://www.nutrition.org.uk
http://www.rnib.org.uk/xpedio/groups/public/documents/PublicWebsite/public_
nutrition_eye.hcsp
http://www.transceiver.com/eye/resources.html
25
Summary of changes to OST curriculum study guide
July 2010
http://curriculum.rcophth.ac.uk/study-guide/practical_skills
Key:
Additions in red support changes made in response to stakeholder feedback
PRACTICAL SKILLS (PS) STUDY GUIDE
PS1 Recognise and assist with the special needs of people with visual impairment in
the clinical environment
Think:

How would you assist a visually impaired person who came to see you in the
eye clinic? and what changes could be made to the physical environment?
Resources:




www.guidedogs.org.uk - Guidelines on internal and external physical
environment
www.rnib.org.uk - all sorts of help and advice
www.actionforblindpeople.org.uk/ - eg Can help with local staff training
Sinclair A, and Ryan B. Low Vision: The Essential Guide for
Ophthalmologists. The Guide Dogs for the Blind Association, Reading, (2008)
ISBN 978-0-9559268-0-8
PS2 Perform a refractive assessment and provide an optical prescription
Think:

How does refracting children differ from refracting adults?
Activity:




Ask your departmental or local optometrist to teach you to refract
Familiarise yourself with optical prescription documentation
Practice on colleagues, friends, secretarial staff and as many patients as you
can. Get a senior colleague to observe and give feedback
Consider going on a Refraction Course
Resources:

Elkington AR, Frank HJ, Greaney MJ. Clinical Optics. 3rd ed. Blackwell
Science; 1999: 165-215.
Self-Assessment:

Optics and Refraction section www.mrcophth.com
PS3 Administer periocular and intraocular drugs
Think:


What clinical anatomy is relevant to the administration of periocular drugs?
What are the methods of action and pharmacokinetics of these drugs?
26
Summary of changes to OST curriculum study guide
July 2010

How do you constitute and administer intravitreal antibiotics? Remember ! this
is often performed in an emergency situation out of hours
Resources:



Kunimoto DY, Rapuano CJ, Friedberg MA, Maker M, Kanitkar KD. The Wills
Eye Manual:Office and Emergency Room Diagnosis and Treatment of Eye
Disease. 4th ed. Appendix 7. Technique for Sub-Tenons and subconjunctival
injections. Lippincott Williams and Wilkins; 2004
Duane's Ophthalmology 2004 CD-ROM. Chapter 23 Pharmacokinetics. Joel
S. Mindel
British National Formulary
PS4 Perform venesection, cannulation and set-up intravenous infusions
Resources:

The Hands-On Guide for House Officers. 2nd Ed. Anna Donald and Michael
Stein. Blackwell Publishing. 2002. Chapter 13 - Practical Procedures
PS5 Achieve appropriate local anaesthesia, and recognise the possible
complications
Think:

How much local anaesthetic can I safely give a patient?
Resources:



British National Formulary
Canavan KS, Dark A, Garrioch MA. Sub-Tenon's administration of local
anaesthetic: a review of the technique. British Journal of Anaesthesia 90[6],
787-793. 2003
Royal College Guidelines on Local Anasthesia at
http://www.rcophth.ac.uk/docs/publications/LocalAnaesthesia.pdf Lots of
useful references.
PS6 Use diathermy appropriately and safely
Think:

What settings do you start with on your diathermy machine for ocular and
extraocular procedures?
Resources:

Gonnering R S. Ch5. Physical Modalities and their Application. Monograph
No 8 Surgery of the Eyelid, Orbit and Lacrimal System. American Academy of
Ophthalmology; 1993
PS7 Use cryotherapy appropriately and safely
Activity:
27
Summary of changes to OST curriculum study guide
July 2010

Dig out the manual for your departmental cryotherapy machine and ensure
you know how to operate it safely
Resources:


Gonnering R S. Ch5. Physical Modalities and their Application. Monograph
No 8 Surgery of the Eyelid, Orbit and Lacrimal System. American Academy of
Ophthalmology; 1993
The Unwanted Eyelash. Focus. Royal College of Ophthalmologists. Winter
2002 http://www.rcophth.ac.uk/scientific/focus
PS8 Assess lacrimal function
Think:

How would you examine a patient who complained of a watery eye?
Resources:



Management of Epiphora. Focus. Royal College of Ophthalmologists. Spring
2000. Available on request
www.emedicine.com/oph/topic465.htm
Nguyen LK, Linberg JV: Evaluation of the lacrimal system. In: Surgery of the
eyelid, orbit, and lacrimal system. American Academy of Ophthalmology
1995; 3: 254-69
Self Assessment:

www.djo.harvard.edu/site.php?url=/physicians/kr/731&page=KR_ QU
PS9 Perform anterior chamber paracentesis
Think:







When is anterior chamber paracentesis indicated?
What are the pros and cons of the procedure?
Where is the best place to perform the procedure?
What steps do I need to take to maximise patient safety?
Do I need to use the operating microscope?
What instruments are best to use?
What are the patient consent issues?
Activity:


Discuss the indications and technique of the procedures with your trainers
and colleagues
Keep alert for occasions when the procedure is going to be undertaken in
your department and try to be present/ask to perform it under supervision
Resources:

Duane's Clinical Ophthalmology, Eds Tasman W and Jaeger EA. Volume 4,
Chapter 35. Lippincott, Williams and Wilkins, 2002.
28
Summary of changes to OST curriculum study guide
July 2010

C M G Cheung, O M Durrani and P I Murray. The safety of anterior chamber
paracentesis in patients with uveitis. British Journal of Ophthalmology 2004;
88: 582 - 583
PS10 Perform a corneal scrape
Activity:

Contact your local microbiology department to find out what the plating
procedures are in your hospital
Resources:

Coster DJ. Procedures. Cornea. BMJ; 2002.
PS11 Remove ocular surface foreign bodies
Activity:

This is a very common procedure in casualty clinics. Take advantage of
opportunities very early in your training to performing this under supervision
as it is a skill you are likely to need soon!
PS12 Occlude the nasolacrimal puncta
Think:

What are the various permanent and non-permanent ways of occluding the
puncta?
Resources:

Surgery of the Eyelid, Orbit and Lacrimal System. American Academy of
Ophthalmology (1993)
PS13 Remove sutures from eye and adnexae
Think:


Can you identify the different types of suture material?
When may it be appropriate to prescribe topical treatment following suture
removal?
PS14 Fit a bandage contact lens
Think:

How would you determine which size of bandage contact lens to use?
Resources:

www.assoc-optometrists.org/uploaded_files/pdf/fm-tcl-info1.pdf
29
Summary of changes to OST curriculum study guide
July 2010
PS15 Administer periocular botulinum injections
Think:



Is the dose of botox for inducing a ptosis the same as that for treating squints
or blepharospasm?
Using botox for strabismus may be a procedure you will not get exposure to in
training but it is worth knowing about as a management option
What complications would you warn the patient of before giving a botox
injection for Blepharospasm
Resources:






Adams GG. Kirkness CM. Lee JP. Botulinum toxin A induced protective
ptosis. [Journal Article] Eye. 1 ( Pt 5):603-8 (1987)
Costa J. Espirito-Santo C. Borges A. Ferreira JJ. Coelho M. Moore P.
Sampaio C. Botulinum toxin type A therapy for blepharospasm. [Review] [49
refs] [Journal Article. Review] Cochrane Database of Systematic Reviews.
(1):CD004900 (2005)
Dutton JJ: Botulinum-A toxin in the treatment of craniocervical muscle
spasms: mic Short- and long-term, local and systemic effects. Surv
Ophthalmol 41:51-65 (1996)
Harrison AR. Chemodenervation for facial dystonias and wrinkles. [Review]
[46 refs] [Journal Article. Review. Review, Tutorial] Current Opinion in
Ophthalmology. 14(5):241-5 (2003)
MacEwen CJ, Gregson RMC. Manual of Strabismus Surgery. 1st ed.
Butterworth Heinemann. (2001)
Kirkness CM. Adams GG. Dilly PN. Lee JP. Botulinum toxin A-induced
protective ptosis in corneal disease. [Journal Article] Ophthalmology.
95(4):473-80, (1988 Apr)
PS16 Apply corneal glue
Think:
 When might glueing be necessary?
 When might I have to do it myself in an emergency?
 How can I ensure my competence, as it is needed only rarely?
Activity:
 You MUST have 2 DOPS assessments by OST7
(If necessary this can be done in the wet-lab)
Resources:

Coster DJ. Procedures. Cornea. BMJ. (2002) (Some good tips here)
PS17 Perform ocular ultrasound
Think:

What extra information can you gain from actually performing the ultrasound
as opposed to looking at a still print-out?
30
Summary of changes to OST curriculum study guide
July 2010
Resources:

Examination Techniques for the Eye. In: Byrne SF, Green RL, editors.
Ultrasound of the Eye and Orbit. 2nd ed. 15-44. Mosby. (2002)
PS18 Demonstrate lid hygiene to a patient
Think:

Are you aware of any patient literature on this topic in your department?
PS19 Perform anterior chamber and vitreous sampling
Think:


Post operative endophthalmitis is an emergency. How would you deal with
this situation if you were on call? Discuss this with a senior colleague in
anticipation
How do you constitute and administer intravitreal antibiotics? Remember !
This is often performed in an emergency situation out of hours
Resources:

Steinart RF, Gionni RJ, Osher RH, et al. Complications of Cataract Surgery.
In: Albert, Jacobiec, editors. Principles and Practices of Ophthalmology. 2nd
ed. 1586-1587. (2002)
PS20 Take samples for blood culture
Resources:

The Hands-On Guide for House Officers. 2nd Ed. Chapter 13 - Practical
Procedures. Anna Donald and Michael Stein. Blackwell Publishing. (2002)
PS21 Perform the correct hand hygiene technique
Think:

Do you disinfect your hands between every patient?
Resources:



http://www.dh.gov.uk/en/Publichealth/Flu/PandemicFlu/DH_078752
http://www.ich.ucl.ac.uk/clinical_information/clinical_guidelines/cpg_guideline
_00030
http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947403810
PS22 Carry out irrigation and debridement of ocular contaminants
Resources:
31
Summary of changes to OST curriculum study guide
July 2010



Chemical injuries of the eye: current concepts in pathophysiology and
therapy. [Review] [428 refs] [Journal Article. Review] Wagoner MD. Survey of
Ophthalmology. 41(4):275-313. (1997)
Prompt treatment for chemical eye injuries. [Review] [14 refs] [Journal Article.
Review. Review, Tutorial] Nursing Standard. Hooper M. 11(36):40-3. (1997)
Simple step by step tables on lid eversion, glass rodding and irrigation
PS23 Prepare a biopsy sample for subsequent histopathological and microbiological
assessment
Think:

When might you consider performing a conjunctival biopsy? How would you
do it?
Activity:

Liaise closely with your local laboratories regarding specific requirements for
sample preparation and documentation - particularly if it is a type of biopsy
you do infrequently
Resources:

The Clinician and the Laboratory. Harry J, Mission G.Clinical Ophthalmic
Pathology. Butterworth-Heinemann. (2001)
PS24 Perform forced duction tests
Activity:

Take appropriate opportunities in theatre during squint lists to perform forced
duction tests
Resources:


Manual of Strabismus Surgery. 1st ed. MacEwen CJ, Gregson RMC.
Butterworth Heinemann. (2001)
The Wills Eye Manual:Office and Emergency Room Diagnosis and Treatment
of Eye Disease. 4th ed. Appendix 5. Forced Duction Test. Kunimoto DY,
Rapuano CJ, Friedberg MA, Maker M, Kanitkar KD. Lippincott Williams and
Wilkins. (2004)
Reason for change:
The Curriculum Sub-committee has concluded that this Learning Outcome (PS16) is
important but that the opportunity to demonstrate competence in an actual patient
may not always crop up during a trainee's time in training.
32
Summary of changes to OST curriculum study guide
July 2010
http://curriculum.rcophth.ac.uk/study-guide/surgical_skills
Key:
Additions in red support changes made in response to stakeholder feedback
Additions in green support medical leadership enhancements
Additions in brown support Common Competencies Framework
enhancements
Additions in grey support ethics curriculum enhancements
SURGICAL SKILLS (SS) STUDY GUIDE
SS1 Surgical skills
a) early in training
Think:





Do I know my anatomy?
What instruments will I be using, how do I use them and what are they called?
(As you progress) what are my weak points and how can I improve?
Can I practice this in a simulated environment (see resources)?
Can I be assessed in a simulated environment/wet-lab setting?
Activity:





Go on the College Microsurgical Skills Course (compulsory)
Ask a theatre sister/deputy to show you the instruments, and to let you be
scrub nurse
Watch experienced surgeons and ask questions
Practise, practise, practise
Many skills, such as suturing, can be assessed in a simulated environment
Resources:



Wet lab, or operating microscope out of hours (use plastic practice eyes) with
and without supervision
Surgical simulator
Videos, web sites, books
b) later in training:
Think:



(As you progress) What are my weak points, how can I improve?
What useful techniques have I seen used that are not assessed under other
SS learning outcome requirements?
What surgical procedure do I have the opportunity to perform part of the
utilises a different skills than I have had assessed previously?
Activity:

Watch experienced surgeons to identify different skills and techniques
33
Summary of changes to OST curriculum study guide
July 2010


Discuss with your trainer additional surgical skills they can assess such as
different suturing techniques for different ocular and adnexal tissues to show
understanding of different sutures and knots
Ask to perform steps in a longer procedure that would be a transferable skills,
where you might be unlikely to perform the entire procedure
SS2 Use the operating microscope
Think:





How does the microscope work (optics and mechanics)?
Which buttons do what?
How should I get comfortable at the microscope?
What checks do I need to make before I start operating?
What do I do if the bulb goes out?
Activity:




Go on the College Microsurgical Skills Course (compulsory)
Ask an experienced surgeon to show you the controls and to help you get
comfortable
Watch experienced surgeons and ask questions
Practise under supervision, and on your own, both in and out of hours
Resources:


Manufacturer's manual (?web based?)
Videos, books, websites
SS3 Aseptic surgical technique
Think:



By what routes could the operative field become contaminated?
What can I touch safely when scrubbed?
What is "no-touch technique?
Activity:




Ask theatre sister/deputy to check your scrubbing, gowning & gloving
technique
Ask to be a scrub nurse for a week
Watch experienced surgeons and ask questions
Practise and ask for constructive criticism
SS4 Cataract surgery
a) Early in training
Think:


Exactly what am I trying to achieve by each manoeuvre?
What am I trying to avoid?
34
Summary of changes to OST curriculum study guide
July 2010

How can I learn this with minimal risk to the patient, and minimal stress to the
patient, the trainer and me?
Activity:






Go on the College Microsurgical Skills Course (compulsory)
Ask for supervised wet-lab (or out-of-hours in-theatre) instruction on plastic
eyes then practise over and over again
Discuss with your trainer how (s)he will organise your training (modular,
"reverse-chaining", etc) and how you will be given protected operating time
Agree what signal the trainer will give to tell you (s)he must take over
Record every operation, to review regularly yourself and frequently with your
trainer
Note that although no specific number of cataract operations is required of
trainees, the College advises an indicative minimum number of 50 complete
procedures during the first 2 years of training to help ensure adequate
progress. A continuous audit of the outcomes of your cataract surgery should
be a key part of your practice.
Resources:

Books, videos, meetings, wet lab/out-of/hours theatre, surgical simulator
b) Later in training
Think:



How can I refine my skills to be safe and effective in all cataract cases, even
complex ones?
How can I learn this with minimal risk to the patient, and minimal stress to the
patient, the trainer and me?
How can I be sure that my surgery is good enough?
Activity:





Go on an advanced phaco course
Ask your trainer to show you how to approach difficult cases and then to take
you through them
Continue to use video recording
Continue to seek feedback from your trainers, both formal and informal
Note that although no specific number of cataract operations is required of
trainees, the College advises an indicative minimum number of 350 complete
procedures during the 7 years of training to help ensure satisfactory progress
to fully independent practice. These procedures should include the full variety
of complex cases; in this context complex cases must include high myopes,
cases with previous anterior or posterior segment surgery, cases with
previous iritis, unusually hard or soft cataracts, white cataracts, cases with
pseudoexfoliation syndrome, subluxated lenses and post-trauma cases. A
continuous audit of the outcomes of your cataract surgery should be a key
part of your practice.
35
Summary of changes to OST curriculum study guide
July 2010
SS5 Surgical measures to lower IOP
Think:




When is surgery appropriate?
What am I trying to achieve?
What am I trying to avoid?
How can I learn this with minimal risk to the patient, and minimal stress to the
patient, the trainer and me?
Activity:




Go on the College Microsurgical Skills Course (compulsory)
Ask for supervised wet-lab (or out-of-hours in-theatre) instruction then
practise over and over again
Discuss with your trainer which procedures are appropriate for you to learn,
and how your training will be achieved
Record every operation, to review regularly yourself and frequently with your
trainer
Resources:

Books, videos, meetings, wet lab/out-of-hours theatre, surgical simulator
SS6 Perform surgical repair of ocular and adnexal tissues after trauma
Think:




How can I maximise my exposure to ocular trauma management?
What can I do to practice in a simulated situation?
In what elective procedures can I develop transferable skills for trauma
repair?
What are the generic principles of surgical repair?
Activity:



Take full advantage of training opportunities to learn suturing in elective,
simulated and trauma situations; ask trainers/senior trainees to supervise you
in these contexts
Watch trainers and ask questions
Ensure you are readily available for on-call duties
Resources:

Books, videos, meetings, wet lab/out-of-hours theatre, surgical simulator
SS7 Undertake the surgical management of lid problems
Think:



What anatomy do I need to know?
What can go wrong with eyelids which is amenable to surgical correction?
What complications are possible, and why?
36
Summary of changes to OST curriculum study guide
July 2010




Who can I watch performing lid surgery?
Are my basic tissue-handling/suturing skills good? - what can I do to improve
them?
How should I plan my progression through simple to more-complex lid
surgery?
How should I explain the options and procedures to the patient?
Activity:







Read up lid anatomy and patho-anatomy
Ask to attend clinics dealing with structural lid problems
Watch more senior surgeons and ask them to explain what they are doing,
and why
Practise suturing in the wet-lab, or using spare sutures with apples, grapes,
etc
Ask to be taken through lid procedures (simple at first) and practise them
under supervision
Assess your patients carefully pre and post-op and audit the results
Your surgical logbook should include a range of procedures and your training
should concentrate on helping you develop transferable skills. It is expected
that the procedures would include correction of simple entropion and
ectropion, pentagon excision for lid margin lesions, and upper lid
blepharoplasty.
Resources:

Books, videos, meetings, practice situations
SS8 Undertake surgical measures for the protection of the ocular surface
Think:




When is surgical lid protection necessary?
Does it need to be temporary or permanent?
How can I learn the different techniques?
Who can best teach me?
Activity:





Ask to attend clinics/ward visits dealing with corneal exposure
Look up the surgical techniques available
Watch experienced surgeons performing these procedures
Ask to be taken through the procedures
Practise the procedures until confident
Resources:

Textbooks/videos on lid surgery
37
Summary of changes to OST curriculum study guide
July 2010
SS9 Perform lateral canthotomy and cantholysis
Think:




When is cathotomy/cantholysis required?
What may be the alternatives?
How can I get involved with patients needing these procedures?
Can I manage this patient myself, or do I need help?
Activity:



Actively try to get involved with patients needing these procedures
Watch experienced surgeons/ask to be taken through the procedures
Get involved in the follow-up of these patients
Resources:

Textbooks/videos
SS10 Perform a biopsy of ocular and adnexal tissues
Think:







What tissues may I need to biopsy?
Is incisional or total biopsy indicated?
What are the risks, and can I explain them well enough to the patient?
Can I apply skills I have learned elsewhere, or do I need to learn new skills?
Can I do it myself alone, or with supervision, or do I need to refer the patient
to an expert?
How can I be sure I can cope (eg in emergency with endophthalmitis needing
vitreous biopsy?)
When will the result be available, and who will ensure that it is acted upon
expeditiously?
Activity:






Attend clinics dealing with lid and external eye tumours
Practice skills in "wet-lab" or other simulated situation
Ask to attend lid surgery lists, observe biopsy and ask to be taken through
appropriate procedures
Take advantage of on-call opportunities to perform vitreous biopsy under
supervision
Ask to attend VR lists and to be allowed to set up for pars plana vitrectomy
and perform the core vitrectomy yourself under supervision
Chase up the result yourself (ideally) or at least ensure that someone knows
they are delegated to do so
Resources:

Books, videos, meetings, wet-labs (formal or informal)
38
Summary of changes to OST curriculum study guide
July 2010
SS11 Biopsy the temporal artery
Think:






What are the indications for temporal artery biopsy?
How urgently is it required?
What are the risks and benefits, and how should I explain these to the
patient?
Which side should be biopsied, and where?
How large a specimen is required?
How can I learn the technique safely and effectively?
Activity:





Get involved in appropriate cases
Read up the indications and technique
Watch and ask to be taken through the procedure
Follow up your patient
Ensure that you will receive the result promptly, or at least ensure that
someone knows you have delegated this to them Ensure you know the
significance of the result, and discuss this with colleagues/trainer if necessary
Resources:

Books, videos, trainer, case discussions
SS12 Perform surgery on the extraocular muscles
Think:



How do I decide whether this patient needs muscle surgery at all, and if so
which muscle and which operation?
What are the pros and cons of surgery and how should I explain these to the
patient/parent?
How can I learn muscle surgery with the least possible risk to the patient and
minimal stress to my trainer and myself?
Activity:




Take an active role in orthoptic clinics seeing child and adult patients
Read up on muscle surgery
Discuss cases with, and then watch, experienced surgeons and then ask to
be taken through simple, then more complex procedures
Follow up your patients
Resources:

Orthoptic clinics, textbooks, videos
39
Summary of changes to OST curriculum study guide
July 2010
SS13 Remove the eye when indicated
Think:







When should removal of an eye be considered?
What are the alternatives?
How should I approach the subject with the patient, and how much time
should I give them to consider the alternatives? (And is it really as urgent as I
think it might be?)
What alternative techniques are there, and do I need to balance pros and
cons (eg good cosmesis with implants against risks of extrusion and possible
future delay in detection of secondary tumour)
How can I learn the techniques with minimal risk to the patient and minimal
stress to the trainer and myself?
Can I provide adequate counselling, or does my patient need expert help?
What special considerations apply to the removal of a donor eye from a
cadaver?
Activity:






Get involved in trauma cases
Attend clinics dealing with ocular tumours
Read up about the options and discuss with experts
Observe expert surgeons and ask to be taken through procedures of
gradually increasing complexity You must observe and then perform at least
one enucleation and one evisceration; if the opportunity to perform these
does not arise in your clinical practice you should be assessed (using
OSATS) in the retrieval situation (for enucleation) and the wet-lab (for
evisceration)
Follow up your patients when feasible
Find out what support services are available and how to access them
Resources:

Books, videos, manufacturer's information (on orbital implants, etc)
SS14 Apply appropriate laser for the management of the lens capsule
Think:







What are the indications for laser to the lens capsule?
How does the laser work and what safety precautions are required?
Does my Trust require a formal laser induction process?
What is the balance of risks and benefits, and how should I explain these to
the patient?
Are there any underlying conditions which would alter the risk/benefit ratio?
What complications could ensue, what follow-up is necessary, what warnings
should the patient be given, and will I be able to handle complications myself
or will I need help?
How can I learn the techniques with minimal risk to the patient and minimal
stress to my trainer and myself?
40
Summary of changes to OST curriculum study guide
July 2010
Activity:







Read up on the subject
Check up on Trust procedures
Read the laser manufacturer's manual
Listen to experts talking to patients about the procedure
Watch experts performing laser, then ask to be taken through it with easy and
then with more tricky cases
Follow up your patients and consider an audit
Talk to patients before and after laser
Resources:

Books, videos, meetings, manufacturers' manuals
SS15 Apply appropriate laser for the management of raised intraocular pressure
Think:







What sort of laser procedures are possible for IOP, and what are their
indications?
How does the laser work and what safety precautions are required?
Does my Trust require a formal laser initiation procedure?
What is the balance of risks and benefits, and how should I explain these to
the patient?
Are there any underlying conditions which would alter the risk/benefit ratio?
What complications could ensue, what follow-up is necessary, what warnings
should the patient be given, and will I be able to handle complications myself
or will I need help?
How can I learn the techniques with minimal risk to the patient and minimal
stress to my trainer and myself?
Activity:







Read up on the subject
Check up on Trust procedures
Read the laser manufacturer's manual
Listen to experts talking to patients about the procedure
Watch experts performing laser, then ask to be taken through it with easy and
then with more tricky cases
Follow up your patients and consider an audit
Talk to patients before and after laser
Resources:

Books, videos, meetings, manufacturers' manuals
SS16 Apply appropriate laser for the management of retinal problems
Think:

What are the indications for laser treatment to the retina, and what tests may
be helpful in deciding about treatment?
41
Summary of changes to OST curriculum study guide
July 2010






What sort of lasers are available, and on what basis should one choose
between them? How do the lasers work and what safety precautions are
required?
Does my Trust require a formal laser initiation procedure?
What techniques of laser application are available (delivery systems and
treatment strategies)?
What are the pros and cons of treatment, and how can I best communicate
these to the patient?
What complications could ensue, what follow-up is necessary, what warnings
should the patient be given, and will I be able to handle complications myself
or will I need help?
How can I learn the techniques with minimal risk to the patient and minimal
stress to my trainer and myself?
Activity:








Read up on the subject
Check up on Trust procedures
Read the laser manufacturer's manual
Learn about the various imaging techniques which help with clinical decisionmaking
Listen to experts talking to patients about the procedure
Watch experts performing laser, then ask to be taken through it with easy and
then with more tricky cases
Follow up your patients and consider an audit
Talk to patients before and after laser
Resources:

Books, videos, meetings, manufacturers' manuals
Changes agreed at Curriculum Sub-committee 21 July 2009 and 1 December 2009
Changes made to Curriculum website 31 July 2009 relating to study guide for SS1
Rationale for generic changes: to clarify areas where confusion has arisen in the
present curriculum
42
Summary of changes to OST curriculum study guide
July 2010
http://curriculum.rcophth.ac.uk/study-guide/health_promotion
HEALTH PROMOTION AND DISEASE PREVENTION (HPDP) STUDY GUIDE
Key:
Additions in red support changes made in response to stakeholder feedback
Additions in green support medical leadership enhancements
Additions in brown support Common Competencies Framework
enhancements
Additions in grey support ethics curriculum enhancements
HPDP1 Promote the value and assist in the organisation of screening for eye disease
Think:


What are the risks and benefits of screening for disease?
What would be the consequences of not screening for diabetic retinopathy?
Knowledge:



Understanding of which diseases merit screening programmes
Which screening programmes for ophthalmic conditions currently exist
Organisation and quality control issues related to screening and how
outcomes of screening are dealt with
Activity:

Attend and observe diabetic retinopathy screening, ROP screening and
community vision screening in children
Resources:


www.rcophth.ac.uk/scientific guidelines for diabetic retinopathy, retinopathy of
prematurity, hydroxychloroquine, vigabatrin, management of strabismus and
amblyopia
Oxford Textbook of Medicine
HPDP2 Prevent contagion and cross infection
Think:

What are common sources of clusters of infections in theatre?
Knowledge:



Principles of contagion and cross infection particularly in relation to general
medicine as well as ophthalmic diseases
Prevention of cross infection and contagion in eye clinic and operating theatre
settings
Role of national infection-control bodies (e.g. Health Protection Agency)
Resources:

Induction packs re microbiology and infection control protocols in Trusts
43
Summary of changes to OST curriculum study guide
July 2010



Ocular Infection : Investigation and treatment in Practice. Seal, Bron and Hay.
Dunitz, 1998
Oxford Textbook of Ophthalmology, Easty and Sparrow, Oxford Medical
Publications, 1999
Control of Hospital Infection A Practical Handbook 4th edition. Eds. GAJ
Ayliffe, AP Fraise, AM Geddes, K Mitchell. Arnold, 2000
HPDP3 Notify and facilitate contact tracing of communicable diseases
Knowledge:


Which infections require notification and who is the local " Proper Officer",
particularly in relation to ophthalmic infections or ones with ophthalmic
symptoms
Process of notification [inform Consultant in Communicable Disease Control
(CCDC) at Local Health Protection unit (HPU)]
Resources:


Communicable Diseases Control Handbook 1st edition. Hawker, N Begg, I
Blair, R Reintjes, J Weinberg. Blackwell, 2001
www.hpa.org.uk (Health Protection Agency website)
HPDP4 Promote issues of injury prevention, especially in regard to protective
eyewear
Think:


What precautions would you advise for workers in chemical/glass
manufacture?
What responsibilities do I have regarding safety in my workplace – for fellow
staff and for patients – and what precautions should I take in this regard
(environment, condition of equipment etc.)?
Knowledge:



Occupations, leisure activities and criminal activites associated with
ophthalmic injuries
What eye protection is available and how to use it
Principles and practice of risk management and patient safety
Resources:



College advice on specific events e.g.solar eclipse
www.alphatech-int.co.uk
www.nlm.nih.gov/medlineplus/eyeinjuries.html
44
Summary of changes to OST curriculum study guide
July 2010
HPDP5 Implement risk reduction strategies relating to ophthalmic and relevant
systemic diseases
Think:

Do I take opportunities to educate patients to enable them to maintain health
and reduce risks of ophthalmic and systemic diseases? 1
Knowledge:




Systemic risk factors associated with ophthalmic diseases
Risk reduction strategies pursued in general practice e.g. hypertension,
cholesterol, weight control, exercise,etc
Smoking cessation services in hospital and in community and how to access
theses programmes
The risks of environmental factors such as chemical containment on ocular
health (both community and individual) and how they can be mitigated
Resources:



Essential Medical Ophthalmology. A problem oriented approach. Ferris.
Butterworth (2001)
www.nlm.nih.gov/medlineplus/smokingcessation.html NIH site on smoking
cessation
www.givingupsmoking.co.uk
HPDP6 Provide advice on contact lens care
Knowledge:

The various contact lens types, lens hygiene and associated risks
Activity:


Attend contact lens fitting clinics
Experience managing complications of contact lens wear
Resources:



Courses on contact lensesfitting and hygiene (e.g.Institute of Optometry
course)
Ocular Infection investigation and treatment in practice. Seal, Bron and Hay.
Dunitz (1999)
www.ioo.org.uk (Institute of Optometry website)
HPDP7 Take appropriate care of laser and diagnostic contact lens
Knowledge:


1
Types and materials used in diagnostic and laser lenses
Correct cleaning procedures for reusable lenses
Agreed at Curriculum Sub-committee 21July 2009 to enhance patient self care awareness
45
Summary of changes to OST curriculum study guide
July 2010

Availability of disposable lenses/tips and their advantages and disadvantages
Activity:


Prepare clinic equipment and clean lenses yourself
Attend a laser safety course (eg Trust-based course)
Resources:



"The Physics of light and lasers." Oxford textbook of ophthalmology. Sparrow
and Easty. Oxford Medical Publications (1999)
Written information provided with diagnostic contact lenses and tonometers
Local trust protocols for laser safety
HPDP8 Give advice on the avoidance of allergens and other triggers
Think:






What can I remember about allergies from medical school?
Do I need to revise the topic?
What questions can I ask the patient to help them identify potential allergens?
What tests are available to identify allergens, and how safe and reliable are
they?
What avoidance methods are available to the patient?
What other triggers may be relevant to ophthalmic patients?
Activity:




Read up on allergy and migraine
Contact your local immunologist and see if you can sit in on an allergy clinic
If you have a patient with allergy problems, who needs skin testing, see if you
can arrange to attend the immunology department when you patient goes
there
Ask your local programme director to arrange a teaching session on allergy
Resources:



http://www.asthmallergy.com/allergy_avoidance.htm
http://www.allergycontrol.com/education_main.asp
http://www.migraine.ie/index.cfm/loc/2-3/articleId/0953B29B-B493-B7AC7572CAC701104BFB.htm
HPDP9 Promote appropriate immunisation
Think:

What advice would you give to a junior doctor who has suffered a needle stick
injury?
Knowledge:

Theoretical and practical aspects of immunisation in children, those with
occupational hazard and specific situations in adults
46
Summary of changes to OST curriculum study guide
July 2010

Risks and benefits of immunisation
Resources:


Local occupational health department protocols and guidance
www.hpa.org.uk (Health Protection Agency website, gives information on
childhood and adult immunisation schedules, post exposure prophylaxis,
travel vaccinations and vaccinations in immunocompromised individuals)
HPDP10 Understand the implications of investigations and therapeutics during
pregnancy
Think:

What advice would you give to a diabetic woman in the first trimester of her
first pregnancy?
Knowledge:

Risks to eye and health in pregnancy, with respect to investigation and
treatment
Resources:



http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/119573
3757920?p=1192454969657
Terminology and Guidelines for Glaucoma, 2nd edition, Chapter 3.3. European
Glaucoma Society. www.eugs.org
British National Formulary
HPDP11 Make recommendations for bone protection
Knowledge:


How to prescribe steroids appropriately
Risk of osteoporosis and how this can be minimised
Activity:

Attend lecture on osteoporosis prevention
Resources:


www.health.state.ny.us/nysdoh/osteo/fda.htm
www.arc.org.uk
47
Summary of changes to OST curriculum study guide
July 2010
HPDP12 Follow local and national guidance with regards to prophylaxis
Knowledge:

Principles of cross infection, common sources and how to reduce incidence
Activity:


Observe and participate in cleaning/disinfection processes for surgical
instruments
Participate in audit of post operative infections in your department
Resources:




Local hospital prophylaxis and cross infection guidelines
Local trust infection control officer/team
College guidelines on cataract surgery and endophthalmitis
www.rcophth.ac.uk
48
Summary of changes to OST curriculum study guide
July 2010
http://curriculum.rcophth.ac.uk/study-guide/communication
COMMUNICATION (C) STUDY GUIDE
Key:
Additions in red support changes made in response to stakeholder feedback
Additions in green support medical leadership enhancements
Additions in brown support Common Competencies Framework
enhancements
Additions in grey support ethics curriculum enhancements
C1 Rapport
Think:





Achieving a rapport with all patients is essential for good medical
management
How should I greet a patient to establish a relationship? (even if it is only
briefly in a busy casualty or clinic)
What difficulties may arise to prevent this relationship? - eg. a language
barrier, my own prejudices
Do my patients understand what I am saying?
Am I using too much jargon?
Activity:







Maintain interest in your patient
Ask questions to establish a relationship (it may be relevant to know what
they do for a living and how that impacts on their illness)
Be aware of communication skills scenarios and attend any courses run by
your Trust or elsewhere
Be aware patients may not understand medical jargon - avoid using it
Ask a colleague to observe you talking to a patient
Do I need to attend a 'conversation class' to improve my English?
Ensure that you get some multisource feedback from colleagues
Reflect:

How could a consultation have gone better
C2 Listen
Think:






How do you listen to a patient? (it is difficult especially in a busy clinic or
casualty)
How do you filter relevant information from irrelevant?
How do you draw the consultation to a close
Should I add to the verbal communication by a follow-up letter, email or
phone-call to the patient?
What should I tell the patient about how information on their case will be
used?
How should I approach enquiries from the media?
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Activity:









Remember to listen actively and to try and sort the wood out from the trees
Do not let your mind wander - you might miss something relevant
Try not to repeat anything, unless you really don't understand - it looks and
sounds as though you are not listening
Make sure you especially listen to any questions the patient, relative or carer
may have and specifically answer them
Do not allow the patient to wander, however
Clearly indicate that the consultation is coming to an end. Check the patient's
understanding and close with a summary to include any further action
Ensure that you sum up the problem and allow the consultation to come to a
satisfactory end
Ask a colleague to sit in with you during a consultation
Ensure that you get some multisource feedback from colleagues
Reflect:


How could a consultation have gone better?
What questions may have been left unasked/unanswered?
Resources:

Be aware of communication skills scenarios and attend any courses run by
your Trust or elsewhere
C3 Deliver information
Think:






Information needs to be delivered to the patient, their relatives and carers
appropriately and sensitively. How do I do this without confusing the patient or
appearing to be insensitive?
How do I handle challenging questions?
Does the patient fully understand the benefits/risks of your recommendation?
Should I add to the verbal communication by a follow-up letter, email or
phone-call to the patient?
What should I tell the patient about how information on their case will be
used?
How should I approach enquiries from the media?
Activity:







Put yourself in the patient's position. If you had the same problem, how would
you wish the information to be given?
Don't talk down to the patient but be aware that you have more knowledge
than the patient sometimes needs
Be aware of the impact that this information will have on the patient
Be prepared to justify the treatment you recommend.
Advise the patient of any period of recovery and/or activity restrictions
Discuss and guide the patient on any rehabilitation needs
Ask a colleague to sit in with you during a consultation
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
Ensure that you get some multisource feedback from colleagues
Reflect:



How could a consultation have gone better?
What questions may have been left unasked/unanswered?
Did the patient understand all you told him/her?
Resources:

Be aware of communication skills scenarios and attend any courses run by
your Trust or elsewhere
C4 Sources of information
Think:

What other information is available for your patients, their relatives and
carers?
Activity:


Know Find what patient information leaflets are available in your department.
Have them prominently displayed in the waiting area and clinic rooms
Familiarise yourself with your Trust’s patient occupational therapy and
rehabilitation process
Resources:



Be aware of patient user groups especially local ones. Use the internet to
become aware of the numerous groups that are there
Be aware of the advantages and the disadvantages of recommending such
groups to your patients
Be aware of what community social services are available to assist your
patient in their rehabilitation
C5 Consent
Think:



What information do I need to provide to patients, their relatives and carers to
allow them to have an informed opinion as to their condition and its
management?
How do I convey this to patients who may be limited in their understanding of
their problem?
What are the implications regarding patient care and consent of the Mental
Capacity Act?
Activity:

Put yourself in the position of the patient or their relative. What would you
wish to know and how will it impact on your life?
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
Explain any risks that a particular procedure might produce, but be aware of
any anxiety that this might engender
Resources:




When completing consent forms for a particular procedure make sure you are
aware of any local Trust guidelines and the GMC guidelines
http://www.gmcuk.org/guidance/ethical_guidance/consent_guidance/index.asp
http://pmj.bmjjournals.com/cgi/reprint/77/906/238
www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/Co
nsent/fs/en
C6 Breaking bad news
Think:


This is particularly important and may be the source of much distress to both
the patient and the doctor
The way bad news is delivered will be remembered by the patient and may
affect them for the rest of their life
Activity:







Check whether the patient wants a friend/relative/carer in on the discussion
Be aware of the implications this will have to the patient, their relatives or
carers
Do allow ample time for questions to be asked and to have the appropriate
responses ready (so prepare yourself)
In most cases an appropriate timely follow-up should be made with yourself
and/or another appropriate professional, as the patient will probably forget
much of what they are told; a follow-up phone-call, letter or email may also
help
Ask a colleague to sit in with you during a consultation
Ensure that you get some multisource feedback from colleagues so that it
becomes a learning experience for you
Discuss and reflect with colleagues how your emotions may have affected
your communication
Resources:



Be aware of communication skills scenarios and attend any courses run by
your Trust or elsewhere
http://www.postgradmed.com/issues/2002/09_02/editorial_sep.ht m
Buckman, R. (1992) How To Break Bad News: A Guide For Health Care
Professionals. Basingstoke. Papermac
C7 Language
Think:
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
What is the effect of not being able to communicate effectively to patients
because of a language barrier or because of culture, hearing impairment, age
or mental state?
Activity:



Try and identify this barrier before the consultation. Work out how you are
going to rectify this, for example using an interpreter or to invite relatives or
carers into the consultation
Ask a colleague to sit in with you during a consultation
Ensure that you get some multisource feedback from colleagues
Reflect:



How could a consultation have gone better?
What questions may have been left unasked/unanswered?
Did the patient understand all you told her/him?
Resources:

Be aware of communication skills scenarios and attend any courses run by
your Trust or elsewhere
C8 Body language
Think:

Body language is very powerful and forms much of the opinion gained by you
of the patient and vice versa. How is your non-verbal communication revealed
to patients, their relatives and carers and what about theirs to you?
Activity:




Be aware that your body language can reveal much about you and your
attitudes to the patient
Often patients do not like to communicate as much as they want in front of a
doctor that they may not know, and/or who has very little time to see them.
Appreciate this and use cues that they may employ to extract as much
information from them as you need
Ask a colleague to sit in with you during a consultation and identify any nonverbal communication that you or the patient employs
Ensure that you get some multisource feedback from colleagues
C9 Complaints
Think:


Sadly complaints will arise during the course of a medical career. These may
be directed at you or at your organisation. How will you respond to these
complaints and how might it affect your relationships with your patients and
colleagues?
What support may I and/or other staff require in coping with a complaint, and
from where can such support be provided?
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Summary of changes to OST curriculum study guide
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
What can I learn from dealing with this complaint?
Activity:





Accept that you will get complaints and do not bury your head in the sand and
ignore them. Act upon them quickly and learn from them. It is easy to become
defensive in these situations, but try and react constructively. Many may be
trivial, but none should be dismissed
If your clinical practice is questioned ensure that you respond in a way that
does not compromise the treatment of the patient
If you receive complaints about the clinical practice of other health
professionals you should respond in a sensitive and professional manner
You should understand and comply with local Trust guidelines and know who
your Complaints Officer is within the Trust
You should be aware of national GMC guidelines and other professional
bodies.
Resources:


RCOphth Ophthalmic Services Guidance Chapter on Complaints in
Ophthalmology
National Patient Safety Agency Guide on Being Open
http://www.nrls.npsa.nhs.uk/resources/?entryid45=65077
C10 Communication with other professionals
Think:




Why do I need to communicate with other relevant health care professionals
and community social services?
How does it benefit the patient?
What special considerations are required when I communicate with the legal
profession in cases of injury or of medical mishap?
When should I communicate with the legal profession and what special
considerations apply?
Activity:








Communicate to others using all available means such as email, telephone
and even writing a letter
Include all relevant information including images where helpful
Respond to requests for information quickly
Do not keep letters hanging around
Always keep your intray empty
Seek opportunities to discuss the writing of medicolegal reports with a senior
colleague
Attend a medicolegal workshop
Ensure regular opportunities to make presentations to colleagues and others,
using visual and other aids as appropriate
Assessment:

You may be assessed on your letter writing/receiving skills
54
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C11 Written records
Think:

It is essential to keep clear, well written patient notes
Activity:




Ensure that every note you write in a patient record or relating to a patient is
contemporaneous, accurate and legible
If you use electronic records, ensure that these are secure
Be aware of the security and patient confidentiality of every record
Ask a colleague to scrutinise a patient record and offer constructive criticism
C12 Letter writing and dictation
Think:

Communication with others is essential. How does it affect patient
management?
Activity:






Write letters regarding patients accurately and immediately; make sure you
dictate a letter where appropriate after seeing the patient rather than wait until
the end of a clinic
Ensure that the dictating machine is working and that you speak legibly.
Some secretaries have the talent to interpret the most illegible speech but
mistakes can be made to the patient's detriment
Make sure that you read the secretary's hard copy before you sign your letter
to ensure that what is written is accurate and reflects what you have told the
patient
You might think it appropriate to send copies to other health professionals, for
example the referring optometrist. Make sure you have the patient's
permission before doing so
You may also find it useful to send a copy to the patient themselves or a
parent
Ask a colleague to scrutinise a patient letter and offer constructive criticism
C13 Prepare an operating list
Think:


How do I best prepare an operating list?
How will it help the patients and myself as a trainee
Activity:


Observe someone more senior preparing an operating list in your hospital
Ensure that you know in which order patients are operated and which take
priority. You may want to bear in mind the age of the patient (younger children
often go first) or other medical conditions (diabetics are often put higher up a
list)
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Summary of changes to OST curriculum study guide
July 2010

Some units do intraocular procedures first. Also be aware that if you are in the
operating theatre, how you can manipulate a little to allow you the time to
operate on suitable cases
C14 Planned and unplanned leave and on-call
Think:

Having a break from work and study is vital for your health and the health of
the patients. How does your absence impact on the running of the service?
Activity:




Ensure your full involvement with colleagues in the planning of rotas and
other clinical duties
In particular ensure that your absence for leave does not impact greatly on
the service. Make sure that it is planned well in advance and notification is
given to all appropriate parties
Be aware that there may be times due to unexpected leave taken by
colleagues that you will have to assume other duties in addition to your own.
Accept this gracefully as you may be the one that needs the leave next time
Always plan study leave for courses and self-directed learning well in
advance. Be aware of your timetable for examinations etc
Changes agreed at Curriculum Sub-committee on 21 October 2009 and 1 December
2009 to enhance recognition of patient feedback and health inequalities curricula
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Summary of changes to OST curriculum study guide
July 2010
http://curriculum.rcophth.ac.uk/study-guide/info_handling
Key:
Additions in red support changes made in response to stakeholder feedback
Additions in green support medical leadership enhancements
Additions in brown support Common Competencies Framework
enhancements
INFORMATION HANDLING (IH) STUDY GUIDE
IH1 Use appropriate learning resources, including electronic reference sources
Think:


What learning and reference sources are available to me?
What resources might my patients use and how can I best guide their use
thereof?
Resources:


European Computer Driving Licence (ECDL) (free for NHS staff)
"Beyond the clinic - Survival Skills for Ophthalmologists" Merrick J. Moseley
and PI Murray
Assessment:

Take the ECDL exit test
IH2 Use appropriate paper-based and electronic records, databases and statistical
packages
Activity:



Talk to personnel in Hospital Audit and research departments
Attend local induction programmes
Contact local IT department for in-house training of EPR and/or PAS
Resources:



www.mo.md - lots of information on PDA, internet and medical software
http://careers.bmj.com/careers/advice/view-article.html?id=1747 - the
Progress of Medical informatics in the United Kingdom
NHS Care Record Guarantee
IH3 Use professional guidelines appropriately
Think:

How are clinical guidelines produced?
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Summary of changes to OST curriculum study guide
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Activity:




Check Data Protection Act 1998 and www.the-mdu.com
www.medicalprotection.org and www.hospital-doctor.net
Be aware of Patient confidentiality guidelines (hospital, GMC and Medical
Defence Union)
Actively seek opportunities to contribute to local and/or national evidence
based guidelines
Check regularly for new safety guidelines from national organisations
(NCEPOD, NPSA etc.)
Resources:




www.dh.gov.uk/PolicyAndGuidance/InformationPolicy/fs/en - the development
and ongoing implementation of the DoH IT strategy
General Medical Council guidelines at www.gmc-uk.org
Local trust guidelines
Royal College guidelines, including those at www.rcophth.ac.uk
IH4 Maintain a personal portfolio
Resources:

The Royal College of Ophthalmologists www.rcophth.ac.uk
IH5 Use appropriate IT and email facilities
Think:




Keep in mind email etiquette and protocol
Be secure on-line and do not share personal details
What IT tools and databases can be used in enhancing the effectiveness and
safety of my clinical practice? (e.g. prescribing tools, drug databases,
medicolegal information etc.)
What is meant by “Clinical Coding” and what systems are in common use?
Activity:


Make use of local IT department for training
Use PowerPoint or similar software regularly so as to become fully fluent in its
use in presentations
IH6 Manage patient referrals
Think:

About local hospital referral guidelines and protocol
Activity:

Discuss appropriateness/guidance of referrals initially with Clinical
Director/educational supervisor/senior trainee
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IH7 Manage waiting lists
Activity:

Liaise with Admissions department and theatres
Assessment:

Carry out audit to see whether improvements can be made in theatre
efficiency
IH8 Be actively involved in national databases
Resources:

The Royal College of Ophthalmologists website and newsletters
www.rcophth.ac.uk
IH9 Use audit/critical incident reporting data sheets
Think:



What are my responsibilities regarding Critical Incidents in which I am
involved?
How can I learn about management of Critical Incidents even if I am not
directly involved?
What can we learn from critical incidents to ensure they do not recur?
Activity:



Approach audit and pharmacy department
Be aware of critical incident form location, discuss the form with charge
nurse/theatre manager
Read up on root cause/significant event analysis and the role of human
factors
Resources:


Adverse incident reporting and significant event auditing: AIR and SEA
rescue BMJ Career Focus 2004;328:173-174
Institute for Safe Medication Practices http://www.ismp.org
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Summary of changes to OST curriculum study guide
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http://curriculum.rcophth.ac.uk/learning-outcomes/basic_clinical_sci
Key:
Additions in red support changes made in response to stakeholder feedback
Additions in green support medical leadership enhancements
Additions in purple support patient self care enhancements agreed at
Curriculum Sub-committee 21 July 2009
Additions in brown support Common Competencies Framework
enhancements
Additions in grey support ethics curriculum enhancements
BASIC AND CLINICALS SCIENCES STUDY (BCS) STUDY GUIDE
BCS11
All trainees must understand and apply knowledge of medical
sociology relevant to ophthalmic practice. They should be aware of the distribution of
health inequalities both nationally and internationally and consider the factors that
contribute to this.
Think:
o
o
o
o
o
What are the major causes of global ophthalmic morbidity? What
interventions could reduce these?
What is the effect of social upheaval, natural disaster or armed conflict?
How do social issues affect access to ophthalmic care?
How may social problems influence ophthalmic symptoms?
Do I know how to refer a patient for appropriate social services support?
Activity:
o
o
Ensure your history taking includes sensitively asked questions about
employment, socioeconomic status and other relevant social issues.
Consider how wealth inequalities in your region might be reflected in health
inequalities
Resource:
o
www.apho.org.uk
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Summary of changes to OST curriculum study guide
July 2010
http://curriculum.rcophth.ac.uk/study-guide/attitudes_ethics
Key:
Additions in red support changes made in response to stakeholder feedback
Additions in green support medical leadership enhancements
Additions in purple support patient self care enhancements agreed at
Curriculum Sub-committee 21 July 2009
Additions in brown support Common Competencies Framework
enhancements
Additions in grey support ethics curriculum enhancements
ATTITUDES, ETHICS, RESPONSIBILITIES (AER) STUDY GUIDE
AER1 Compassionate approach to patient care
Think:
o
o
o
o
o
What approach would I like my doctor to take if I were the patient?
How can I tell whether my patient would like me to take that
approach?
How can I learn to tailor my approach to the patient's needs?
How can I ensure that my body language is consistent with what I
say?
How can I ensure that the patient feels valued and important?
Activity:
o
o
o
o
Go on a communication course
Watch senior staff in their approach to a range of patients
Ask yourself (and them!) why they took that approach
Decide if it was the right approach - and if not, why?
Resources:
o
http://www.patient.co.uk/showdoc/40000020/
AER2 Ethical approach to clinical care making that recognises and respects patient
autonomy
Think:
o
o
o
o
o
o
o
What is in the best interest of my patient?
Can I think of any situation in which I should go against this?
How am I fulfilling my role as advocate for my patient?
What should I do if the best treatment for my NHS patient is not
available on the NHS?
What prejudices may I have which could adversely affect my
decision?
For what reasons may a patient sometimes decide to ignore my best
advice?
How hard should I try to persuade such a patient to change their
mind?
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o
o
o
Can I continue to treat a patient who chooses not to take my advice?
How do I empower the patient to take responsibility for their own
condition?
How should I distinguish between factual knowledge and moral values
in guiding a patient to a decision?
Activity:
o
o
o
o
Watch how senior colleagues handle difficult decision-making
Ask them afterwards why they handled it in this way
Discuss with them how you would have handled the situation
Ask colleagues to watch you when you are in such a situation and to
give you feedback on how you coped
Resources:
o
http://www.ethics-network.org.uk/ethicalissues/confidentiality/confidentiality
AER3 Considerate approach to clinical practice, in particular to patients with
disabilities and visual impairment
Think:
o
o
o
o
o
o
o
Have I got any prejudices against those with disabilities?
How can I try to correct these?
How would I wish to be approached if I had this patient's disability?
Can I think of any reason why this patient's wishes may be different
from mine?
How could the physical environment in our clinic be improved to help
those with disabilities?
When must I be particularly sensitive with those whose social,
religious or cultural background is different from mine?
How should I manage anger and conflict in myself, work colleagues or
patients/carers?
Activity:
o
o
Take opportunities to talk to patients about their problems and how
they cope
Ask them what particularly annoys them in health professionals
Resources:
o
o
o
RNIB literature
http://www.rnib.org.uk/xpedio/groups/public/documents/code/Inte
rnetHome.hcsp
Sinclair A, and Ryan B. Low Vision: The Essential Guide for
Ophthalmologists. The Guide Dogs for the Blind Association, Reading,
(2008) ISBN 978-0-9559268-0-8
o
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AER4 Empathy with patients with eye problems and in the recognition of the impact
of visual impairment on the patient and their relatives or carers
Think:
o
o
o
o
o
How may my patient be stigmatised by their eye condition?
How can I show this patient that I care without being patronising?
How would I feel if I had their problem or if I were their relative/carer?
How can I know whether their feelings are different from mine?
How can I be an advocate for those with visual impairment, helping to
combat the myths and stigma associated with it?
Activity:
o
o
o
Talk to those who work regularly with patients with visual and other
disabilities (eg members of the local sensory support team)
Arrange to go on home visits with the above
Take opportunities to strike up informal conversations with visually
impaired patients
AER5 Respect for patient confidentiality and appropriate disclosure of patient
information
Think:
o
o
o
o
o
o
o
o
Why is medical confidentiality so important?
How can I ensure it is protected?
What are the Data Protection Act and Freedom of Information Act and
how do they apply to me?
What is a “Caldicott Guardian”?
What is “Information Governance”?
When must I obtain my patient's permission to communicate with
others about her/him?
Are there any situations in which confidentiality should be breached?
What should I do if I have a patient whose vision is inadequate for
driving but who insists on continuing?
Resources:
o
o
o
http://www.gmc-uk.org/guidance/current/library/confidentiality_faq.asp
http://www.connectingforhealth.nhs.uk/systemsandservices/infogov
http://www.dh.gov.uk/en/Managingyourorganisation/Informationpolicy/
Patientconfidentialityandcaldicottguardians/DH_4100563
AER6 Able to recognise and work within the limits of personal knowledge, skills and
understanding (reflective practice)
Think:
o
o
How can I get the balance right between acceptance of responsibility
and working beyond the limits of my competence?
How am I expected to know what I don't know?
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Summary of changes to OST curriculum study guide
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Activity:
o
o
o
o
o
Meet with your supervisor at the start of your attachment, to discuss
your strengths and weaknesses and what you should do when you are
uncertain how to proceed with a patient
If you find you are put into a situation where you feel out of your depth,
tell your superior
Watch how more-senior colleagues handle uncertainty
Make every uncertain situation a learning opportunity - learn from
advice you are given, and try to read up about the problem to be
better prepared next time
Be honest with patients where management is uncertain
AER7 Prepared to seek help and advice when appropriate
Think:
o
o
o
o
What sources of help can I call on? - does it always have to be my
consultant?
If I ask for help too often, will my consultant think I am useless and
give me a bad reference?
(In any particular clinical situation) Is there any risk to the patient if I
proceed with an uncertain management plan?
Do I need to ask for help here and now? - is it urgent?
Activity:
o
o
Discuss in advance with colleagues who can provide what sorts of
advice, and what sort of problems are to be regarded as urgent
When on-call, ensure you always know how to contact the next most
senior member of the team
AER8 Seeks feedback from all colleagues in multi professional team (multi-source
feedback) and from patients/carers
Think:
o
o
o
In what ways can I obtain feedback on my attitudes and performance?
How should I react when feedback seems unfavourable?
How should I react when feedback is positive?
Activity:
o
o
Take opportunities for informal feedback - eg to ask medical and other
colleagues how they think you are doing, especially after you have
handled a difficult situation
Take a full roll in multi-source feedback, discuss the result with your
Trainer an do your best to act thereon
Resources:
64
Summary of changes to OST curriculum study guide
July 2010
o
http://bmj.bmjjournals.com/cgi/content/full/330/7502/1 251
AER9 Engaged in appraisal and revalidation
Think:
o
o
o
o
o
o
What is the purpose of appraisal?
How does it differ from assessment?
What is the purpose of revalidation?
What can I gain from them which may improve my performance as an
ophthalmologist?
How can I best prepare for them, so as to gain the most from them?
What lessons can I learn from appraisal and revalidation as a trainee
which will be useful after I am accredited?
Activity:
o
o
o
o
o
Ask senior trainees how they prepare - ask them to show you their
portfolio, and to advise you on yours after you have started it
Ask your trainer what is expected of you in this regard
Try to keep up-to-date with your portfolio, don't leave it all until the
night before your RITA!
Read GMC documentation on revalidation and keep up-to-date with
changes and developments
When you are a more-senior trainee go on a course for appraisers
and then ask to get involved in the appraisal of others – and seek
constructive feedback
Resources:
o
o
o
http://www.appraisalsupport.nhs.uk/
http://www.dh.gov.uk/en/Managingyourorganisation/Humanresourcesa
ndtraining/EducationTrainingandDevelopment/Appraisals/index.htm
www.gmc-uk.org
AER10 Ethical approach to clinical care, especially in relation to the appropriate use
of resources, clinical research and issues of equality and diversity
Think:
o
o
o
o
o
o
o
o
o
o
Is there a role for rationing in healthcare?
What should I do if the best treatment for my patient is not available
on the NHS?
What conflicts of responsibility may I meet in my practice? (eg family
versus work)
Does research ever conflict with patient care?
What prejudices can I identify in myself? - and what can/should I do
about them?
What prejudices can I identify in "the system", and can I do anything to
help solve these?
How may my patient be stigmatised by their eye condition?
How can I show this patient that I care without being patronising?
How would I feel if I had their problem or if I were their relative/carer?
How can I know whether their feelings are different from mine?
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o
How can I be an advocate for those with visual impairment, helping to
combat the myths and stigma associated with it?
Activity:
o
o
o
o
o
o
Initiate discussion on these issues with friends and colleagues, both
medical and lay
Discuss day-to-day rationing issues with your trainer
Analyse your own motives from time to time
Plan research carefully and always ensure ethical approval is obtained
Go on an "Equality and Diversity" course - it will probably be essential
when you become a trainer yourself
Ensure your assessments and interventions are always patientcentred, and respectful of diversity.
Resources:
o
o
o
o
www.gmc-uk.org/guidance/good_medical_practice/index.asp#Rese
arch
http://www.bma.org.uk/ap.nsf/content/hubequalityanddiversity
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publica
tionsPolicyAndGuidance/DH_086039
http://www.dh.gov.uk/en/Managingyourorganisation/Equalityandhuma
nrights/index.htm
AER11 Aware of issues of probity and possible conflict of interest in professional
practice
Think:
o
o
o
o
o
o
What does "probity" mean?
 Dictionary definition
 For me in practice
Have I slipped up integrity-wise in the past?
Is there anything I do now which could be interpreted as showing
dubious probity?
What conflicts of interest have I met so far in my career, or might I
meet in future?
What should I do if ethics and values are compromised, e.g. my
patient's interests seem to conflict with the interests of my research,
my employer, my colleagues, my family or myself?
Am I always honest about my mistakes, with patients and colleagues?
Activity:
o
o
Talk these issues over with colleagues (both medical & non-medical)
and your trainer
Take part in ethical discussions and forums
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o
o
o
Check through your financial interests and ensure there are no
conflicts here
Ensure that all research is fully "ethics-approved"
Ensure mistakes are always treated as learning opportunities
Resources:
o
www.gmc-uk.org/guidance/good_medical_practice/index.asp#Prob ity
AER12 All doctors must practice according to the GMC document Duties of a Doctor
Think:
o
o
o
What actually are the duties of doctor?
How do these apply to me in my everyday practice?
What duties, rights and responsibilities do I have as an employer
(where relevant) or co-worker? (regarding safety of fellow staff as well
as patients)
Activity:
o
o
o
Think about a doctor you admire. What is it about the way they
interpret and fulfil their duties which appeals to you - and how can you
best emulate them?
Talk these issues over with colleagues (both medical & non-medical)
and your trainer
What disciplinary processes may be used against me in the event of
malpractice either in clinical or medicolegal practice?
Resources:
o
o
www.gmc-uk.org/guidance/good_medical_practice/index.asp
http://qhc.bmjjournals.com/cgi/content/full/9/1/14
AER13 Application of the law in relation to data protection and its relevance to health
care
Think:
o
o
o
o
In what circumstances may I be at risk of offending under this law?
What sort of data is protected?
What should I do if I need to collect personal data?
Who can give me advice?
Activity:
o
o
o
Discuss the issue with your trainer or a senior member of the IT
department
Find out who is your Trust's Caldicott Guardian and talk to her/him
about any problems
Ensure that you always seek Trust approval and ethics committee
approval for any research
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Resources:
o
o
http://www.opsi.gov.uk/Acts/Acts1998/ukpga_19980029_en_1
http://www.ico.gov.uk/
AER14 Application of the law in relation to the use of human tissue
Think:
o
o
In what circumstances may my research ideas put me at risk of
breaking the law on human tissue?
What are my responsibilities when I am seeking/obtaining/using donor
tissue?
Activity:
o
o
o
Talk to your local transplant coordinator
Always ensure that your research projects are properly approved
If you intend to harvest donor tissue yourself, make sure you go on a
suitable course first
Resources:
o
o
o
o
http://www.mrc.ac.uk/PolicyGuidance/EthicsAndGovernance/UseofHu
manTissue/index.htm
http://www.uktransplant.org.uk/ukt/default.jsp
http://www.hta.gov.uk/
http://www.opsi.gov.uk/ACTS/acts2004/ukpga_20040030_en_1
Human Tissue Act 2004 Chapter 30
AER15 Understands the responsibilities of an ophthalmologist in child protection
Think:
o
o
o
o
Why should I take an interest in this subject?
When should I be on the lookout for signs of child abuse/neglect?
Who can I turn to for urgent help on this matter?
What should I do if I am asked to examine a potentially abused child?
Activity:
o
o
o
o
Read up about child protection issues
Invite a senior paediatrician to come and talk to your local
postgraduate meetings
Talk to your paediatric colleagues about these issues before you have
to deal with them yourself
Talk to your medical defence society immediately if you have any
concerns which you cannot resolve with local help
Resources:
o
o
www.nspcc.org.uk/inform/
www.dh.gov.uk/assetRoot/04/07/19/80/04071980.pdf
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o
www.dh.gov.uk/assetRoot/04/06/08/34/04060834.pdf
AER16 Able to manage time effectively and deal with stress
Think:












Do I ever waste time?
When did I last find it difficult to fit everything I had to do into the time
available?
How did I cope on that occasion? - Could I have done better, and if so, how?
When time is short at work, which activities should I give priority to?
How can I avoid offending others when I do not have time for them?
What is my reaction when colleagues are too busy to help me?
What situations do I find stressful? Why?
Is it possible for me to avoid such situations without shirking my
responsibilites?
When it is not possible what should I do?
When is it appropriate to delegate tasks to others, or simply to ask for help?
What matters to me most in my life?
Do I take enought physical exercise?
Activity:





Talk to colleagues and trainers about how they cope with shortage of time
and/or stress
Watch how they actually cope in such situations
Think of a time when you think you coped badly and try to work out what you
should have done - discuss with colleagues if necessary
Remind yourself from time to time that everyone finds this sort of thing difficult
Enrol on a time management course, and/or ask your programme director to
arrange one for you and your colleagues
Resources:





http://www.mindtools.com/pages/main/newMN_HTE.htm
http://www.tsuccess.dircon.co.uk/timemanagementtips.htm
http://en.wikipedia.org/wiki/Time_management
http://www.mindtools.com/smpage.html
http://www.stress.org.uk/
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http://curriculum.rcophth.ac.uk/study-guide/decisions_reasoning
Key:
Additions in red support changes made in response to stakeholder feedback
Additions in green support medical leadership enhancements
Additions in brown support Common Competencies Framework
enhancements
DECISIONS, REASONING, JUDGEMENT (DMCRJ) STUDY GUIDE
DMCRJ1 - Make decisions by applying appropriate and clear clinical reasoning using
evidence based approach
Think:


How can I apply critique and analytical methods to published research?
How can I learn to apply critical reasoning to management decisions as well
as clinical decisions?
Activity:




Make use of hospital and departmental library
Arrange and participate in journal clubs
Talk to your local managers about their decision making techniques
Go on a management course to learn more about management decisions
Resources:




Textbook of Evidence based Ophthalmology- available in hardcopy, PDA and
PC (PDF)
BMJ Clinical Evidence
Evidence based medicine- How to Practice and Teach EBM. David L Sackett,
et al
Cogni-Q- PDA based data updated frequently www.unboundmedicine.com
DMCRJ2 Participate in departmental audit and understands its value in improving
practice
Audit is an essential component of clinical governance. All ophthalmology
departments are required to undertake a review of the clinical services they provide.
The review should compare these clinical services to a defined standard. The
standards used might be published by international and national bodies,
commissioners, the Trust or agreed as best practice in the department.
Think:








How can I apply clinical governance principles to everyday practice?
Which audit standards can be applied to clinical practice in your department?
What were the results of any audits carried out in your department?
Were the recommendations identified from the audit implemented?
Which areas of clinical practice lend themselves to audit?
How can I ensure that patient feedback on service provision is obtained and
incorporated into departmental processes?
What methods of data collection are available to me?
How can audit improve practice?
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
What is the “audit cycle”?
Activity:









Approach and discuss ideas with supervising Consultant and local audit
department
Read about the principles of audit
Identify the clinical lead for audit in your department
Get involved in any current audits that are taking place
Present a departmental audit to the clinical team and upload your
presentation to your e-portfolio (your educational supervisor, programme
director or clinical audit lead must validate this)
Organise the introduction of recommendations from an audit
Complete the audit loop by reviewing changes in practice that have occurred
as a result of the last audit
Submit a poster of your audit to a local or national conference e.g. the
RCOphth annual Congress
Upload an audit to your e-portfolio describing your contribution to the process
(no more than 3 trainees can claim a significant contribution to an audit (your
educational supervisor, programme director or clinical audit lead must
validate the audit document)
DMCRJ3 - Participate in personal audit and understands its value in improving
practice
Audit of your own clinical practice is an important part of annual appraisal and will
provide evidence of good medical practice for revalidation. Paragraph 14 of Good
Medial Practice (2006) includes guidance on maintaining and improving performance
that includes audit. You are expected to maintain a logbook of surgical practice that
contains details of the results and complications of your performance with cataract
surgery.
Think:




Which parts of your clinical practice would you like to review?
Are there any standards that you can use or will you have to agree your own
standards with your clinical supervisor?
How will you plan the audit so that the results are easily obtained, reliable and
relevant?
How will you respond if the audit identifies areas of your practice that need to
be improved?
Activity:





Approach and discuss ideas with supervising Consultant and local audit
department
Identify an area of your clinical practice that you can review.
Track down or agree your own standards.
Get advice from your clinical audit department or clinical audit lead.
Plan and write an audit protocol.
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How might you be assessed on this learning outcome?
Your e-portfolio should contain at least an audit of your cataract surgery (a minimum
of 50 consecutive cases) to satisfy the ARCP panel before you can be recommended
for CCT.
The complication rate of ALL your cataract surgery must be available for the ARCP
panel.
The structured viva part of the part 2 FRCOphth examination will assess your
understanding and experience of audit.
Resources:





Clinical audit support centre: http://www.clinicalauditsupport.com/
Audit and clinical effectiveness information for ophthalmologists:
http://www.rcophth.ac.uk/docs/profstands/ophthalmicservices/AuditandClinicalEffectivenessApril2008.pdf
NICE guidance on audit:
http://www.nice.org.uk/usingguidance/implementationtools/auditadvice/audit_
advice.jsp
Good Medical Practice:
http://www.gmc-uk.org/guidance/good_medical_practice/index.asp
DCMRJ4 - Appreciates of the importance of basic scientific and clinical research in
advancing knowledge so as to begin contributing to the evidence base
Activity:

Plan research activities - clinical or laboratory based
Resources:

Attend Conferences- College Congress, AAO, ARVO, EVER etc
DCMRJ5 - Understand service management, so as to allow involvement in the
organisation of ophthalmic clinical services
Activity:


Shadow the clinical director or business manager for a day
Attend departmental administrative meetings
Resources:





Looking Forward Programme organised by Pfizer
"ORYCLE" organised by OTG
Management courses organised by the NHS
www.healthcareskills.nhs.uk
A Guide to Finance for Hospital Doctors
Rationale for change: To emphasise the importance of audit and give more guidance
as to how it should be carried out.
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http://curriculum.rcophth.ac.uk/study-guide/health_serv_role
Key:
Additions in green support medical leadership enhancements
Additions in brown support Common Competencies Framework
enhancements
Additions in grey support ethics curriculum enhancements
ROLE IN THE HEALTH SERVICE (HS) STUDY GUIDE
HS1 Understand how the Health Service is organised.
Introduction:
The ophthalmologist needs a good level of understanding of the way in which the
Health Service is organised and managed, to include the interaction between major
organisations such as the Department of Health, General Medical Council, the
various Royal Colleges, and the primary and secondary healthcare delivery
organisations.
Think:









Who is ultimately responsible for the running of the Health Service?
What are the roles and responsibilities of the Department of Health?
How do Primary and Secondary Care Trusts relate to the DOH, and how is
health care "purchased"?
What do I know about NHS targets and how should I respond?
What are the roles and responsibilities of the GMC and the various Royal
Colleges?
Which regulatory agencies are involved in the licensing and use of drugs and
instruments, and what are their roles?
How do doctors, nurses, managers and patients have an input into the
running of the National Health Service?
What are the differences in health legislation between the four UK countries
and how does that affect my patient?
How does teaching fit into the role of the NHS and what other institutions are
involved?
Activity:

Read up from the study resources below.
Resources:



www.dh.gov.uk
www.gmc-uk.org
www.aomrc.org.uk
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HS2 Understand the principles of Clinical Governance.
Introduction:
The ophthalmologist needs a good level of understanding of the principles of
clinical governance. The ophthalmologist must have an appreciation of the
application of clinical governance principles to their own practice.
Think:
o
o
o
o
o
o
o
What is Clinical Governance?
How is the quality of the delivery of clinical care assured?
How do Clinical Governance principles respond when quality of
clinical care is found to be below standard?
What are the principles of risk assessment and risk management?
What is my role in ensuring that correct site procedures are
performed?
What is my responsibility regarding others in the healthcare team
whom I perceive to be a cause for concern?
In practice, what does a “no-blame culture” mean to me?
Activity:
o
Read up from the study resources below.
Resources:
o
o
www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/Cli
nicalGovernance/fs/en
www.rsmpress.co.uk/cgb.htm
HS3 Understands and applies the principles in the GMC document "Good Medical
Practice"
Introduction:
The ophthalmologist should demonstrate an understanding of the principles of
GMP and show that those principles lie at the heart of his practice of clinical
medicine.
Think:
o
o
o
What principles are covered in the GMC document "Good Medical
Practice"?
Why are those principles important to the delivery of high quality
clinical care?
Does my practice reflect the requirements of GMP?
Activity:
o
Read up from the study resources below.
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Resources:
o
www.gmc-uk.org/guidance/good_medical_practice
HS4 Professional relationships
Introduction:
The ophthalmologist should understand the importance of maintaining
effective professional relationships with all other health professionals where
there might be shared care of a patient's clinical problem. These relationships
extend to other medical, nursing and paramedical colleagues, as well as to
members of lay bodies, where those bodies have a legitimate interest in a
patient's medical care.
Think:
o
o
o
o
o
o
What other medical, nursing, paramedical and lay persons/bodies
have a role in the delivery of care to my patient?
How best can I actively seek the views of other professionals?
How should I best maintain the professional relationships between us
to optimise the treatment of my patient?
What do I do if that relationship fails or breaks down?
Who is responsible for restoring clinical and other links between the
various interested parties?
How can I best give other professionals and lay bodies the benefit of
my knowledge and expertise as a doctor?
Activity:
o
Read up from the study resources below.
Resources:
o
www.gmc-uk.org/guidance/good_medical_practice/index.asp#Wor
king%20with%20Colleagues
HS5 Leader/Team working
Introduction:
The ophthalmologist should understand his role as the leader of a clinical
team, involving nursing, paramedical and other workers involved in the clinical
management of a patient under his care. His should acknowledge his part in
multidisciplinary medical management, and be aware of and sensitive to the
priorities of sometimes conflicting management strategies in the treatment of
patients with multisystem disease.
Think:
o
o
What are the responsibilities of a clinical team leader?
What are my responsibilities as patient advocate in relation to the
team?
75
Summary of changes to OST curriculum study guide
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o
o
o
o
o
o
o
o
o
o
o
o
How do I ensure the cohesion and efficient functioning of the team?
In particular, how can I encourage good team dynamics, especially
ensuring that all members contribute, and building and maintaining
good relationships within the team?
How can I ensure that I am accessible to team members as a leader?
How do I identify and remedy breakdowns in team effectiveness
sensitively and assertively? Especially in regard to unprofessional
behaviour, bullying and/or harassment, and conflict management.
Of which national and local regulations should I be aware which are
relevant to leadership and team working?
How can I actively promote professional activities and values?
In what circumstances should I accept that the team has different
opinions to mine and what attitude should I take on such occasions?
How can I appropriately praise staff when they do well?
How can I best identify when other team members are struggling or
failing, or under stress (e.g. with patients receiving bad news), and
how can I best support them?
How can I encourage a whole-team approach to patient safety?
How do I ensure that new staff are properly inducted and that no-one
practices beyond their capabilities?
How do identify and remedy breakdowns in team effectiveness?
Activity:
o
o
o
Explore leadership styles and prejudices with colleagues and trainers
in a peer-learning environment, and discuss these where relevant in
CbD.
Seek opportunities to act in a leadership role (e.g. during a theatre list)
under the mentorship of more senior colleagues
Read up from the study resources below.
Resources:
o
o
www.cgsupport.nhs.uk/default.asp
http://www.bristolinquiry.org.uk/final_report/report/sec2chap22_10.htm
Assessment:
o
Case Based Discussion
HS6 Children and others with special needs
Introduction:
The ophthalmologist should recognise and understand his role in the
management of very vulnerable patients - particularly children or those with
special needs. He should be able to liase professionally with the parents or
carers of such patients, always recognising that his overwhelming
responsibility is to the well being of the patient. He should be able to intercede
in the best interests of the patient even if there is conflict of opinion with other
parties.
Think:
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o
o
o
o
o
Does this patient (child, adult with special needs) require specialised
clinical management techniques to reflect those needs?
If so, where will I source them from?
Are the parents/carers fully aware and in agreement with proposed
treatment strategies?
Is the care of the patient at the heart of my management plan?
The possibilities of deliberate harm (both self-harm and harm from
others) must always be borne in mind when dealing with vulnerable
patients
Activity:
o
Read up from the study resources below:
Resources:
o
o
www.bma.org.uk/ap.nsf/Content/childprotection
National Patient Safety Agency http://81.144.177.110/
HS7 Provision of optimum health care in the community
Introduction:
The ophthalmologist should understand his role as a provider of health care in
the context of the wider community. He should promote good practice in
community ophthalmic healthcare amongst medical, nursing and paramedical
colleagues.
Think:
o
o
o
o
How can ophthalmic disease be managed in the community?
By whom?
What is the interaction between non-medical health care providers in
the community and the medical profession?
Do I know how to access resources (e.g. policy documents) relevant
to community healthcare?
o
Activity:
o
Read up from the study resources below.
Resources:
o
o
o
o
www.rcophth.ac.uk/docs/college/OPC.pdf
www.rcophth.ac.uk/docs/college/SpreadingtheLoadSafely.pdf
www.rcophth.ac.uk/docs/college/OPC-Career.pdf
www.rcophth.ac.uk/docs/college/PrescribingByOptometristsAug200
4.pdf
HS8 Role as a researcher
Introduction:
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The ophthalmologist should understand the importance of research in the
field of ophthalmology, and seek to promote it wherever possible.
Think:
o
o
o
o
o
What is research?
Do I need to obtain some research skills in order to understand
research publications?
What sort of research can I do?
Where do I get ideas for research from?
What do I know about research ethics and the law in relation to
research?
Activity:
o
o
o
o
o
o
o
Attend a research skills course
Contact your local research ethics committee.
Contact your Trust R&D department
Read published research
Attend journal clubs
Ask others if there are any projects you can join
Discuss research ideas with your trainers
Resource:
o
o
o
www.site4sight.org.uk/
http://www.dh.gov.uk/en/Managingyourorganisation/Informationpolicy/
Patientconfidentialityandcaldicottguardians/DH_4100563
http://www.gmc-uk.org/guidance/ethical_guidance/research.asp
Reflect:
o
o
How could that published research project have been carried out
differently?
What sort of research questions have been left unanswered?
HS9 Role as a teacher
Introduction:
The ophthalmologist should understand the importance of teaching and be
able to make a positive contribution to the undergraduate and postgraduate
development of doctors, nurses and paramedical staff in the field of
ophthalmology.
Think:
o
o
o
o
o
How do I learn to best effect?
What is the optimum way of teaching others?
What teaching aids do I need, and where can I source them from?
Are there any "training the trainer" courses I could attend?
How can I ensure that patient safety is maintained as I teach others?
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o
o
o
What are the forms of assessment (formative, summative) and what
are their roles in medical education? (especially work-place based
assessment)
What should I do if I become aware of a trainee in difficulty?
How should the needs of service and training be balanced?
Activity


Seek opportunities to teach junior colleagues, students and allied
professionals
Seek opportunities to act as a mentor e.g. to medical students
Resources:
o
www.rcophth.ac.uk
HS10 Role as a manager
Introduction:
The ophthalmologist should acknowledge the role of medical staff in medical
management, and should be able, where necessary and where called upon,
to make a positive contribution to the management of departments, Trusts
and the wider community for the better delivery of ophthalmic health care.
Think:
o
o
o
o
o
o
o
o
o
o
o
o
o
What is medical management?
Why is it important for me to be involved?
Where can I obtain training in medical management techniques?
What is my responsibility and role in ensuring efficient and effective
use of resources?
What role can I play in appraising other staff and ensuring they are
playing their full role in meeting service objectives?
What sort of risks does a service face on a day-to-day basis?
What techniques can be used to assess risks associated with a
proposed change in service provision and modification of clinical
services?
How can risk be reduced?
Should I consider a higher qualification in medical management? If
not, how involved should I be?
What are my responsibilities in regard to the development and
maintenance of a safe environment for patients and staff?
When should I consider involved medical regulatory bodies?
What regulations cover statutory rest periods and what part can I play
in ensuring they are satisfied?
How can I ensure that there is appropriate involvement of patients and
the public in the management of my department?
Activity:

Seek opportunities to work with a manager to identify risks associated
with a proposed change in service provision
79
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
Discuss with colleagues how procedures and processes can be
modified to improve patient and staff safety
Resources:
o
o
o
http://www.gmcuk.org/publications/gmc_today/gmc_today_june08/management_matt
ers.asp
http://www.dh.gov.uk/en/Aboutus/MinistersandDepartmentLeaders/Chi
efMedicalOfficer/CMOPublications/QuoteUnquote/DH_4102564
http://www.gmcuk.org/guidance/current/library/management_for_doctors.asp
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http://curriculum.rcophth.ac.uk/study-guide/continu_prof_dev
Key:
Additions in red support changes made in response to stakeholder feedback
Additions in green support medical leadership enhancements
Additions in brown support Common Competencies Framework
enhancements
Additions in grey support ethics curriculum enhancements
CONTINUING PROFESSIONAL DEVELOPMENT (CPD) STUDY GUIDE
CPD1 Adopts reflective practice
Introduction:
All trainees must be able to adopt the principles of reflective practice. They must
maintain a reflective diary as part of their portfolio and use this in their appraisals.
Think:
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What information do I need to keep for my training portfolio?
How often should I update the information?
Who acts as guarantor of accuracy of the information, apart from myself?
How often should I arrange a portfolio review with my trainer?
Have I got adequate backup information if the portfolio is lost/damaged?
Resources:
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http://www.hpc-uk.org/registrants/cpd/
http://www.gmcuk.org/education/continuing_professional_development/cpd_guidance.asp
CPD2 Aware of limits of knowledge
Introduction:
All trainees must maintain an awareness of the limits of their knowledge. They must
pursue means of gaining insight into their limitations and feedback on clinical practice
in complex situations.
Think:
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Am I trained/competent to perform the planned procedure?
What supervision is available in the event of an unforeseen problem?
How do I get feedback regarding my competence in a particular procedure?
What will I do if my level of competence is below that expected?
Resources:
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http://www.hpc-uk.org/registrants/cpd/
http://www.gmcuk.org/education/continuing_professional_development/cpd_guidance.asp
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Summary of changes to OST curriculum study guide
July 2010
CPD3 Directs own self-learning
Introduction:
All trainees must be able to identify and respond to their learning needs. They must
be able to prepare and follow a learning plan. They must utilise all learning
opportunities that are made available.
Think:
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How do I learn, to best effect?
Who will tutor me, and in what kind of learning environment?
How do I arrange a programme of learning for any given task?
How often should I meet with and discuss my progress with my Educational
Supervisor?
Resources:
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http://www.hpc-uk.org/registrants/cpd/
http://www.gmcuk.org/education/continuing_professional_development/cpd_guidance.asp
CPD4 Art of medicine
Introduction:
All trainees must be able to apply their knowledge and skills in a flexible way and
practice effectively in an environment of clinical uncertainty.
Think:
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What do I do when thinks go unexpectedly wrong?
How do I inform the patient/carers of unexpected problems?
How do I manage patients where I am unable to provide accurate predictions
of clinical outcome/complication risks, etc.
Resources:
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http://www.hpc-uk.org/registrants/cpd/
http://www.gmcuk.org/education/continuing_professional_development/cpd_guidance.asp
CPD5 Continuing professional development
Introduction:
All trainees must show that they actively participate in continuing professional
development.
Activity:
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Maintain and keep up to date a clinical and learning activities portfolio
Ensure regular, recorded and verified attendance at postgraduate teaching
opportunities
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Summary of changes to OST curriculum study guide
July 2010
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Ensure reasonable spread of subspecialty specific and non-specialty generic
learning activities
Ensure that you keep up to date with therapeutic alerts etc.
Resources:
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http://www.hpc-uk.org/registrants/cpd/
http://www.gmcuk.org/education/continuing_professional_development/cpd_guidance.asp
CPD6 Personal career development
Introduction:
All trainees must take responsibility for their own career development with the
support and guidance of the educational supervisors.
Think:
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Is my clinical training delivering the educational targets I need to complete the
requirements of Higher Specialist Training?
Am I aware of what those targets are and the recommended timing of
acquisition of clinical skills
Do I need targeted retraining in any specific subspecialty field?
Resources:
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http://www.hpc-uk.org/registrants/cpd/
http://www.gmcuk.org/education/continuing_professional_development/cpd_guidance.asp
CPD7 Responsibility for personal health
Introduction:
All trainees must take responsibility for their own personal health and well-being.
They must take appropriate steps to protect patients when their own health is
affected by illness or disability.
Think:
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Is my personal physical and mental health in any way compromised in such a
way that delivery of clinical care to my patients is at risk?
Do I need to seek the advice of colleagues, educational supervisors,
occupational health, etc, for advice on my fitness to practice?
Has my fitness to practice ever been called into question?
Resources:
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http://www.hpc-uk.org/registrants/cpd/
http://www.gmcuk.org/education/continuing_professional_development/cpd_guidance.asp
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