PATIENT MANAGEMENT (PM)

Management Plan

Learning Outcome Overview

PATIENT MANAGEMENT
Learning Outcome	Management Plan
Code	PM1
Description	Trainees must be able to formulate a management plan based upon their clinical assessment and, where appropriate, the results of relevant investigations. The management plan must acknowledge relevant guidelines or protocols and justify when these have not been followed. They must be able to recognise when their management plan involves a level of expertise that is beyond their own competence. The plan must take full account of the patient's own choices and involve them in self-management as fully as possible.
Assessment	CbD, end of year exams, COECSA Exams
Target Year of Achievement	Year 1 and (annual review)
Related Learning Outcomes	BP3, BP 14 BP 15 BP 16 ML8
Other Links	Study Guide  3.4.1.2 below

                                                                                        

Patient management plan Study Guide  

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 organize 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
• ·Royal College Ophthalmologists guidelines on common problems: e.g. management of glaucoma, retinal vein occlusion, cataract, diabetic retinopathy (http://www.rcophth.ac.uk/clinicalguidelines)
• ·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)
• ·National Institute for Health and Clinical Excellence guidelines http://guidance.nice.org.uk
• ·The Cochrane Collaboration including Cochrane reviews and links to other databases offering online medical evidence (e.g. TRIP database) http://www.cochrane.org/about-us/evidence-based-health-care/webliography/databases
• ·Basic Clinical Science Course: American Academy of Ophthalmology 2013-2014 editions. The Eye M.D. Association
• ·Clinical Ophthalmology, 7th ed. Kanski, J.
• ·Duane's Clinical Ophthalmology, Ed Tasman W and Jaeger EA. Lippincott, Williams & Wilkins. 2002. Volume 1, Chapters 42-53.

Triage and prioritisation

Learning outcome Overview

PATIENT MANAGEMENT
Learning Outcome	Triage and prioritisation
Code	PM2
Description	Trainees must be able to recognise when a patient's clinical presentation needs priority and make appropriate arrangements to expedite their care. And learn to give priority besides clinical conditions like age (extremes) physical condition and patients with special needs.  In ophthalmic emergencies they must be able to contribute to clinical triage.
Assessment	Assessment - MSF ,CbD, end of year exams, COECSA Exams
Target Year of Achievement	Year 3/4 yr program
Related Learning Outcomes	BP 18, BP30
Other Links	Study Guide  3.4.2.2 below

Triage and Prioritisation Study Guide

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

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
• ·Basic Clinical Science Course: American Academy of Ophthalmology 2013-2014 editions. The Eye M.D. Association
• ·Oxford Textbook of Ophthalmology. Sparrow and Easty. Oxford (1999)
• ·Clinical Ophthalmology, 7th ed. Kanski, J.
• ·Duane's Clinical Ophthalmology, Ed Tasman W and Jaeger EA. Lippincott, Williams & Wilkins. 2002. Volume 1, Chapters 42-53.

Therapeutics/local and systemic therapies

Learning outcome Overview

PATIENT MANAGEMENT
Learning Outcome	Therapeutics/local and systemic therapies
Code	PM3
Description	Trainees must be able to prescribe local and systemic medications safely. They must also be able to administer a limited number of systemic therapies by subcutaneous, intramuscular, and intravenous routes, where appropriate, and in accordance with local and national clinical governance arrangements. They must be aware of the indications, contra-indications, side-effects and possible interactions of the drugs they prescribe.
Assessment	CbD, end of year exams, COECSA Exams
Target Year of Achievement	Year 3 / 4
Related Learning Outcomes	PS2 BCS8 ML2
Other Links	Study Guide  3.4.3.2 below

Local and systemic therapy prescription and administration Study Guide

Think:

• ·When should I be wary of dilating the pupil?
• ·What is the anatomy of eye/ orbit?
• ·What needle should I use?
• ·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?
• ·What are the maximum doses? E.g. local anaesthetics
• ·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?
• ·Has the drug been stored properly and is it within its expiry date?

Activity:

• ·Administration of :
• ·Topical drops
• ·Subconjunctival injections
• ·Intraocular injections (AC & vitreous) (see also PS3)
• ·Oral medications
• ·Intravenous medications including steroids

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 short and long term effects of steroids and other immunosuppressive (e.g. from rheumatologist)
• ·Wills Eye Manual
• ·Clinical Ophthalmology, 7the ed. Kensky, J.
• ·The Pharmacological Basis of Therapeutics, 9the ed. Goodman and Gilman. McGraw Hill (1996)
• ·Basic Clinical Science Course: American Academy of Ophthalmology 2013-2014 editions. The Eye M.D. Association
• ·Oxford Textbook of Ophthalmology. Sparrow and East. Oxford (1999)
• ·Duane's Clinical Ophthalmology, Ed Tasman W and Jaeger EA. Lippincott, Williams & Wilkins. 2002. Volume 1, Chapters 42-53.

Patient selection for surgery

Learning outcome Overview

PATIENT MANAGEMENT
Patient selection for surgery	Patient selection for surgery
Code	PM4
Description	Trainees must be able to identify patients for whom surgery would be an appropriate management option and to know who and when to admit them. They must be able to recognise how selection for surgery is informed by the patient's unique medical, psychological and social circumstances. They must involve the patient, and where appropriate their carer, partner or relatives, in the decision and enable them to express their informed consent.
Assessment	Cubed, end of year exams, COECSA Exams
Target Year of Achievement	Year 1 (annual review)
Related Learning Outcomes	BCS6, COM5
Other Links	Study Guide  3.4.4.2 below

Select appropriate cases for surgery AND TAKE CONSENT Study Guide

Think:

• ·What is the purpose of the surgery?
• ·Does the patient need surgery?
• ·What is the purpose of consent?
• ·Where written consent is taken, which form is most appropriate for my patient?

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
• · Medical council guidelines on informed consent, consent taking for children and those patients with reduced capacity to give consent
• ·Essential ophthalmic surgery Foss, A. Butterworth (2000)

Recognizing and manage complications

Learning outcome Overview

PATIENT MANAGEMENT
Learning Outcome	Recognizing and managing complications
Code	PM5
Description	Trainees must be able to recognise when a patient has or is developing a complication or side-effect from treatment. They must be able to manage the complication in an appropriate and timely manner. They must be able to inform and counsel the patient, and where appropriate their carer, partner or relatives, in an honest, open and sensitive way. They must be able to document and report a critical incident to their supervisor. They must be able to recognise when complications occur at a higher than expected frequency and respond appropriately.
Assessment	CbD, end of year exams, COECSA Exams
Target Year of Achievement	Year 1 (annual review)
Related Learning Outcomes	COM6 ,COM10, COM12, ML2,  ML9
Other Links	Study Guide  3.4.5.2 below

Recognizing and managing local and systemic complications of treatment Study Guide

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
• ·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
• ·National clinical guidelines, Ministry of Health
• ·Clinical Ophthalmology, 7th ed. Kanski, J.
• ·Wills Eye Manual
• ·Basic Clinical Science Course: American Academy of Ophthalmology 2013-2014 editions. The Eye M.D. Association
• ·Oxford Textbook of Ophthalmology. Sparrow and Easty. Oxford (1999)
• ·Duane's Clinical Ophthalmology, Ed Tasman W and Jaeger EA. Lippincott, Williams & Wilkins. 2002. Volume 1, Chapters 42-53.

Emergencies

Learning outcome Overview

PATIENT MANAGEMENT
Learning Outcome	Emergencies
Code	PM6
Description	All trainees must be able to initiate management of medical emergencies and offer first aid until expert help arrives. They must recognise when the patient's condition requires further medical care or intervention and make the appropriate referral.
Assessment	National, emergency medicine protocols, CbD, end of year exams, COECSA Exams
Target Year of Achievement	End of foundation years
Related Learning Outcomes	CA10 ,BCS8
Other Links	Study Guide  3.4.6.2 below

Emergency management Study Guide

Think:

• ·What is a medical emergency?
• ·What are vital signs and can I assess deterioration in these signs?
• ·What are the basic essential procedures I should carry out on any emergency case?

Activity:

• ·Attendance in Accident and Emergency Department or on acute Medical Firm
• ·Practice BLS on mannekins
• ·Attend a basic life support course

Resources:

• ·Basic Life support for health care providers pdf(provider handbook)
• ·Basic life support provider- AHA e-books.heart.org
• ·http://www.resus.org/

Rehabilitation and Low vision

Learning outcome Overview

PATIENT MANAGEMENT
Learning Outcome	Rehabilitation and Low vision
Code	PM7
Description	Trainees must be able to recognize when patients need low vision rehabilitation. They must be able to assess a patient, prescribe low vision aids, recommend support groups and refer to special schools or national organisations.
Assessment	CbD, MSF , end of year exams, COECSA Exams
Target Year of Achievement	Year 2
Related Learning Outcomes	COM6, BP3, BP13
Other Links	Study Guide  3.4.7.2 below

Rehabilitation and Low Vision STUDY GUIDE

Think:

• ·Do I know the criteria for registration of partial and severe visual impairment?
• ·Do I know about local and national organizations which support visually impaired people?
• ·Patients involved in a support group can contribute to helping others as well as benefiting themselves.
• ·What are the  social & psychological implications of the visual impairment the patient
• ·Know the criteria for certification of partial and severe sight impairment and how is the Certificate of Visual Impairment completed?
• ·What are the implications of registration as sight impaired, both the benefits and any possible disadvantages?
• ·Which low visual aids may be appropriate to various common ophthalmic conditions?

Activity:

• ·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
• ·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
• ·http://www.blindinbusiness.co.uk/

Refer appropriately

Learning outcome Overview

PATIENT MANAGEMENT
Learning Outcome	Refer appropriately
Code	PM8
Description	Trainees must be able to involve other health care professionals in patient management when appropriate. They must be able to make appropriate referrals in a timely and efficient manner and in accordance with local protocols and guidelines.
Assessment	CbD MSF, end of year exams, COECSA Exams
Target Year of Achievement	Year 3/4
Related Learning Outcomes	COM10 COM 11 BP3 BP6 CEH5
Other Links	Study Guide  3.4.8.2 below

APPROPRIATE REFERRAL STUDY GUIDE

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?
• ·Are there any local guidelines or protocols for referrals?

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
• ·Get feedback on the appropriateness of your referrals. Reflect on the response letter; did you miss anything?
• ·Keep a note of your referrals and check what happened to the patient
• ·Make a referral the subject of a CbD

Resources:

• ·Clinical Ophthalmology, 7th Ed. Kanski J
• ·http://www.rnib.org/
• ·Local Social services for visual impairment - NICE.org.uk for clinical guidelines on various conditions

Systemic Implications

Learning outcome Overview

PATIENT MANAGEMENT
Learning Outcome	Systemic Implications
Code	PM9
Description	All trainees must be able to recognise when a patient's ocular problem is a manifestation of a systemic disorder. They must recognise when an ophthalmic diagnosis may indicate an increased risk of a systemic illness. They must be able to explain this to the patient and make appropriate arrangements for further management.
Assessment	CbD, end of year exams, COECSA Exams
Target Year of Achievement	Year 3/4
Related Learning Outcomes	CA9 CA11 BP3 BCS9
Other Links	Study Guide  3.4.9.2 below

Ocular findings and treatments WITH SYSTEMIC implications Study Guide

Think:

• ·Do I know, and can I recognize, 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?
• ·Are there any guidelines or protocols that I can use to estimate the risk of systemic disease e.g. Transient monocular visual loss and stroke risk? Xanthelasmata and vascular disease

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, 7th Ed. Kanski J.
• ·Eye in Systemic Disease Kanski J, et al Butterworth Heinemann
• ·Wills Eye Manual
• ·Basic Clinical Science Course: American Academy of Ophthalmology 2013-2014 editions. The Eye M.D. Association
• ·Oxford Textbook of Ophthalmology. Sparrow and Easty. Oxford (1999)
• ·Duane's Clinical Ophthalmology, Ed Tasman W and Jaeger EA. Lippincott, Williams & Wilkins. 2002. Volume 1, Chapters 42-53.

Spectacle lenses AND PRISM USE

Learning outcome Overview

PATIENT MANAGEMENT
Learning Outcome	Spectacle lenses
Code	PM10
Description	Trainees must be able to identify when a patient may benefit from the use of spectacle lenses and prisms. They must be able to assess the type and strength of lens or prism and provide an appropriate prescription. They must be able to liaise with and, where indicated, seek advice from optometrists and orthoptists. They must be able to advise a patient on the purpose, duration and optical effects of the prescription.
Assessment	CbD , end of year exams, COECSA Exams, certificate of refraction
Target Year of Achievement	Year 1/2
Related Learning Outcomes	PS1 BCS5
Other Links	Study Guide  3.4.10.2 below

Spectacle lenses and prisms USE Study Guide

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?
• ·How do patients with refractive errors present to the eye department?
• ·When is a refractive error caused by other ocular or systemic disease e.g. cataract, diabetes, keratoconus?
• ·How will a refractive error influence the management of eye disease e.g. cataract surgery

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:

• ·Basic Clinical Science Course: Section 3; American Academy of Ophthalmology 2013-2014 editions. The Eye M.D. Association
• ·Oxford Textbook of Ophthalmology. Sparrow and Easty. Oxford (1999)
• ·Duane's Clinical Ophthalmology, Ed Tasman W and Jaeger EA. Lippincott, Williams & Wilkins. 2002. Volume 1, Chapters 42-53.
• ·Clinical Optics, Elkington AR, Frank HJ and Greaney MJ. 1999

Contact lenses

Learning outcome Overview

PATIENT MANAGEMENT
Learning Outcome	Contact lenses
Code	PM11
Description	Trainees must be able to recommend the use of contact lenses when indicated by the patient's clinical problem. They must be able to make an appropriate referral and make appropriate provision for the patient to be reviewed. They must be able to advise on basic contact lens care and be able to recognise and manage the complications of contact lens use.
Assessment	CbD, end of year exams, COECSA Exams
Target Year of Achievement	Year 1 – 2 yr program/ Year 3/4 yr program
Related Learning Outcomes	PS1 BCS5 PI2 CA3
Other Links	Study Guide  3.4.11.2 below

CONTACT LENS STUDY GUIDE  

Think:

• Do I understand the optics of contact lenses?
• What are the basic principles of fitting hard and soft lenses?
• What are the indications for use of contact lenses and how do different uses affect the care and advice given to patients?
• Do I understand techniques and guidelines for safe use of contact lenses, including the use of topical medications in association with lenses?
• Can I recognise and manage complications of contact lenses, and discuss the implications of contact lens associated problems with patients?
• Can I insert and remove contact lenses in clinic and in the acute ophthalmic service.

Activity:                                                                       

• ·        Read up the optics of contact lenses
• ·        Ask your local optometrist to teach you how to fit a contact lens
• ·        Attend an optometry clinic for more learning sessions

Resources:

• ·        Clinical Optics, Elkington AR, Frank HJ and Greaney MJ. 1999
• ·        American Academy Ophthalmology BCSC section on contact lenses

Contact lenses and Diagnostic equipment care

Learning Outcome Overview

PATIENT MANAGEMENT(PM)
Learning Outcome	Contact lenses and Diagnostic equipment care
Code	PM12
Description	Trainees must understand the proper use of diagnostic contact lenses and other diagnostic equipment and how they should be cleaned and cared for.
Assessment	MSF, Portfolio and end of year 2,3/4 review/exams
Target Year of Achievement	Year 2 yr program/ Year 3/4 yr program
Related Learning Outcomes	CPS1 BCS5 PI2 CA3, PM11
Other Links	Study Guide  3.4.12.2 below

Contact lens AND DIAGNOSTIC EQUIPMENT care STUDY GUIDE

Knowledge:

• The various contact lens types, lens hygiene, handling, storage and associated risks

Activity:

• Attend contact lens fitting clinics
• Experience managing complications of contact lens wear

Resources:

• Courses on contact lenses fitting 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)