When I was starting off in ophthalmology my then boss had a standard spiel after completing a cataract case. It did not vary and I do not recall an instance of it not taking place. “The operation went well and I don’t expect any problems. Should you experience any difficulties at all don’t go to your GP, don’t go to accident and emergency. Come to the ward. Turn up anytime, day or night. Now that I have cast that spell you will be safe and not need to.”
Whilst his cataract skills were second to none and indeed he initiated me into the world of phacoemulsification, he was not so good at casting spells. People undergoing any operation become concerned for a thousand and one reasons. They saw a floater, Betty from the next road said the eye looked red, the dog coughed and they’re fearful they have an infection or they were visiting their niece in the maternity ward and thought they would get the eye checked out as it was feeling a bit gritty on day one postop.
The call would usually come at night or during a shower. “Your patient has arrived.” Which patient? “Mrs Davies. She had an operation yesterday. She says she was told she could turn up.” There was never any way out of those situations. You would get dressed, turn up, reassure the not so worried Mrs Davies and she would feel happy at the BUPA-esque service.
Sometimes the on-call ophthalmologist did not know how to play the game. They might have been locums, or tired, or simply attempted to triage the situation for what it was and tried to arrange an appointment in eye casualty the following day. Almost inevitably the patient would end up seeing the boss again at some point and would then complain they were not seen as he had promised. I feared this breaking of an unspoken bond more than a needlessly disrupted evening, so always ended up seeing these kinds of patients.
Everywhere I worked from then on there would be a consultant or two who would tell their patients to come to the ward whenever they felt the need. Patients belonging to those consultants inevitably would. As time went by I became bolder and tried to direct these patients towards calling up instead of simply turning up. This was met initially with a withering look; the look of a person unwilling to allow an underling to remove their special privileges. “The consultant said I could come anytime.” “Yes, but it is better to phone as you might not need to come in that day. Perhaps all you need is advice over the phone.” “The consultant was most anxious that I could come anytime as I have a serious eye condition.” Usually further attempts at changing hearts and minds would result in annoyance and could only fail.
“Although I had prevented a pointless emergency appointment I felt drained, and what is worse, I felt bad.”
There is a huge psychological barrier to asking a consultant to change the advice they give patients. When you finally pluck up the nerve the consultant in question usually sighs, leans back in his chair and tells a story or two about how a patient came to serious harm from not seeking help in a timely manner.
Perhaps for every thousand patients attending with trivial post cataract operation complaints one or two serious problems can be averted. For others there can never be any usefulness in coming out of hours, anytime of day or night.
A Spanish patient with known choroidal neovascular membrane undergoing treatment attended at the end of a busy overbooked afternoon casualty session without an appointment as she had been told she could come anytime. The casualty sister was unimpressed as she would have to be seen out of hours and the patient refused to be seen any other day. After seven years of needlessly disrupted evenings, an anger welled up inside me. She could be booked as an extra in the next available Lucentis clinic in a few days time. I went into the waiting room, prepared to do battle.
I narrowed my eyes, explained the fact that the casualty was full, overbooked, and there was simply no use coming after hours. “I will wait,” she said. “My consultant said I should come anytime. I feel my vision starting to go again.” This time it was clear cut. The sequence of events that would have to take place out of hours to enable this lady to have an intravitreal injection were more complex than launching a nuclear missile from a British submarine at a heavily populated urban target in the Middle East. She would need an optical coherence tomography (OCT), locked away without a technician in outpatients, which would have to be opened by security. I would have to book a slot to do the injection in theatre, there being no nurse to help in the clinic out of hours and asking ward nurses for help in giving an intravitreal injection would be as useful as asking the Chuckle Brothers for assistance. The theatre nurses would not know where the Lucentis was kept and would be frustrated that the case was in theatre at all.
“Come back to the Lucentis clinic,” I said. Like some Western duel she used her lines but this time there was no turning back. I made a stand. It took twenty minutes and with both patient and myself exhausted she left the clinic in a state of agitation clutching an appointment slip for the next Lucentis clinic. Although I had prevented a pointless emergency appointment I felt drained, and what is worse, I felt bad. She clearly felt that I had deprived her of the right to an appointment anytime and I knew the sequence of events that would follow. She would turn up to the clinic, get an OCT and in all likelihood, an injection. She would regale her tale of woe and the consultant would soothingly apologise and they would together condemn the uppity registrar who clearly did not know what he was doing in turning away a patient who so clearly needed treatment.
When I grow up I will not attempt to cast spells. But for now I know I am powerless to undo them and should a bewitched patient turn up again I know it is easier to work with the spell rather than trying to lift it. Ophthalmologists are no good at magic.
The views expressed are those of the author and do not represent those of the editorial team or the publisher.
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