About 2 years ago I had this patient who I had a hand in almost permanently blinding. But the thing was, I pretty much did all the stuff I was “supposed to do.” I had referred him to an ophthalmologist when I thought it was looking bad. But when I could feel it in my gut that the patient had been mismanaged, it was the fact that I didn’t act on that instinct that almost led to my patient going blind. Thankfully his GP saved the day and sent the patient back to me when she felt that something was wrong and at that point I was able to then get the patient the care he urgently required.
I call it a lesson in sticking to my guns because I think that there are times when as experienced clinicians our instincts tell us when a patient isn’t getting the care they require, and we need to listen to those instincts and act on them.
So let’s have a look at what happened.
In late October 2014 a man in his 80s presented for an eye test. Let’s call him Mr XY. He had just been discharged from hospital where he had been diagnosed as having had a stroke. He had experienced a painless, catastrophic vision loss in the right eye and looked generally unwell. Examination of the fundus in the right eye revealed a cherry red spot at the macula, that is, a central retinal artery occlusion. I figured that he hadn’t been investigated and treated for temporal arteritis, which I suspected he had.
So I referred Mr XY to the local ophthalmologist, a general ophthalmologist who Mr XY knew, but whom I felt over the last 12 months had become increasingly “disinterested” if I sent along patients with anything apart from cataracts. His rate of investigations for systemic disease where appropriate, had, in my opinion, dropped. So my first mistake was sending the patient to who I felt was the wrong practitioner.
So onto my second mistake. My referral went along the lines of “thank you for seeing Mr XY for further investigations following his recent CRAO”. I remember writing that letter like it was yesterday, because my ridiculous thought process was “I won’t write that I suspect temporal arteritis because I don’t want to come across as telling this ophthalmologist how to do his job.” Isn’t that the most ludicrous thing I could have done in that situation? On what planet is that a good idea?
But it gets worse….
So when I received the letter back from the ophthalmologist, I had the feeling that the undertone of the letter was “Amanda, this patient has had a CRAO. You knew that. Why did you bother to send them to me?” Maybe that was or wasn’t the case, but the facts remained that this patient hadn’t been investigated for temporal arteritis, and I knew it.
This brings up my third mistake, which was to figure “oh well, I must have been wrong about the potential temporal arteritis” even though every fibre in my being was screaming at me that this patient needed to be investigated. So I let it go and got on with life. This was my fourth mistake.
So in late January 2015 Mr XY presented because of intense pain in that right eye. And yep, optometrists, I’m sure you can see where this is going…… he had neovascular glaucoma in that eye. He’d been in hospital for the intense pain in the right eye and “three doctors” had looked at the eye. He’d been given systemic analgesia, which had temporarily relieved the pain to the point where it was bearable and had then been discharged from hospital. Thankfully this is when his GP stepped in and sent him back to me regarding the sore eye. She had written a note asking me to call her with the results. On the day I saw him, he looked unwell. Really unwell.
So after I’d called a different ophthalmologist’s rooms and had booked Mr XY in for an urgent appointment, I called the GP to let her know what was happening. I was so pleased that she said she’d ordered an ESR amongst other tests. So on that referral letter I was able to write “thank you for seeing Mr XY who has developed 100 day neovascular glaucoma in the right eye following a CRAO in October 2014. Due to suspicion of temporal arteritis his GP has ordered tests including an ESR and obviously we are concerned about the left eye.” As a happy ending, the patient’s right eye was treated and he was put on oral steroids and retained vision in the left eye.
So what is the moral of the story?
I have always felt responsible for the fact that Mr XY needlessly developed neovascular glaucoma. That first ophthalmologist I sent him to was clearly not thinking straight, and given that I knew something was wrong, that’s when I should have stepped in. I am grateful for the fact that Mr XY did not end up with vision loss in the left eye as well, as I’m not sure with my fragile sense of confidence that I would have been able to find it in myself to learn the lesson, move on from it and continue as an optometrist knowing that I’d messed up so badly. Was I suffering from “Imposter Syndrome” at the time, and would it have unmasked me as the fraud of an optometrist I felt like I was at the time? I’m not really sure.
Obviously anyone who has been practising for a while will have those patients who “almost got away” or “did get away” in terms of vision loss or other detrimental effects because we made a mistake or a series of mistakes. We’re all human and it’s just not possible to go through a career without stuffing up from time to time, despite our best intentions. It’s obviously important that we learn from our mistakes, understand the lesson and move on.
The one thing that it took me quite a while to learn though, is that in not acknowledging and working through my shame around Mr XY going to close to permanent blindness, this shame was essentially then acting as a lens through which I was approaching every subsequent consultation. I was looking through a lens tinted with the fear of “stuffing up.” While I feel that as health practitioners a healthy sense of vigilance is a good thing, I’d much prefer to be looking through a lens of “how can I best use my knowledge, clinical judgement and ability to help each patient” rather than “how can I make sure I don’t stuff up this patient’s care.” Because in best using our knowledge, clinical judgement and ability, it gives us the basis of the way we need to be practising, rather than working from a place of fear.
Sometimes we do need to stick to our guns, and sometimes we need to realize when we’re in over our heads and refer a patient to another practitioner. And if, for a change of pace you want my opinion on why it can be easy to think you’re a legend in your own mind in primary health, click here to read more on that!!
Amanda Griffiths is the founder of the website My Health Career. Since starting the website she has been an invited speaker for organisations including the Career Development Association of Australia and Career Education Association of Victoria, myfuture, and the Master of Ceremonies at the HealthFusion Team Challenge. She graduated from her optometry degree with first class honours in 2003, and spent two years as a part-time clinical supervisor of optometry students in a university setting. Amanda has worked as an optometrist in full time, part time and locum roles that have stretched from far north Queensland to Tasmania.
More articles on My Health Career:
- Can optometrists please agree that we will be wary of these 5 things?!?! by Amanda Griffiths
- Professionalism in an age of shifting expectations – by Amanda Griffiths
- Optometric care of diabetes – when doing the right thing can seem like the wrong thing – by Amanda Griffiths