I could not live without…

A clinical outcome review

AOP Awards 2019 Newly-Qualified Optometrist of the Year, Joseph Ong, discusses the importance of the clinical outcome review process that has been adopted at the independent practice where he works

Joseph Ong

Many newly-qualified optometrists can attest to the steep learning curve that comes with managing patients independently and developing confidence – not just competence – in our clinical decision-making upon qualification.

As the saying goes, some things only come with experience…However, what if there was more that we could learn from our patient episodes, and in doing so, shorten the learning curve?

Learning more intentionally

I’ve been fortunate to work in a practice where there is an embedded culture of learning from colleagues and where experience sharing is for the common good.

At Aaron Optometrists, I’ve learnt a staged process of dealing with cases that I wanted to get a second opinion on. This involves:

  • Coming up with a working hypothesis based on the clinical presentation. Where applicable, I would apply medical sieving, deciding if the presentation was a case of: degeneration, inflammation, infection or trauma. This broad classification serves as a basic structure for the diagnosis and management of conditions. It is also worth considering what the hospital eye service (HES) would do if the patient were to be referred
  • Formulating a clinical management plan; almost always involving the patient in it
  • Consulting with a colleague (all of whom are IP-qualified) for a second opinion
  • Performing an outcome review as the patient is managed to resolution or to a level comparable to that of the HES.

By ‘outcome review,’ I refer to the process of finding out what happened to the patient following a clinical intervention and considering how it fits in with the patient management as a whole. This can be done by receiving feedback following a referral or by the patient’s self-report. While it is the final step in the aforementioned process, rarely does the learning end there.

Instead an outcome review tends to serve as a catalyst in the learning process by triggering a whole chain of thoughts – and ‘eureka’ moments – around the patient management.

In retrospect, I find this key practice of outcome reviewing especially helpful in facilitating my learning as a community optometrist. ¬

A proactive approach

Most optometrists can sympathise with the frustration of not receiving any feedback following a referral. Therefore, perhaps we could, in some instances, adopt a more proactive approach towards obtaining feedback.

Whenever I encounter an ‘interesting’ case, refer a patient without a definite diagnosis, or apply certain management strategies that I am not particularly experienced in,
I encourage my patients to let me know how they get on with the discussed management plan or referral. This may be as simple as leaving me a message over the phone or bringing in a letter from the hospital stating their diagnosis or treatments discussed.

I keep a dated log of these patient episodes in order to keep track of them. In some instances I would call the patient at a later date to do a telephone follow-up.

The underrated value of outcome review

Firstly, every outcome review presents a learning opportunity. When a management plan was successful in addressing the issue, it provides validation and validation boosts confidence. If it did not solve the problem fully, or if new evidence suggests the condition may not have been what I thought it was, I can adapt my clinical management plan accordingly.

In the event that I have referred and the HES has managed it differently to what I would have expected, it prompts me reconsider how I derived my provisional diagnosis and think of possible reasons that could account for that. Either way, knowing the outcome of my clinical management helps inform my clinical decisions in the future.

Secondly, follow-up keeps communication between myself and the patient open, which helps to build rapport in the long term. Little did I realise how much our patients appreciated the phone call follow-ups until I started doing it. One example is Mr HP, an elderly gentleman I saw in clinic recently who, during conversation, recounted the time when a ‘very kind’ optometrist (my colleague) rang him to follow-up after referring him urgently to the HES for sudden loss of vision a few years ago. He is still so grateful that it seemed as if the positives from that simple act had overshadowed any memory of anxiety back then.

While not its intended purpose, follow-ups can also serve as a fail-safe on the off-chance that a referral has not gone through or was not acted upon as promptly as we had expected. It puts us in a position to reassure the patient, alleviate anxiety and act in their best interest if necessary.

Finally, knowing how your clinical decision-making is saving sight or improving the quality of life of patients is one of the most rewarding aspects of this career. Outcome reviews give us the opportunity to see (or hear) first-hand the fruits of our labour.

While the effort to log and follow-up with patients means a couple of extra ‘to-dos’ in-between patients or outside of clinic hours, this is outweighed by the invaluable and intangible benefits to patient and the practitioner, certainly making it a worthwhile endeavour.

  • As told to Emily McCormick