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PURSUING EXCELLENCE

In the first of a new series where key opinion leaders look at trends in ophthalmology, Peter Barry discusses the concept of ‘excellence’ in the field

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I would like to reflect on this topic under four headings: Money, Quality, Safety and Measurement.

Money:
Firstly, we must dissociate affluence from healthcare. Femto-assisted cataract surgery is not better because it is more expensive, but this message is often implied. “Premium” IOLs is a misnomer. It implies that toric and multifocal IOLs are the better option if you can afford them and the monofocal is a shoddier article and the poor man’s choice! All modern IOLs used in Europe are “premium” with different sub-types suitable for different patients and different patients’ requirements. One never hears a cardiologist advocating “premium” heart valves. In my country, Ireland, FRCS (Fellow of the Royal College of Surgeons) is a testimony to achievement and a badge of honour. It should not be used as a marketing acronym for Femto Refractive Cataract Surgery.

Quality:
Quality can only be achieved by listening to patient feedback. Cataract care pathways are full of detail but light on symptoms and, too often, by the time the patient meets the surgeon, it is too late to abort. PROMS (Patient Reported Outcome Measures) are as important as clinical trials. Quality is never an accident – it is the result of high intentions. Quality can only be assessed at follow-up. Surgery does not end at the door of the operating theatre: it ends when the patient is cured and discharged by the specialist. Quality is being transparent and professional when things go wrong. It is not “getting rid” of the problem-patient back to primary care whilst fooling yourself their problem will be adequately sorted there. This irresponsibility is often justified by the need to adhere to the healthcare managers’ requirements of NTFUR (New to Follow Up Ratio). Do not pass the buck. Do not refer a postoperative IOP of 26mm Mercury to the Glaucoma Clinic or the cystoid macular oedema to the Retinal Service. Be responsible and manage your own problems. Quality is not “goodbye, thank you and enjoy your multifocal – you’ll get used to the glare and haloes over the next six months”. Be honest in discussion with your patients. Spectacle independence “most of the time” is true for monofocals. Clear lens extraction does not prevent cataract and who knows the long-term risk of retinal detachment following cataract surgery and likely subsequent Yag Laser Capsulotomy when performed in the middle-aged? A reputation for excellence is not built by marketing but by achievement in the public hospital system. Is “neuro-adaptation” a fancy name for surgically induced amblyopia? Remember Tannenbaum’s dictum – “the diagnosis of cataract is like the diagnosis of cancer; it requires immediate surgery lest it metastasise across the street!”

Safety:
Safety is doing common things uncommonly well. To achieve a culture of safety, we need a culture of improvement and a culture of improvement must come from the top. Inertia is unsafe. You must get out of your comfort zone if you wish to improve. Do not repeat the same mistake with e v e r - i n c r e a s i n g confidence and call it experience.

Measurement:
Surgeons who don’t count, don’t count. Measurement is the key; with it we can compare better or worse, today or yesterday, me or someone else. It is for these reasons we published “Evidence based guidelines for cataract surgery based on data in the EUREQUO database” (Lundstrom, M. et al. J Cat Refract Surg, 2012: Jun; 38(6):1086-93). It is for these reasons the ESCRS is conducting a registry of FLACS (Femto Laser Assisted Cataract Surgery) wherein consecutive FEMTO cataract procedures in multiple European clinics will be compared to non-Femto phaco procedures matched from the EUREQUO database. The aim is to determine if FEMTO cataract surgery has the ability to achieve a superior outcome by the cumulative benefit of multiple detailed steps which surpass the human hand or whether it is simply an expensive method for improving a number of details which, ultimately, do not count. The study is in progress and results will be presented at the ESCRS Annual Congress in London in September 2014.

Peter Barry: peterbarryfrcs@theeyeclinic.ie

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