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"It’s a Tuesday morning, and I’m in the presence of one of the most mind-boggling accomplishments in human history. This thing is so astounding in its complexity and scope, it makes the Panama Canal look like a third grader’s craft project. This marvel I see before me is the result of thousands of human beings collaborating across dozens of countries. It took the combined labour of artists, chemists, politicians, mechanics, biologists, miners, packagers, smugglers and goatherds.

It required airplanes, boats, trucks, motorcycles, vans, pallets and shoulders. It needed hundreds of materials – steel, wood, nitrogen, rubber, silicon, ultraviolet light, explosives and bat guano. It has caused great joy but also great poverty and oppression. It relied upon ancient wisdom and space-age technology, freezing temperatures and scorching heat, high mountains and deep water. It is my morning cup of coffee.”
– AJ Jacobs, 2018

 

In his book Thanks a Thousand: A Gratitude Journey, AJ Jacobs reflects on the miracle that is his morning cup of coffee [1]. He undertakes a seemingly simple quest and pledges to thank every single person who made it possible. On his gratitude journey from bean to cup, he meets the barista, the farmer who grew the bean, and everyone in between. The people that he meets come from a wide range of professional backgrounds and work together and separately, in parallel and in series, to produce coffee, in a process called multi-professional working. No product would exist without this process – but we are often ignorant of it. In this article, inspired by these insights, I reflect on a patient called Alison’s experience of modern-day eyecare and the profound process of multi-professional working that made it possible. I argue that it is in fact the process, multi-professional working, not the product, modern-day eyecare, that is truly miraculous.

“My name is Alison. I’m a 49-year-old wife and mother of three from Birmingham. I was diagnosed with punctate inner choroidopathy (PIC for short) 26 years ago. This chronic inflammatory eye condition and the glaucoma that I’ve developed as a consequence have had a massive impact on me and my family. The relapsing and remitting nature of PIC meant that, for many years, my life, my husband’s life, and my children’s lives revolved around my eyes and were largely dictated by my need for treatment.

I was constantly in and out of hospital for appointments and injections. I couldn’t work, which meant our income was much reduced; and I couldn’t plan anything, which meant no days out, no social events, and no holidays. I was totally reliant on my husband, in-laws, dad, and sister. I was very aware of the stress and worry that I was causing everyone; it was a horrible feeling as I knew they all wanted to be there for me. I stopped going out with friends as I was worried that they would get fed up asking me how things were going when I couldn’t give them a positive answer. The worst moment of it all was not being able to perform as well as I wanted to as a mum; I remember having the twins in their highchairs, trying to feed them yoghurt, and missing their mouths altogether.

The treatment I’ve received over the years has radically improved things, though. I’ve gone from being in clinic three times per week to having three-monthly check-ups. My quality of life has been transformed: I can read a book without the fear of not being able to finish it; help my children with their homework; and simply spend time having fun with my family without worrying about it being interrupted. Thinking of all the professionals who work together at Queen Elizabeth Hospital Birmingham to provide people like me with eyecare amazes me.

A typical hospital visit for my PIC would involve: the secretary, who would arrange an appointment for me; the receptionist, who would check me in; the specialist nurse, who would carry out any tests and investigations that I needed; and the uveitis expert, who would coordinate my care. Sometimes I would see also the phlebotomist who would take my bloods. If I needed injections, the injection coordinator would arrange them, and the operating theatre staff and specialist nurses would perform them. I eventually started having separate appointments to see the glaucoma specialist on top of all of this too. But it is not just professionals who provide people like me with eyecare. Outside of hospital, my support predominantly came from my family, who drove me to and from clinic and accompanied me to my many, many appointments. I was also supported by a patient involvement group for people with uveitis. We would meet every three months to talk to and teach one other about uveitis and uveitis care.

I was nominated through this as a patient expert to take part in National Institute of Health & Care Excellence (NICE’s) approval process for Iluvien; a steroid implant which is sometimes used to treat uveitis and was life-changing in my case. This gave me the opportunity to give something back and help other people with uveitis and highlighted the part that people like me can play in providing eyecare too.”
– Alison, 2020

The first thing to note is the brilliance of the product. Alison is the recipient of safe, timely, effective, efficient, equitable and patient-centred eyecare [2]. This is spectacular considering that, in the past, refractive error wasn’t correctable without considerable cost, chronic eye conditions like uveitis and glaucoma weren’t controllable, and cataract wasn’t curable without considerable complications [3]. Nowadays, conditions like refractive error, uveitis, glaucoma and cataract are more than manageable. In fact, approximately 80% of visual impairment is considered avoidable; effective interventions are available to prevent and treat most eye diseases; and vision rehabilitation is an option for irreversible ophthalmic conditions [4]. Alison is lucky to live in the UK where high-quality eyecare is available. Consider, for a moment, the consequences of visual impairment if conditions like refractive error, uveitis, glaucoma, and cataract were left untreated: individuals would needlessly face a lifetime of inequality and an inevitable inhibition of independence, with barriers to access education and employment, and an increased risk of falls, depression and dementia, amongst other things; and societies would be burdened with massive, avoidable, direct and indirect health and social care costs [5].

The second thing to note is the profundity of the process. Following Alison’s footsteps from home to hospital reveals that modern-day eyecare would not exist without multi-professional working. There is someone involved at every stage – and not always who you would expect. Of course, there are the obvious players – ophthalmologists, ophthalmic nurses, optometrists and orthoptists – with the root “opt(i/o)” or prefix “ophthalm(i/o)” in their job title. These professionals – as well as eye clinic liaison officers, ophthalmic equipment technicians, ophthalmic imagers, ophthalmic photographers and ocular prosthetists – contribute directly through eyecare-related jobs. But there are plenty of professionals in care-related jobs who do not exclusively work with eyes that contribute to eyecare too. For example, social workers, who support individuals and their families to find solutions to their problems, ophthalmic or otherwise; and all of the other medical professionals who support ophthalmologists.

There are also professionals, across the public and private sectors, who contribute to eyecare through non-care related jobs. Some are down on the ground, driving patients with visual impairment to and from their hospital appointments in buses and taxis; whilst others are up at the top, civil servants and charity workers, working in government and non-government organisations to secure and establish funding for eyecare programmes. Some are at the front – receptionists and volunteers – greeting patients with eye disease as they enter hospital and guiding them to the appropriate clinic; whilst others are at the back – administrators, cleaners, managers and security – working behind the scenes to keep eyecare services running smoothly. Underneath it all – academics, engineers, scientists and statisticians – the mothers of innovation and invention. And, as Alison’s story teaches us, patients and their families have important parts to play too.

Undoubtedly, modern-day eyecare is a miracle in Alison’s eyes. I would call it marvellous; but I would not call it a miracle. A miracle is defined as something extraordinary that is not explicable by natural or scientific laws [6]. Modern-day eyecare is certainly extraordinary; but it is entirely explicable too. Instead, I would argue that multi-professional working is the miracle. The complex ways in which multiple professionals cooperate and collaborate to produce and provide modern-day eyecare is incomprehensible and, in my opinion, truly miraculous. Now, all that is left to do – on behalf of myself, patients, and the public – is to take a moment to sincerely thank every single person who has made and continues to make modern-day eyecare possible: thank you.

 

References

1. Jacobs AJ. Thanks a Thousand: A Gratitude Journey. London: Simon & Shuster UK Ltd; 2018.
2. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington DC: National Academy Press; 2001.
3. Fishman S. The History of Ophthalmology. The Bulletin of the History of Medicine 1999;73(1):174-5.
4. World Health Organisation. Blindness and vision impairment: Key facts.
https://www.who.int/en/
news-room/fact-sheets/detail/
blindness-and-visual-impairment

5. World Health Organisation. Blindness and vision impairment: World report on vision.
https://www.who.int/publications/i/
item/world-report-on-vision

6. Lexico. Miracle.
https://www.lexico.com/
en/definition/miracle

(All links last accessed February 2021)

 

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CONTRIBUTOR
Hussein Ibrahim

University Hospitals Birmingham NHS Foundation Trust.

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CONTRIBUTOR
Alison Richards

Queen Elizabeth Hospital Birmingham, UK.

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