Ever Play Golf in the Dark?

The essential value of gaining feedback as optometrists


In this first, of what may turn out to a regular blog post on this site, I want to briefly explore the importance of gaining feedback on our performance as clinicians.

I have recently been reading a great book by Matthew Syed called ‘Black Box Thinking.’ It looks at how many of us in different roles and professions learn the lessons from situations where things have maybe gone wrong and try to implement improvements. In the early stages of the book a lot of comparisons are drawn between how lessons are learnt in the airline industry versus the medical world. The airline industry appears much more open and progressive on this front, though one conclusion may be that the pilot has a strong vested interest in their plane not crashing. Medical professionals on the other hand often feel that their professional credentials and standing can become threatened when something goes wrong, so are more likely respond more defensively.


One really nice analogy that came out of this book, was that of playing golf in the dark. Golf is a good example of how we take a skill, and try through repetition to improve our swing and technique so that the ball goes where we intend. If it veers off in one direction then next time we try to adjust, so there is a very immediate feedback loop. There would be little value of this process in going to a driving range with a basket of 100 balls, in the dark and hitting them somewhere out into the night, as we lose any feedback loop and any hope  of improving.

This led me to consider how we as optometrists gain the feedback required to improve what we do. There is always a slight risk of working in isolation in our profession, in our clinical room with little or no feedback and perhaps become comfortable in ourselves that we are doing a grand job. Thankfully with respect to spectacles and contact lenses, patients will provide fairly quick feedback if things aren’t quite right. One early lesson I had in my career was as a pre-reg, that if a patient returned with problems with either of these, I had to do all of my own rechecking. A perfect way to learn and refine what to do clinically on this front. And indeed throughout the pre-reg process there is a rich seam of feedback, if you have an engaged supervisor and assessor.

One area where there is a big learning opportunity is when letters are sent back following a referral to secondary care. Was my diagnosis correct? Is my threshold for referring a cataract seem to be at a sensible level? I have no idea what condition that patient had, I would really love to know! Just some of the questions clinicians would love to get answers from so that they can close the feedback loop on these patients and learn going forward. Unfortunately there is probably still big variation on how consistently and constructively this is provided. It may come down to time pressure within secondary care centres, but I would always encourage this provision of feedback as it is ultimately very mutually beneficial. The optometrist gets the benefit of the feedback, and may then fine-tune how they refer. Win win.

The last decade or so has brought about the requirement for peer review sessions for optometrists which I think has been a really positive step. The opportunity to chat cases and conditions over with colleagues in a non-judgemental and open forum is really helpful. Working in the hospital service, this type of activity occurs regularly amongst our ophthalmology colleagues. Often cases are presented which present diagnostic or management challenges and uncertainties and so knocking a case around, looking at the evidence and gaining the opinion of others can be a great source of learning and enhance the management of a patient.

One final area where feedback is going to be really important as optometrists is in the whole field of Independent Prescribing. Again, another really big forward step for the profession over the past decade almost now, but this is definitely an area where we can not afford to be playing golf in the dark. I have managed so far in this not to mention one of the driest words in the English language – ‘Audit’……..sorry! Always been a difficult thing to get excited about, but in this case having some means of auditing or gaining feedback on prescribing decisions is really crucial. Correct knowledge and follow-up of patients for whom we prescribe is vital, particularly with those medications which can have potentially dangerous side-effects. I have been doing glaucoma clinics for about 12 years now and still get patients coming back reporting symptoms and problems with some of these medications which I haven’t encountered before. I guess the key is to remember these experiences and try to use them when balancing up the risk/benefit equation when making a decision on treatment. But also giving the patient information on potential problems and reviewing them within a safe time period so that I gain the feedback of their experience on a new medication.

Feedback from its many sources is crucial to how we improve and evolve as clinicians, even if it challenges some of our previous views and learning. I hope that this post has been interesting, and in the spirit of its theme, all comments and feedback are welcome! Thank you for reading!


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