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Even though this visit is termed a stage 2 'assessment', the format is more exam-like than the stage 1 visits, and has a pass or fail result for the three parts.
The three elements that make up the visit are a routine eye examination, a contact lens check and fitting and then 1.5-2 hours of looking through patient records (PR) to evidence all the remaining 8 over-arching competencies not covered in the Stage 1 visits.
Let us now consider each part in turn.
• 1 Eye examination on a 'mystery' patient. 45 minutes is allowed for this and the patient will be a presbyope who has allegedly lost their spectacles. The assessor will check the spectacle Rx and ophthalmoscopy beforehand so they know what results should be seen and found. To get to this stage a student must have tested over 350 people so they will have developed a familiar routine in the eye examination. However many pre-reg.s decide to do a more comprehensive 'exam-type' routine that is unfamiliar to them and usually end up wasting time performing irrelevant and illogical tests. This part of the assessment should be the easiest as it's doing something familiar in your own testing room with plenty of time to do it in. The assessor should ask if time checks are required. This is a good idea but also have a clock or watch yourself to check and know at what stage you should be at in the routine at each time check so you know whether to speed up or not.
o The examination findings are to be recorded on a record sheet supplied by the assessor on the day. This sheet is 2 side of A4 long and it is a very good idea to thoroughly familiarise yourself with this before the assessment. This is best done by testing patients for a couple of days in practice using the form, which can be found in the College handbook.
• 2. Soft contact lens fit then aftercare on a separate 'mystery' patient. One eye is fitted then the cornea checked after removal of the lens. Next an aftercare is performed on the second eye of the same patient, which should include a tear film assessment. Again the assessor will have looked at the patient on the slit lamp prior to the fit and aftercare to check fit, cornea and measure keratometry readings. Twenty minutes is allowed for each of these sections (40 minutes in total) however in practice the fit can be much more straight forward and therefore quicker than the aftercare. So I've found most students take around 15 minutes for the fit and then can have 25 minutes for the aftercare. This probably better reflects the complexity of each task.
The fit is quite straight forward because the assessor provides all relevant information including a scenario. This could be:- 'This patient wishes to wear lenses for 3-4 hours a week to play football'. The scenario will suggest a particular modality of wear i.e. monthly, twice monthly or daily replacement. The modality chosen will probably be one different to the lens to be seen for the aftercare. The student should take a couple of moments to consider the information (possibly measure horizontal visible iris diameter or pupil diameter) and then choose a trial lens to insert. Insertion and removal of a soft lens is one of the specific competencies assessed in this part. Don't worry if it takes a couple of attempts to insert or remove the lens though, assessors are well used to seeing nervous candidates. As long as it gets in safely without causing injury to the patient. After insertion and an over refraction and assessment of fitting the lens can be removed. Then insert fluorescein and check the cornea before recording a final lens choice and other relevant information.
The aftercare part is more involved, a good thorough symptom and history taking can often take more than 5 minutes. Try to be succinct though as an over long interrogation can leave scant time for the clinical tasks. Remember to record lens condition as well as fit and watch the patient remove the lens themselves. Fluorescein would be expected then and a tear evaluation specifically recorded. Modifications should be recorded and advice given to the patient. I would look poorly on a student who afterwards allowed a patient to re-insert lenses immediately with fluorescein in their eyes unless irrigation was performed. Best to just let the patient wear their spectacles which they should have brought.
Over-arching competency 2.1 which describes 'managing patients in a safe fashion', is hard to evidence (it is actually probably easier to evidence a fail). Good hygiene in the routine and contact lens appointments is one of the few ways to prove competence. This would include wiping chin rests and washing hands, although doesn't maybe need to be done to the OCD level that some candidates do!
• Assessment of Over-arching Competencies. After a 5 minute 'breather' the assessor will sit down with the pre-reg and chose 14 PRs to look at in order to sign off the 8 over-arching competencies. PR is used for every competency as well as any evidence seen in the routine and Contact lens appointments. Some competencies have specific evidence types that are peculiar to them e.g. evaluation of a field plot is used for Core Subject 5 - Ocular Examination. Field plot examples are taken from a pre-approved selection issued to assessors and I will always choose a plot produced from a machine different to one the student uses in practice. So it is advisable to become accustomed to evaluating plots from a variety of field screeners.
• Another specific evidence type used is an Image (I) for Core Subject 6 - Ocular Abnormalities. So again it is good practice to get used to looking at images of pathology to diagnose and suggest management. This is a good exercise to be done regularly with a supervisor.
• Preparing your PR evidence well for this part is vital. Make sure PRs are recorded and originals provided for each and every patient episode type on the Stage 2 Patient Evidence List. A student cannot pass if any episode types are missing. Similarly make sure EVERY PR is annotated that it is ok to be viewed by a third party, otherwise the assessor cannot view the record and it therefore cannot be used as evidence. It is also a good idea to photocopy the Patient Evidence List as the assessor will need to take a copy.
• Finally the assessor will look at the Logbook evidence to look for proof of refraction and dispensing totals and sample 3 random PRs, one from each quarter to assure the numbers are accurate.
When finished the assessor will not give any indication of how the candidate has fared but will complete a report within a week that will get emailed to the student.
? Neil Constantine-Smith practises in Lymington, Hampshire. He is an assessor for the College of Optometrists. The views expressed in this column are based on his own experiences