Swallowing Professional Pride

Untreated cataract remains the most common cause of blindness in all low-income countries, as well as many middle-income countries. Why, when it is easily, cheaply and quickly treated with good results?

In the developing world, where there may be barely one ophthalmologist for 1 million people, the bulk of surgeries become cataract surgeries. But this is not enough to eradicate cataract blindness, and our likely failure to eradicate treatable blindness by 2020 shows that the situation is under-resourced. In my view, the obvious solution is to train non-doctors (such as nurses). Many people have suggested this approach, and some countries, mostly in Africa, have accepted it. There are many advantages of training non-doctor cataract surgeons:

• Both the undergraduate academic training and postgraduate practical training are much shorter and less costly.
• Such a person is more likely to stay in the rural areas where they are needed rather than migrating to the big cities.
• Having had less training and less qualifications, they are likely to be content with a lower salary scale and less likely to emigrate.
• Because the training is more focused and intensive, their surgical results should be as good if not better than the “fully” trained ophthalmic surgeon.

In modern slang, it would be considered a “no-brainer” in those countries where there is still a huge backlog of cataract blindness. But the idea remains a controversial one, and I don’t understand why. I have been involved in training “nurse cataract surgeons” in Africa, and could see little difference in their skills compared with those of the local ophthalmologists or with my own. Unfortunately, in some instances, although the government accepted this training, the local ophthalmologists were often very unsupportive, and in one case plainly obstructive. One would like to think that the reason for this opposition was to maintain professional standards. However, numerous audits have shown that the surgical results of a properly trained nurse cataract surgeon are just as good as those of an ophthalmologist. 

I believe the opposition comes from more subtle causes. It could relate to professional rivalries; some ophthalmologists may feel like they have to preserve their privileged position (and income) after many years of training and education. Ophthalmologists may also be fearful that nurse cataract surgeons may take away some of their business. But in these underserved countries, there is potentially more than enough work for everyone. Unfortunately, ophthalmologists in developing countries often face challenging situations: government salaries are low and government hospitals often dispiriting places in which to work, and the only social security is the extended family. This usually means entering the very competitive – and sometimes ‘cutthroat’ – private practice market in the big cities to maximize one’s income.

For the most part, the boundaries between duties and responsibilities of doctors and nurses are blurred in both rich and poor countries. For instance, in the USA, nurses can be trained to administer anesthetics, but most routine births are delivered by obstetricians. By contrast in the UK, anesthetics are always given by doctors, and nearly all babies are delivered by midwives. In my own postgraduate teaching hospital in Leicester (UK), most carpal tunnel surgery is now performed by a specifically trained nurse rather than an orthopedic surgeon. His audited results have always been excellent, and he has probably performed more carpal tunnel surgery than anyone else in Britain.

It is high time for us to swallow our professional pride and accept that where there is a desperate shortage of fully trained specialists, that anyone who has been properly trained and accredited is the right person to do the work. An ophthalmologist does not just perform cataract extractions, and there is still a great deal of other needy work for the fully qualified surgeon to undertake.