EDITORIAL 601

Cataract surgery On the other hand, successful imple- Br J Ophthalmol: first published as 10.1136/bjo.2003.034918 on 16 April 2004. Downloaded from ...... mentation of high quality, high volume units within the NHS can be achieved and be a positive experience. Some exem- Cataract surgery plary units, including the one reporting in this issue, were used as examples of R P Wormald, A Foster best practice to form policies in the ‘‘Action on cataract’’ document. These ...... units show that despite many barriers, The times they are a changing progress can and has been made within the National Health Service. It is puz- zling why more effort has not been re our cataract surgical outcomes The cataract surgical rate (CSR, catar- made to disseminate and implement as good as they can get? If the act operations per million population per these examples of best practice. Aanswer is that there is still room year) in the United Kingdom is probably There is a separate point to consider for improvement, then how? between 4000 and 4500. This is about from Habib and colleagues’ article. The The outcome of cataract surgery is 100 operations per working week per authors were able to review complication determined by the patient, the techni- million population. If a rate of 8–10 cata- rates from a database of nearly 17 000 que, and the surgeon: the patient where ract operations per week is associated cases. Over time the complication rates there is coexisting morbidity; modern with a lower complication rate then 10– fell for those performing fewer than 400 techniques (most notably the implanta- 12 ‘‘cataract surgeons’’ are needed per operations per year as well as for those tion of an intraocular lens and probably million population. (Of course it may be performing more than 400. Yorston et al small incision methods) have trans- that doing 12–14 per week gives even have shown that prospective monitoring formed the quality of visual rehabilita- lower complication rates.) At present the of complications and visual outcome tion; and—dare we say—the ‘‘better’’ the United Kingdom has approximately 14 leads to an improvement in results over surgeon the ‘‘better’’ the results. There is ophthalmologists per million population time.3 This strategy of routine monitoring often little we can do to influence co- (all specialties). Australia has a CSR of every 100 cases is now being encouraged morbidity. As for technique, we have around 6500, or 150 cataract operations as part of the ‘‘Vision 2020—right to countless papers, posters, presentations, per week per million population. If the sight’’ strategy to improve the results of and videos promoting new techniques United Kingdom wish to have a CSR like cataract surgery worldwide. High volume, claiming excellent results (but rarely of Australia (currently the highest world- high quality, and low cost units have sufficient study design quality to justify wide) then it would require 75% of UK been pioneered in many parts of south the claims). But what of the surgeon? ophthalmologists performing 14 catar- Asia and are now emerging in Africa. Can the surgeon improve and if so how? acts per week (approximately 7 hours Increasingly, these centres are monitor- Habib et al’s paper in this issue of operating), 44 weeks per year. It would ing the visual outcome in order to give BJO (p 643) describes the association therefore seem that the number of ‘‘cata- objective real time feedback of the results between higher volume and lower com- ract surgeons’’ is not the main limiting to the surgeon. This is not to compare one plication rates which has been noted in factor in reducing cataract waiting times, surgeon with another, but rather for each other spheres of surgery but not so far in and one could argue that if too many surgeon to monitor his own results over http://bjo.bmj.com/ ophthalmology. The message is—the people are performing cataract surgery, time. more you do, the fewer the complica- the complication rate may be more than Ophthalmology has pioneered and tions. This is just an association, and optimal. embraced many changes in technology— one cannot tell from this kind of study cataract extraction is just one example. A which way the cause and effect works. Change in the way cataract services growing elderly population with a greater It could be that ‘‘better’’ surgeons do are provided may be difficult to expectation of good vision, means that more surgery because they have fewer

high volume, high quality cataract ser- on September 24, 2021 by guest. Protected copyright. complications or is it, as the old adage accept but, if well planned, could become a rewarding challenge for vices are required. Change in the way states, ‘‘practice makes perfect’’ and cataract services are provided may be that doing more makes you better? the profession with significant socie- tal benefits difficult to accept, but, if well planned, If, as seems plausible, practice does could become a rewarding challenge for make perfect and increasing one’s surgi- the profession with significant societal In order to reduce time on waiting lists cal experience improves results, then benefits. Efficient use of an ophthalmol- there is a need to increase volume (CSR); what is the optimum number of cataract ogist’s time making best use of surgical a point made in an editorial several years surgeries per week? Habib et al suggest skills in a way which optimises those ago in response to Minassian et al’s that the complication rate is lower in skills seems a sensible part of planning a modelling of cataract backlog in the those who perform more than 400 opera- sustainable cataract service for the NHS. tions per year (8–10 per week) than in United Kingdom.12 The government, in those who perform fewer. Given there order to reduce cataract waiting time, Br J Ophthalmol 2004;88:601–602. are not a limitless number of cataracts to has introduced ‘‘treatment centres’’ as doi: 10.1136/bjo.2003.032623 be extracted each year, what is the they are now termed. This move has not ...... optimum number of cataract surgeons been welcomed by many consultants and for the population operating at an opti- there is a concern about training the next Authors’ affiliations R P Wormald, mum rate? We know that in the generation of surgeons. The use of Moorfields Eye Hospital, City Road, London EC1 2PD, UK surgical teams from outside the United Americas and western Europe there are A Foster, London School of Hygiene and too many ophthalmologists for most of Kingdom has further aggravated the Tropical Medicine, UK them to perform regular cataract surgery. situation and does not provide the basis So are more cataract surgeons actually for a sustainable cataract service for the Correspondence to: R P Wormald, Moorfields required in the United Kingdom to United Kingdom which can meet the Eye Hospital, City Road, London EC1 2PD, UK; reduce time on the waiting lists? growing needs of an ageing population. [email protected]

www.bjophthalmol.com 602 EDITORIAL

REFERENCES epidemiological modelling of the population 3 Yorston D, Gichuhi S, Wood M, et al. Br J Ophthalmol: first published as 10.1136/bjo.2003.034918 on 16 April 2004. Downloaded from dynamics ofcataract. Br J Ophthalmol Does prospective monitoring improve 1 Minassian DC, Reidy A, Desai P, et al. The deficit 2000;84:4–8. cataract surgery outcomes in Africa? in cataract surgery in England and Wales and the 2 Wormald R. Cataract surgery—quantity and Br J Ophthalmol escalating problem of visual impairment: quality. Br J Ophthalmol 1999;83:889–90. 2002;86:543–7.

Opticin providing linkage to form a contiguous ...... network; on the other hand, these molecules also might prevent aggregation of the vitreous fibrils which Shedding light on a new eye would destabilise the gel. During ageing or disease, particularly after cellular J V Forrester infiltration of the gel, these molecules are likely to be damaged or degraded ...... and thus lead to collagen fibril aggrega- tion, lacunae formation, and gel con- Opticin is a proteoglycan of the small leucine rich repeat family densation, clinically known as vitreous located in the syneresis. Most recently a further role for opticin t is reassuring to realise that there are important structural roles. In addition has been suggested—namely, as a repo- 4 still new molecules to be discovered to versican and fibulin mentioned sitory for growth factors. Binding of Iusing classic biochemical methods already, fibrillin containing microfibrils growth factors by matrix molecules is rather than the blockbuster genomic are an important component although well recognised. For instance, vitreous approach. Opticin is an eye specific without their usual partner elastin. type II collagen binds TGF-b and BMP- 56 molecule discovered by Reardon and Other minor are present 2. Fibroblast growth factor among colleagues in 20001 using a 4 M guani- instead such as microfibril associated many other factors is stored extracellu- dine hydrochloride extract from bovine glycoprotein-1 (MAGP-1). Opticin is larly in basement membranes bound to vitreous collagen fibrils to prepare pep- a heparan sulphate proteoglycan (syn- present in significant amounts in vitr- 7 tides as a starting point for molecular decan). Now opticin appears to bind eous and it is surprising that it has not 4 cloning. Almost simultaneously, a sepa- been identified previously. It binds to growth hormone. Growth hormone has rate group of researchers discovered an heterotypic vitreous collagen fibrils and been implicated in new vessel growth both directly and through its mediator specific molecule which they termed appears to be the only member of the 2 insulin-like growth factor 1 (IGF-1), oculoglycan and was later found to be LRR family of proteins present in the particularly during development, and identical with opticin. In this issue of vitreous. One of the proposed functions matrix molecules such as opticin may the BJO (p 697), Ramesh et al describe of this family of proteins is the preven- have a role in ensuring a sufficient more fully the distribution of opticin in tion of lateral association, or aggrega- supply of growth hormone for ocular the human eye. Opticin was found to be tion, of collagen fibrils, and its vasculogenesis. This may also apply to present in significant quantities in sev- abundance in the vitreous may be the and other ocular tissues since eral ocular tissues, particularly the relevant to the determination of appro- http://bjo.bmj.com/ opticin appears to be widely distributed , the iris, and the anterior priate short range spacing of the thin in the eye. Thus, it may have more vitreous close to the pars plana. It is a collagen fibrils of the vitreous required functions besides promoting the devel- proteoglycan of the small leucine rich to permit light transmission. In this opment of the hyaloid vascular system repeat (LRR) family located in the sense then, these proteins are regulators during embryogenesis. extracellular matrix. of supramolecular organisation of tis- It is likely that further molecular The role of opticin is not clear. In the sues and include other well known vitreous gel, Bishop has suggested a functions for opticin will emerge. proteins such as decorin and lumican. Opticin appears to be restricted to the on September 24, 2021 by guest. Protected copyright. function in maintaining gel stability and These have relevance to spacing of other 3 eye and as such may come under the structure. The is a vir- critical collagenous matrices such as the tually acellular connective tissue with a umbrella of sequestered ocular antigens corneal stroma (lumican knockout mice and participate in immune privilege. It high content of water, and composed have opaque ) and skin matrix. predominantly of a type II collagen may thus also act as an autoantigen and Opticin is unusual in that it is substi- induce immune mediated inflammation scaffold filled with a matrix of hyalur- tuted with a preponderance of O- onan. Several other are also such as vitritis or pars planitis. So far sialylated oligosaccharides instead of there is no evidence for such a role but it present in smaller quantities such as V/ GAG disaccharide chains, thereby XI, VI, and IX, which act either as seems attractive as a candidate auto- reducing the level of GAG heterogeneity antigen for disorders whose pathogen- crosslinking proteins or directly as pro- in the vitreous. teoglycans, binding together the struc- esis at present remains obscure. tural but thin type II collagen fibrils Br J Ophthalmol 2004;88:602–603. with the hyaluronan filler via other Matrix molecules such as opticin doi: 10.1136/bjo.2003.034918 proteoglycan associated glycosamino- may have a role in ensuring a sufficient supply of growth hormone Correspondence to: J V Forrester, University of glycans (GAGs). Other non-collagenous Aberdeen, UK; [email protected] proteoglycans and proteins such as for ocular vasculogenesis versican and fibulin may also be REFERENCES involved in stabilisation of this delicate Coating of vitreous collagen fibrils 3 1 Reardon AJ, Le Goff M, Briggs MD, et al. structural lattice (for review see Bishop ). with molecules such as opticin and type Identification in vitreous and molecular cloning of In fact, although non-collagenous IX collagen through its chondroitin opticin, a novel member of the family of leucine- proteins form a very small percentage sulphate chains may thus have a dual rich repeat proteins of the extracellular matrix. J Biol Chem 2000;275:2123–9. of the total molecular composition of purpose: on the one hand they permit 2 Friedman JS, Ducharme R, Raymond V, et al. the vitreous gel they are believed to have structural integrity of the vitreous gel by Isolation of a novel iris-specific and leucine-rich

www.bjophthalmol.com EDITORIAL 603

repeat protein (oculoglycan) using differential vitreous. Invest Ophthalmol Vis Sci 6 Fukui N, Zhu Y, Maloney WJ, et al. Stimulation of Br J Ophthalmol: first published as 10.1136/bjo.2003.034918 on 16 April 2004. Downloaded from selection. Invest Ophthalmol Vis Sci 2003;44:5404–9. BMP-2 expression by pro-inflammatory cytokines 2000;41:2059–66. 5 Zhu Y, Oganesian A, Keene DR, et al. Type IIA IL-1 and TNF-alpha in normal and osteoarthritic 3 Bishop PN. Structural macromolecules and procollagen containing the cysteine-rich amino chondrocytes. J Bone Joint Surg Am 2003; supramolecular organisation of the vitreous gel. propeptide is deposited in the extracellular matrix 85-A(Suppl 3):59–66. Prog Retin Eye Res 2000;19:323–44. of prechondrogenic tissue and binds to TGF-beta1 7 Li J, Zhang YP, Kirsner RS. Angiogenesis in wound 4 Sanders EJ, Walter MA, Parker E, et al. Opticin and BMP-2. J Cell Biol repair: angiogenic growth factors and the extra- binds retinal growth hormone in the embryonic 1999;144:1069–80. cellular matrix. Microsc Res Tech 2003;60:107–14.

Dry none that is easily treatable. Treatment ...... is, indeed, the issue here. If we look at Sjo¨gren’s syndrome alone, there have been 70 frustrating years of having to The treatment of dry eyes rely on partially successful ameliorative therapy for both the xerostomia and the J P Whitcher KCS components of the syndrome. We still cannot ‘‘cure’’ Sjo¨gren’s syndrome...... We can only make patients more com- fortable and, fortunately in the case of To know it is still not to love it the eye component, we can usually prevent the complications related to he dry eye is often referred to as a criteria for Sjo¨gren’s syndrome as well microbial keratitis that led to blindness condition, a syndrome, or a disease; as on treatment for all forms of KCS. in some cases of KCS in the past. And Tand it is likewise known by a variety This situation exists because KCS is in yet our treatment is still ameliorative, of terms. Keratoconjunctivitis sicca reality a condition that occurs in a not curative, and until we find a way to (KCS), or more commonly keratitis family of orphan diseases. To be sure, reverse the inflammatory component of sicca, refers to any eye with some degree Sjo¨gren’s syndrome sits at the head of Sjo¨gren’s syndrome, just to name one of of dryness either by history or by the table, but the other orphans in the the orphans, millions of individuals, objective clinical findings. The literature KCS family have a way of frequently mostly women, will suffer daily discom- is confusing on this subject and often showing up quite unexpectedly. After fort and disability. blurs the difference between the symp- Sjogren’s syndrome, there is a second There is no therapeutic panacea for toms of dryness and clinical findings group of diseases that has already been dry eyes. As a clinician taking care of dry based on objective criteria.1 In similar mentioned that can also produce severe eye patients on a daily basis, I find the fashion, the term dry eye syndrome is KCS. These are the conjunctival cicatri- treatments often frustrating and unre- sometimes used interchangeably with sation syndromes: Stevens-Johnson warding. There are no ‘‘quick fixes,’’ and dry eye symptoms, a lapse in descriptive syndrome, trachoma, ocular pemphi- to know the various treatment options terminology that unfortunately clouds goid, drug induced pseudopemphigoid, that are available for our patients is the issue. Other descriptive terms for graft versus host disease, chemical definitely not to love the choices. To be ocular dryness include xerophthalmia, burns, and conjunctival cicatrisation sure, we have learned a few important which is used almost exclusively to that occurs after severe membranous lessons in the supportive treatment of http://bjo.bmj.com/ describe the eye findings associated conjunctivitis. A third group consists of KCS over the past few years. For with vitamin A deficiency in children, those individuals who have signs of KCS instance, we have become vigilant about and xerosis, which connotes the because of a specific ocular disease: recognising and controlling secondary extreme ocular dryness and keratinisa- dacryoadenitis, congenital absence of infections. However, probably the most tion that sometimes occurs after the lacrimal gland, Riley-Day syndrome, important lesson we have learned is that Stevens-Johnson syndrome, trachoma, cholinergic blockade due to drugs such dry eye patients usually do not tolerate and other causes of severe conjunctival artificial tears on a long term basis,

as atropine, chronic blepharoconjuncti- on September 24, 2021 by guest. Protected copyright. cicatrisation. And then there is Sjo¨gren’s vitis, senile atrophy of the lacrimal especially those that have preservatives syndrome, a generalised inflammatory gland, and even the current epidemic in them. The dryer the patient’s eyes disease that stands alone in its own of presumed KCS that occurs after and the more frequently they need eye category. Patients with Sjo¨gren’s syn- refractive surgery. And the fourth group drops, the more important becomes the drome usually have dry eyes or KCS but includes those atypical dry eye issue of preservatives. Before the current they also have or may not have an ‘‘orphans’’ that appear to have clinical preservative free artificial tears became associated rheumatological disease depen- KCS but who in reality have adequate commercially available, many of us used ding on whether they have primary tear production: trigeminal nerve 1.25% or 0.625% preservative free gum Sjo¨gren’s syndrome (without associated paralysis with loss of corneal sensation, cellulose as a drop of last resort. The rheumatological findings) or secondary facial sensory nerve paralysis, exposure solution frequently became contami- Sjo¨gren’s syndrome (with an associated nated with opportunistic pathogens 2 keratitis, and vitamin A deficiency rheumatological disease). Having KCS resulting in xerophthalmia.4 and some patients developed microbial does not necessarily imply that a patient keratitis. Dry eye patients with chronic has Sjo¨gren’s syndrome, but the reverse epithelial keratitis were particularly with few exceptions is usually true. The ultimate goal is to find curative susceptible to corneal infections, so the The truth of the matter is that dry solutions for this disparate family of development of commercial preserva- eyes, for which we can interchangeably diseases; keratoconjunctivitis sicca, tive free artificial tears in individually use the term KCS, is a neglected orphan. in some forms, will always require packaged disposable containers was a Even though it has been recognised for ameliorative therapy godsend. However, development of the 70 years, since Sjo¨gren first described ideal solution that mimics human tears the syndrome that bears his name in So we are presented with a family of with all of their complicated constitu- 1933,3 progress has been frustratingly orphan diseases, all complicated, many ents has remained elusive. One has only slow in agreement on the diagnostic posing as diagnostic dilemmas,5 and to look at a short list of artificial tear

www.bjophthalmol.com 604 COMMENTARY

preparations that have been tried in the et al, is the first to prove conclusively Correspondence to: J P Whitcher, University of Br J Ophthalmol: first published as 10.1136/bjo.2003.034918 on 16 April 2004. Downloaded from recent past to realise that there is no that 50% autologous serum is superior California San Francisco, 95 Kirkham Street, ideal solution. Exotic tear substitutes, San Francisco, CA 94143-0944, USA; Nepal@ to conventional artificial tears for the itsa.ucsf.edu including human serum albumin, fibro- treatment of KCS caused by a variety of nectin, vitamin A drops, and sodium conditions. The authors are to be con- hyaluronase, to name but a few, all gratulated for a beautifully designed REFERENCES purport to contain certain factors and and executed study. Even though the 1 Whitcher JP. Too dry or not too dry—is that really antiproteases that mimic human tears, number of patients in this randomised, the question or do eye symptoms lie? [editorial] but all have proved disappointing. They prospective, crossover clinical trial is Br J Ophthalmol 2003;87:665–6. are either too difficult to manufacture 2 Patel SJ, Lundy DC. Ocular manifestations of small, the authors were scrupulous in autoimmune disease. Am Fam Physician on a commercial basis or they are too the objective criteria they used to docu- 2002;66:991–8. expensive. Other topical medications ment improvement in the patients, and 3 Sjo¨gren H. Zur Kenntnis dur keratoconjunctivitis based on their anti-inflammatory their statistical analysis of the data was sicca (keratitis filiformis bei hypofunktion der 6 Tranendru¨sen). Acta Ophthalmol Suppl effects, such as corticosteroids and flawless. I look forward to further 1933;2:1–151. 7 cyclosporine, are of questionable bene- studies of this quality involving even 4 Whitcher JP. Clinical diagnosis of the dry eye. Int fit especially in cases of severe ocular larger patient populations. Although the Ophthal Clin 1987;27:7–24. dryness. 5 Whitcher JP, Gritz DC, Daniels TE. The dry eye: a ultimate goal is to find curative solu- diagnostic dilemma. Int Ophthal Clin Those of us who take care of patients tions for this disparate family of orphan 1998;33:23–37. with severe KCS have known for several diseases, KCS in some forms will always 6 Avunduk AM, Avunduk MC, Varnell ED, et al. decades that there are some individuals The comparison of efficacies of topical require ameliorative therapy. This aspect corticosteroids and nonsteroidal anti- who cannot use any artificial tears, even of treatment should not be neglected. inflammatory drops on dry eye patients: preservative free, on a sustained long With more information from studies a clinical and immunocytochemical study. term basis without developing an aller- Am J Ophthalmol 2003;136:593–602. like this one, we may one day be able 7 Kunert KS, Tisdale AS, Gilpson IK. Goblet cell gic reaction or toxicity to the drops. We to approach the clinical management of numbers and epithelial proliferation in the have also found anecdotally that the one conjunctiva of patients with dry eye syndrome KCS with greater confidence, secure in tear substitute these patients can almost treated with cyclosporin. Arch Ophthalmol the knowledge that our treatments are always tolerate is their own serum. 2002;120:330–7. safe, effective, and predictable in their 8 Tananuvat N, Daniell M, Sullivan LJ, et al. There has been renewed interest ultimate benefits for the individual Controlled study of the use of autologous serum in recently in the use of autologous serum dry eye patients. 2001;20:802–6. 8 patient. 9 Poon AC, Geerling G, Dart JK, et al. Autologous for the treatment of KCS and persistent serum eye drops for dry eyes and epithelial 9 corneal epithelial defects, but the study Br J Ophthalmol 2004;88:603–604. defects: clinical and in vitro toxicity studies. in this issue of the BJO (p 647 ) by Noble doi: 10.1136/bjo.2003.040022 Br J Ophthalmol 2002;86:832.

Series editor: David Taylor obtaining information quickly and ...... should be followed up in writing. Often they are given because the human resources office does not appreciate how long it takes to receive the invitation Give me a good reference http://bjo.bmj.com/ to give a reference and how long it takes D Taylor in many hospitals to get the reference prepared as an extra duty in an already ...... crowded week. To assume a verbal refe- It is the duty of the referee to be honest, regardless of whether the rence is safe and offer a job on the merit of that reference alone is dangerous: candidate will see the reference or not often a written reference (which may be written by someone else) will not cor- on September 24, 2021 by guest. Protected copyright. young and rather inexperienced different types of references and with respond to the verbal reference. It used to ophthalmologist was asked to the changes in human resources mana- be quite acceptable to canvas by tele- Aprovide a hospital, where he had gement in recent years it should sug- phone on behalf of a candidate: the ‘‘old applied for a 40 month registrar/senior gest to us that we might do well to boy network’’ seemed to work well but it registrar training post, with two refer- better understand the uses of references was unfair, bred inequality, and is not ences, one confidential and another today. adequate now in most circumstances. open. As luck would have it, an admin- Ophthalmology is a bit special where Open references are quite common in istrative slip-up led to the open refer- career assessment and references are some countries and many visitors or ence, which was glowing, being used as concerned because it is where doctors fellows from overseas ask for an open the definitive, confidential, reference need a combination of surgical and reference. Realistically, it is difficult for that contributed to the appointment of medical skills that is not seen to the referees to be completely honest when the unlikely candidate. He was shocked same extent elsewhere. It is also very writing open references and often they to read the returned reference that was difficult for a potential employer at are not considered worth the paper they the confidential one, which was by the interview to judge whether or not a are written on. None the less, it is still same author as the open one: it began ‘‘I trainee is potentially a good surgeon, or the duty of the referee to be honest, cannot in all honesty say that Mr X is for that a matter a good physician, regardless of whether the candidate will the most enthusiastic trainee that I have except by the reference. see the reference or not. Open references had, but…’’ and went downhill from There are three main types of refer- may confine themselves to specific there. The incident shows how luck is ences: verbal, open, and confidential. statements about the nature of the work important in a career, and how little Verbal references are usually given over carried out, how long the candidate had attention is usually paid to open the telephone or when people meet, and worked for the organisation, the depart- references. It emphasises the value of should only be used as a means of ment or unit the candidate had worked

www.bjophthalmol.com COMMENTARY 605

in, and tangible comments as to their out, they must firstly have be made N Does the candidate have a criminal Br J Ophthalmol: first published as 10.1136/bjo.2003.034918 on 16 April 2004. Downloaded from capabilities. known to the candidate and should record? If so, you must consider the A confidential reference can only be have been addressed within the perfor- implications of the crime and if its given adequately if it is focused on the mance management process set down relevance to the working environ- position for which the candidate is by the previous organisation. It is unfair ment. Those with a criminal applying. For job references, the author and illegal to provide a reference based record must not be discriminated should be provided with the job descrip- on previous performance issues that against. tion and the person specification and were not addressed with the individual N Does the candidate have a good must consider the ways in which the during their employment and to which health/sickness record? It is impor- candidate fits the job or otherwise for they did not have the opportunity to put tant to follow up previous reasons which s/he is applying. Under the right during their employment. and periods for absence. A candidate Freedom of Information and Data The following may be a helpful check- should not be penalised for what may Protection acts, the candidate has a list for both questions on a reference be perceived as an unacceptable legal right to see a confidential refer- request and considerations in the inter- record. ence, although many health authorities viewing process: N Does the candidate have good com- have destroyed confidential references munication skills? once considered at the committee meet- N Is the candidate appropriately quali- N Does s/he have good medical skills, ing following conclusion of the recruit- fied for the job? Qualifications do not including basic knowledge, diagnos- ment process. They should therefore just refer to diplomas, higher degrees, tic skill, and medical common sense? only contain factual statements that or fellowships of colleges, etc. can, if required, be backed up with Experience in the required field is as N Is the candidate self motivated? evidence, especially if the statements valuable. N Is the candidate a potential leader may be detrimental to a candidate. (should the skill be required)? N Has the reference writer appraised However, if there are known problems him/herself of the job description and N Does s/he have any difficulties in with a candidate’s performance or if person specification? taking or giving orders or leadership? there are negative perceptions about their performance, true or false, they N Is his/her personality appropriate for It is important to remember that all must be dealt with honestly. They must the job? the above are only guidelines and no be clear and concise, not contain N Is s/he a team player (if, of course, one factor should determine the fate of innuendoes, tittle tattle, or second hand the skill is required)? an individual’s career. Completion of information. The confidential reference N Does s/he display appropriate collegi- any application form, format and con- should never be disclosed outside the ality? tent of the curriculum vitae, the inter- interviewing panel or its value is view, any psychological/ability testing, N Does s/he have an appropriate emo- negated. Many employers abide by the and references form the process and tional intelligence/maturity? rule that a reference should not be used must be considered in totality, not in to form an opinion but to confirm a N Does s/he have a good sense of isolation. fairness? decision, so references are not read until Br J Ophthalmol 2004;88:604–605. the decision to appoint is all but made. N Even temperedness? doi: 10.1136/bjo.2004.041525 Organisations have a duty to each N Does s/he demonstrate an ability to other and to their employees to demon- Correspondence to: D Taylor, Institute of Child http://bjo.bmj.com/ work with staff at all levels and are Health, London WC1N 3EH, UK; strate good performance management they appropriately affable. [email protected] but all too often it is seen as the easy N Does s/he show innovative skills? option to provide a good reference and Accepted for publication 10 January 2004 let the employee move on, sometimes N Does the candidate show common sense? Any views expressed in the article are those of with disastrous consequences. the author and do not necessarily reflect the No one is all good or all bad and if N Does the candidate show honesty to views or policies of any institution at which the

there are negative things to be brought other staff members and patients? author works. on September 24, 2021 by guest. Protected copyright.

www.bjophthalmol.com