Stress is becoming more and more a symptom of modern living and a recent study published in the Journal of the American College of Cardiology found over 40% of cardiac problems were stress-related. It is also considered by many medical practitioners – although there are no hard facts on this – to be a causative factor in many cancers. It can also, and this is the point of this article, impact on our lives as optometrists.
Causes
For patients there may already be stress present by way of worries about work, illness, finances, family or even the general state of the world. However, in the course of an eye examination there are additional factors: Am I going to be told there is something wrong with my eyes? Will I give the correct answers? Does this mean I will have to wear glasses? I do not like things so close to (or in tonometry – touching) my eye?
We have all heard patients says things like ‘I would rather go to the dentist than have my eyes tested’. At first hearing, illogical, but then consider – without teeth life can continue, more or less, as normal but without sight is a different matter altogether.
For practitioners, apart from external problems similar to those of patients, there are profession-related ones such as: being uncertain of a diagnosis or subsequent actions when working alone; running late; lack of time to perform all tests or being unaware of local protocol for referral.
Effects
Interestingly men and women react differently to stress. Men experience raised blood pressure and heart rate while women experience myocardial ischemia (oxygen reduction in their blood) and decreased blood flow to the heart. In practical terms – heart attacks/strokes for men and faintness/collapse in women.
In respect of the eye examination this may affect intraocular pressures and acuities to the point of hysterical amblyopia. Headaches – mainly temporal in males and occipital (often described as a tight band round the head) in females. Other signs to look out for are excessive blink rate and excessive verbosity in adults or an apparently sullen silence in children.
Patient stress
It is fair to say that many patients are affected by ‘white coat syndrome’, so the first requirement is to have a calm atmosphere on entering the practice and well-trained sympathetic reception staff with enough knowledge of eye exam procedures to reassure the patient.
On arrival in the consulting room the optometrist should introduce himself, ask his patient to make themselves comfortable and emphasise that there is no rush. A good idea is to make small talk for a few minutes based on recorded notes – work, address, hobbies, to let them relax in their chair before commencing with taking pre-refraction notes.
For the verbose patient, do not tell them to be quiet but gently say ‘let us take one thing at a time’. For the uncommunicative child try to find some common interest (asking the parents if necessary) such as iPad apps, football, who their favourite TV character is.
Quickly explain the course of events – retinoscopy, subjective testing, ophthalmoscopy, tonometry, fields - what these tests are designed to check and that in the subjective part you will repeat a particular test as often as necessary and that each part will be double-checked to avoid a mistake on their part.
If a patient is very nervous I try to get them involved – letting them look at my eyes through an ophthalmoscope and getting them to rotate the lens in their trial frame for best VA (a good time-saving trick for higher astigmatism even in non-nervous cases) are my favourites. At the conclusion of each test, if negative tell them immediately to reassure them, or if any doubt, say you will advise them of your conclusions when completely finished. Subjectively keep reassuring them they are doing well, even if stuck at 6/12 – and that not everyone can see 6/3.
Finally discuss your findings but not too cold and clinically. Some common notions are: astigmatism is a disease – explain in terms of the corneal cross-section being like a rugby ball rather than a soccer ball. Glaucoma causes the eye to feel pressure and cannot be cured. For all of these conditions, and many more, there are extremely good descriptions and schematic diagrams at www.goodhopeeyeclinic.org.uk which I show to dispel any misconceptions.
If age-related macular degeneration is diagnosed, stress the positives: Much research work is being done on this and stem cell therapy is looking promising for the future, medication such as lutein and zeaxanthin will slow the progress, treatment such as intravitreal injection of anti-VEGF drugs and radiotherapy can give good results –- and above all, in most cases, it will not cause blindness but only loss of central vision.
If referral should be necessary reassure your patient of the excellence of the local facilities, give them a brief idea of what to expect, tell them to contact you again in the event of long delay and ask them to let you know periodically what is happening – this not only keeps you in the picture but indicates your interest in them.
Practitioner stress
Preparation is the answer to minimise stress. Do not go clubbing the night before and arrive with a hangover for a busy clinic. Ensure all equipment is working, in its correct place and any drugs you require are to hand. Check your schedule and if you spot any difficult cases try to allow a bit longer to deal with them. If you do find yourself getting behind schedule try to have a plan B. Could a colleague perhaps (with the patient’s consent) take over your delayed patient? Ensure the reception staff are aware of your problem, or in the event of being really badly delayed, offering another appointment with apologies and some form of compensation or a small gift such as a cleaning spray.
If you are uncertain of a diagnosis be open and tell your patient that you are getting a colleague to have a look or getting them back later for further tests to avoid wasting time or worrying them unnecessarily.
Sometimes in spite all the above you may still feel stressed in which case try shutting the door and try some relaxing exercises such as rotating your shoulders, sitting back in your chair (or sometimes the patient’s chair is more comfortable) with lumbar support and closing your eyes for about two minutes and then applying cold water to your face. My procedure is to do this for about 10 minutes in my lunch break and find it then enables me to face the afternoon.
General
In general terms stressed patients may become irritable, anxious, confused or give false results insofar as they will give the answer they think you want in order to finish the test. In clinical terms stress may produce increased IOPs in men and reduced IOPs in women.
For the practitioner stress and rush produce mistakes, bad patient relationships and mistrust.
Conclusion
I have dealt fully with the problems from the patient’s point of view and how to minimise their stress. For the practitioner however, it may be difficult to apply these suggestions bearing in mind the current commercial pressures of seeing as many patients as possible.
Here it is up to the practitioner to be realistic in what he/she is capable of doing without stress and arranging this beforehand with their employer instead of arriving for a clinic to find themselves, for example, booked for 20 patients at 15 to 20 minute intervals instead of their optimum 14 at 30 minute intervals.
Interestingly, in my own practice, I have extended my examination time to 45 minutes and find that not only do I have less stressed, more satisfied and appreciative patients but also my dispensing values have gone up because I have time to discuss various options of lenses, benefits of a second pair and the pros and cons of the alternatives of contact lenses or refractive surgery.