Welcome to the Ethics Forum! The optometric profession has long recognized its ethical responsibilities to patients, colleagues, other health care professionals and the public. This forum provides an opportunity to review a hypothetical case study containing potential ethical challenges and includes suggestions on how one might handle the situation based upon the American Optometric Association Standards of Professional Conduct and Code of Ethics.

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If you have any questions on ethics, please submit them to EthicsQuestion@aoa.org. The AOA Ethics and Values Committee will respond to your questions as soon as possible. If you have an ethical challenge you wish to share, please feel free to submit a case description to ethics@aoa.org. The case description will be reviewed by the AOA Ethics and Values Committee and may be featured in a future Ethics Forum.

The Modern Practice and Optometrist Burnout

By Douglas L. Totten, O.D.

Case Study #1

Dr. Williams is worn out; seeing more patients per hour, managing a larger staff and experiencing declining reimbursements and lower optical revenue. After long days at the office, Dr. Williams often spends another hour or two every evening reviewing and cleaning up electronic charts.

Dr. Williams has seen steady growth in her practice since purchasing it 12 years ago. The practice has replaced nearly all of the equipment and now has several of the latest diagnostic instruments. Dr. Williams has seen the practice transition from a materials-based model to a medical-model where more than half of the patient encounters are for medical reasons. This change and growth has come at a price and puts a constant strain on the office checkbook. Dr. Williams simply needs to see more patients every day. But while also raising a family and being on the school board, she wonders where she is going and if she can maintain the busyness and stress in her life.

A Monday morning arrives and upon logging in and opening her schedule, she sees a full schedule with several double bookings and remembers that her practice is not meeting a vital measure to meet meaningful use of electronic data. Dr. Williams pushes on as always, but a patient with too many questions pushes her over the edge. She closes the encounter abruptly without ordering a visual field test because she doesn't want to go through the effort to explain why the test might be necessary.

AOA Ethical References

From the Code of Ethics: To maintain their practices in accordance with professional health care standards.

The AOA Standards of Professional Conduct: Optometrists should strive to provide care that is consistent with established clinical practice guidelines such as those adopted by the American Optometric Association that are based on the latest scientific knowledge and procedures and utilize the opinions of authoritative experts and is in accordance with existing laws.

Discussion

Chronic overstress is described as burnout.[1]  Burnout can be defined as "a syndrome of emotional exhaustion, depersonalization, and a sense of low personal accomplishment that leads to decreased effectiveness at work."[2]

Burned out or not, we have standards for the care we know we should be providing. The American Optometric Association's Optometric Clinical Practice Guidelines describe recommended procedures for quality care and every optometrist is responsible to apply the guidelines as is appropriate with each patient.

Doctors of optometry are also held to the population's standards of care, which should be applied to the individual practice setting.

One ethical issue in this case relates to the responsibility that every clinical encounter requires the optometrist to consider how to utilize staffing and technology in a responsible, professional way. Michael Larkin, O.D., in a chapter in An Optometrist's Guide to Clinical Ethics (2000), offers these self-reflection questions:

  •  Am I providing quality care as I have increased by patient load?
  •  Have I reached the limit of my own mental or physical capacity, increasing the risk that I might make errors in diagnosis or treatment?
  •  Am I so busy that I rush my examination and occasionally leave out certain tests?
  •  Do I spend less time with my patients just so I can keep up with my appointment schedule?
  •  Am I becoming unhappy with myself, my patients, or my profession because I feel overworked or burned out?

Answering yes to even one question should be cause to begin to address the issues causing stress or even burnout.

Dr. Larkin writes that providing quality eye and vision care and maintaining a successful practice is a continual exercise in clinical and business judgment. It is prudent that the optometrist balances the care of the patient with the care of him or herself.[3]

Dr. Williams might try to modify the stress by making lifestyle changes. She might also create a schedule that includes fewer patients in exchange for earning less income. She could work to delegate as many responsibilities of practice management and patient care to qualified staff members or associate doctors. Decisions may perhaps be made to terminate contracts with insurance companies that reimburse at low rates. She might leave programs that provide financial incentives but cause increased work that may not ultimately benefit patient care.

In this case, our Codes of Ethics states it is Dr. Williams' duty to make the necessary adjustments to maintain her practices in accordance with professional health care standards.

Strategies to Manage Stress:

1. Manage your time efficiently. Be organized, schedule realistically, and do not overcommit yourself. Set priorities and boundaries. Maintain these limits. Learn to say "No."

2. Anticipate and prepare for situations, both at home and at work. Don't spend time trying to do things "the way it has always been done" or the "perfect" way. Look for options. Set realistic expectations of yourself and accept that good enough is good enough.

3. Create a financial plan. Stick to wise principles, reduce debt, and save. Being financially overcommitted is the second most common reason that physicians do not make changes to decrease their level of stress.

4. If possible, don't take your work home. Define when and where you will work. Give your family your full attention when you are with them.

5. Take care of yourself by scheduling time for regular breaks, leisure activities, and vacations. Eat properly, get enough sleep and stay physically active. Time for yourself can be an investment that allows you to be more readily available for all your other responsibilities. Look for and enjoy humor on a regular basis. Add fun to work.

6. Find a mentor. Share concerns with trusted colleagues and ask for help if needed. Develop a support system. Have at least one good friend.[4]

REFERENCES

1. CANADIAN MEDICAL ASSOCIATION. PHYSICIAN RESOURCE QUESTIONNAIRE. AUGUST 2003; UNPUBLISHED.

2. SHANAFELT, T. D., BRADLEY, K. A., WIPF, J. E., & BACK, A. C. BURNOUT AND SELFREPORTED PATIENT CARE IN INTERNAL MEDICINE RESIDENCY PROGRAMS. ANN INTERN MED.2002;136: 358-367.

3. LARKIN, M. (2000). ALLOCATION OF RESOURCES AND RELATIONS WITH THIRD-PARTY PAYERS. IN N. BAILEY, & E. HEITMAN (EDS.), AN OPTOMETRIST'S GUIDE TO CLINICAL ETHICS (PP.61-72). ST. LOUIS, MO: AMERICAN OPTOMETRIC ASSOCIATION.

4. GAUTAM, M. (2003, SEPTEMBER). BEFORE BURNOUT: HOW PHYSICIANS CAN DEFUSE STRESS. AMERICAN MEDICAL ASSOCIATION JOURNAL OF ETHICS VIRTUAL MENTOR, 5(9). RETRIVED FROM HTTP://VIRTUALMENTOR.AMA-ASSN.ORG/2003/09/PFOR1- 0309.HTML