Stress test

Excerpted from page 36 of the May/June 2021 edition of AOA Focus.

Mile Brujic, O.D., can usually spot his stressed-out patients. They’re the ones who have trouble responding to a standard question during their eye exam: Which lens is better, one or two?

“If somebody is an anxious person to begin with, they’re going to have a more difficult time performing for the test,” Dr. Brujic says. “It’s totally psychological.”

The year-long COVID-19 pandemic has heaped unprecedented stresses on top of the daily tribulations of life, both for patients and doctors of optometry themselves. Dr. Brujic, who is partner of a three-location practice in northwest Ohio, says he’s had more frequent patient conversations about stress and mental health in the past six to nine months—and he’s noticed more antidepressants on his patients’ medication lists.

Even if patients don’t mention stress, their eyes can give them away. Doctors of optometry, who can detect more than 270 serious health conditions during routine eye exams, also can spot signs of stress and mental health problems.

“Anything that affects neurology can affect the eyes,” says Dr. Brujic, who will present a course for paraoptometric staff called “The Eyes are the Window to the Soul” at the 2021 Optometry’s Meeting^® in June. “The retina itself is an extension of the brain via the optic nerve. The question is not, ‘Does mental health affect the eyes?’ But ‘How can it not affect the eyes?’”

How to help your patients

Perhaps the most obvious manifestation of stress in the eye? The telltale eyelid twitch. 

Macular edema, such as central serous retinopathy, and conjunctival retention cysts also can stem from stress. Hormones released by the body during stress can cause eye dryness. In fact, some prescription medications patients take to relieve stress—particularly SSRI drugs for anxiety and depression—also can dry out the ocular surface.

Fortunately, most stress-induced eye issues have relatively simple solutions and aren’t likely to cause long-term damage if treated. Tonic water, which contains quinine, can ease eyelid twitching. Artificial tears can alleviate some dryness. For patients whose medication causes the dryness, Dr. Brujic often recommends an armamentarium of solutions to help improve the quality of tears and retain the tears the eye produces.

It is important to share with patients that their eye issue is stress induced because dealing with a mysterious physical symptom can increase overall worry, compounding a person’s stress and making the eye problem worse, says Cecelia Koetting, O.D., who practices at a secondary tertiary surgical center in Virginia Beach and will present the course “All the Things Your OD Can See: Ocular Manifestations of Systemic Diseases” at Optometry’s Meeting.

“You’ve got an eye that’s twitching all the time and you don’t know what’s causing it and you’re concerned now that you’ve got a brain tumor,” she says. So even just a simple assurance that the issue is normal can help it improve.

It also helps begin a conversation about the source of the stress. When Dr. Koetting notices a possible stress symptom during an exam, she settles in for an eye-to-eye conversation with the patient.

“I say, ‘Hey, how are you doing? ... Because I feel like your eyes are telling me that there may be some stress,’” Dr. Koetting says. “I just start the conversation and try to have it be nonjudgmental. ‘I’m seeing some of this and it could be related to stress. Is there anything that might be going on?’” Then Dr. Koetting, who also is a yoga instructor, will share stress-relieving tips, including getting regular exercise, maintaining good sleep habits and taking time for self-care.

Other patients need help dealing with more complex stressors, such as accessing services and connecting with health care providers, says Diane Russo, O.D., an associate professor of optometry at the New England College of Optometry. Discovering these issues doesn’t require having a conversation about mental health, per se, or even including it in a routine battery of questions, Dr. Russo says. Instead, doctors should follow where a discussion leads, especially during patient education when discussing disease management and barriers to health care access.

Dr. Russo, who practices at a community health center in Boston, recalls speaking with a diabetes patient about her high A1C, which can affect ocular health. During the conversation, Dr. Russo learned the patient was having difficulty sleeping because her mother, who lived with her, was awake at night in pain. Dr. Russo, who also has a master’s degree in public health, reached out to another provider on behalf of the patient’s mother to address the issue.

“You start having these conversations as you start asking questions about what’s going on instead of just saying, ‘The patient has uncontrolled blood sugar and we talked about the importance of managing that,’” Dr. Russo says. “The patients usually know they need to control their blood sugar. But the ability to do it, and all the things that get in the way of doing it, are not so straightforward. Sometimes the best thing I can do is help put the pieces together.”

At the community health center, Dr. Russo shares a hallway with behavioral health providers—a physical reminder to use them as a resource. But doctors without such conveniently located colleagues also can grow their referral network of psychologists, psychiatrists, social workers, dieticians and other providers. Start by seeking recommendations from your state affiliate, Dr. Russo says. Aim to have a few referrals for each type of provider, she says, to account for patients’ differing financial and insurance situations.

“This is already someone who is struggling,” Dr. Russo says. “This is something that’s overwhelming for them to try to research on their own. So, you as the provider are making a recommendation to them. You can give them at least a guided referral.”

How to help yourself

Doctors are not immune to stress, which, when compounded, can lead to burnout. The World Health Organization made burnout an official medical condition in 2019, defining it as “a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed.” Burnout is characterized by feelings of energy depletion, increased mental distance from or feelings of cynicism related to one’s job and reduced professional efficacy.

Data on burnout among doctors of optometry is hard to come by, but studies show that physicians overall experience some of the highest rates of burnout. Nearly half of physicians (44%) reported experiencing at least one symptom of burnout in a 2018 survey in Mayo Clinic Proceedings. Physicians are at increased risk for burnout, the article says, compared to workers in other fields.

Douglas Totten, O.D., who owns a three-location private practice in Michigan and is chair of the AOA’s Ethics and Values Committee, wrote a case study showing how burnout can happen to doctors of optometry—and how it can impact patient care. The case follows the fictional Dr. Williams, whose growing practice puts a strain on her checkbook and requires her to see more patients. When a patient on an overbooked Monday asks “too many questions,” Dr. Williams abruptly ends the visit without ordering a visual field test because she doesn’t want to explain why the test is needed. It is Dr. Williams’ duty, the case concludes, to abide by the AOA’s Code of Ethics and make the adjustments necessary to maintain her practices in accordance with professional health care standards.

As the case study shows, doctors already faced their fair share of stresses, from burdensome student loan payments to increased patient loads, before COVID-19 threw life into turmoil, forcing optometry practices to invest additional time and money to keep staff and patients healthy. For Hilary Hawthorne, O.D., managing the schedule of her Los Angeles-based optometry practice has proved challenging during the pandemic as she juggles the urgent needs of patients with building occupancy limits and a suspension of the walk-in appointments her community relied on. Other, more unexpected situations also have popped up, Dr. Hawthorne says, such as when a laboratory that manufactured materials for her patients’ Medicaid glasses was shuttered and glasses deliveries were delayed.

But perhaps most stressful as the pandemic winds on a second year is the long-term impact it could have on the optometry profession as a whole.

“We are able to deliver care in the best way by talking face-to-face with our patients, and we are now talking face-to-face with a masked patient. That can be challenging,” Dr. Hawthorne says. “If new [virus] strains come and we’re chasing all the time, it could change this face-to-face expertise that we have always branded ourselves with.”

Doctors of optometry are aware of the lifestyle factors that can ease stress, including regular exercise, good sleep, a healthy diet, hydration and breaks to engage with loved ones. But what it really comes down to, Dr. Koetting says, is finding an interest—outside of optometry—that invigorates you.

“You just have to have things that keep you diverse… and replenish your energy,” says Dr. Koetting, who enjoys kayaking and other outdoor pursuits. “If you don’t do something to fill that energy back up, you’re going to run on empty, and we can’t go very far on empty.”

It can be more difficult to manage stressors in the professional setting, where it might not be possible to reduce patient volume or disconnect the electronic health record. But practices such as keeping an organized schedule, following a financial plan and delegating tasks can help. Also work to recognize when you need help—and ask for it.

“Have a mentor in the profession, preferably older, but maybe a peer, who you can vent to at times and share how you’re feeling,” Dr. Totten says. “That can be important, to have that support system.”

Stress and mental health—both for doctors and their patients—deserve attention, Dr. Koetting says. “It probably needs to be focused on more than it is,” she says, “and what we can do to help ourselves, so that we can help our patients.”

Access the Ethics Forum

The AOA Ethics Forum provides an opportunity to review a hypothetical case study concerning ethical challenges and includes suggestions on how doctors might handle the situation based on the AOA Standards of Professional Conduct and Code of Ethics.

Access “The Modern Practice and Optometrist Burnout.”

If you have any questions on ethics, please submit them to ethicsquestions@aoa.org.

If you have an ethical challenge or situation you wish to share, please submit a case description to ethics@aoa.org. The case description will be reviewed by the AOA’s Ethics & Values Committee and may be featured in future Ethics Forum discussions.