As an optometrist, you will encounter patients now and again who are stressed, emotional or who even appear unstable. The ability to recognise symptoms of stress, and how to deal with it, whilst knowing your legal obligations can help you manage even your most challenging patients.
There are three key considerations for dealing with a person who presents as an ’emotional patient’.
The first key is effective communication – both during and after the consultation. Once trust is established, you will be in the ideal position to perform clinical tests and results will be easier to obtain.
The second key is to clinically recognise the visual symptoms of stress and recognise visual conditions exacerbated or caused by stress.
Stay calm and do not respond in a defensive or angry manner, as this may make the patient angrier and more emotional…
Finally, the third key is to be aware of your legal obligations to your patient, particularly if there are indications
that they are a danger to themselves or to others.
1. Effective Communication
An ’emotional patient’ is less likely to take on board the advice of their healthcare professional, and can end up seeing doctors up to 32 times a year. Not only is this time consuming and the cause of great anxiety for the patient but it contributes significantly to medical expenses and the workload on medical staff.1 Appropriate communication can ensure these patients understand the results, diagnosis and treatment intended for them.
There are some key steps for optometrists and practice staff to
take when communicating with emotional patients:2
- Acknowledge they are upset, angry or nervous;
- Address the issue by asking the patient to elaborate those feelings;
- Offer a solution, emphasising that you are working to help them;
- Repeat the solution multiple times within the conversation, so the patient remembers. Better still, write the information down for them;
- Follow them up with a call one to two weeks later to see how they are going with their treatment/management;
- At your discretion, refer the patient to the appropriate specialist for a second opinion to help them rule out or confirm a particular diagnosis.
2. Recognise the Signs
The term ’emotional patient’ is broad and within it there are different types of patients who require a more specific approach. When assessing the ’emotional patient’ character types outlined below, it is important not to judge or accuse.
The Angry Patient
When you’re confronted by an angry patient it is best to stay calm and do not respond in a defensive or angry manner,3 as this may make the patient angrier and more emotional. Assure them that you’re doing your best to help them, maintain eye contact and listen to the patient as they express their problem(s).
The Nervous Patient
Look for ‘hidden agendas’.2 Often a patient may specifically NOT express a concern you would expect them to. For example you find -2.00DS and they do not have symptomatic blur. This may indicate that the patient is nervous about having
to wear glasses.
Explain procedures before they are done and their importance. If your patient is still worried, provide reassurance about whether or not the procedure will hurt and explain that it will not cause any damage, and that it is necessary for diagnosis.
The Overtalkative Patient
Ask direct, closed-ended questions and avoid vague, open-ended questions. Bring the conversation back to the examination by politely interrupting them or, if necessary, refer the patient to the appropriate health care professional.4
The Malingerer
A malingerer is prone to exaggerate a problem to ensure you find it, sometimes for financial or personal gain. Ask them what outcome they are hoping for, and explain that exaggerating the problem to you may be counterproductive.5 Calmly explain that some of the problems they’ve brought up do not make sense and explain why. Suggest another appointment or if they wish to seek a second opinion, explain that the results will probably be similar.2
The Abused Child
Ocular manifestations occur in approximately 40 per cent of physically abused children.6 Children and parents involved in cases of child abuse will be anxious, stressed, and emotional or even appear unstable. Communicating with the parents may be difficult, especially when trying to explain findings. When talking with them it is important to be calm and measured and not short or accusatory.7
Domestic Violence
Statistics from the U.S show that one-third of injuries to victims of adult domestic violence occur to the face and neck.7 Therefore, if you are concerned that domestic violence has taken place, it is important to reassure the patient, promote their safety, inform them of local counselling sources and refer the patient to a GP or medical agency.2
Drug and Alcohol Abuse
A person who comes into your practice who is obviously under the influence or
a threat should be turned away.7, 17 If appropriate, refer the patient to a local GP, care agency or professional service such as Wesley Mission Hospitals and Life Resolutions.8,9
Psychiatric Patients
Psychiatric patients, such as histrionic, narcissistic and paranoid patients are likely to have disclosed their condition in their patient history. It is important to be friendly as well as firm. Establish very firm limits in terms of acceptable behaviour.
As a general guide, open or close-ended questions may depend on the type of personality in the consulting room. For example, a paranoid patient may prefer open-ended questions because focused questions may intimidate or threaten them.2 It is also best to prepare your patient with explanations, reassure them during the consultation and help them feel more in control (without hindering the examination). If the patient is aggressive, reschedule the appointment or refuse consultation. Finally, emphasise what is being done for the patient, rather than what is not.2
Low Vision Patients
Knowing they are losing their sight these patients go through a range of emotions. They may not want help as soon as you tell them they are losing their sight but it is important for them to know what help is available to them.
New Glasses
Like many of your patients stressed, unstable or emotional patients may find it difficult to adapt to new glasses, particularly multifocal lenses. It is wise to highlight that there is a period of adjustment of two to four weeks, but, if they are still concerned after that period, encourage them to make another appointment.
Stressors that Affect Vision
The ability to identify stressors that may affect the way your patients respond during and after consultations will assist you in practice.
Routine tests that return unusual results need to be managed carefully when dealing with a stressed, unstable or emotional patient. This makes it all the more important to identify whether or not atypical results are caused by underlying stressors.
While good communication in these situations is critical, optometrists are not in the position, or qualified, to diagnose any psychological conditions like depression and should leave this to qualified professionals.6
Stressors that cause atypical results include:
Entrance Tests
- Pupils – photophobia has been reported in sufferers of post-traumatic stress disorder;10
- Extraocular motilities – may reveal palsy of cranial nerves possibly due to trauma.11
Refraction
- Near blur – indicates that the accommodation reaction is less active;
- Binocular vision – accommodative or vergence problems. For example a large phoria may not be compensateable under stress and fatigue so an eye turn may become more noticeable.
Slit lamp
- Hyperaemia – due to lack of sleep, drug or alcohol abuse;
- Anterior eye signs of trauma – corneal scratches, recurrent ulceration on cornea, foreign bodies, conjunctival haemorrhages, orbital fracture.10
Funduscopy/BIO/DO
- Signs of trauma – Commotio retinae, haemorrhages, cotton wool spots.12
Conditions Affected by Stress
There are also numerous eye conditions or diseases that may be exacerbated by stress, some of which include:
- Herpes simplex keratitis – a recurrent condition with equivocal evidence regarding the association with stress.13
- Eyelid myokymia – a benign phenomenon of eyelid twitching that can cause anxiety.
- Computer vision syndrome – due to computer use14 and provoked by greater mental workload,15 characterised by eyestrain, irritation, redness, blurred vision or dry eye.
- Streff Syndrome or non-malingering juvenile functional bilateral amblyopia – identified by a unique set of signs and symptoms including reduced visual acuity in both distance and near, constricted visual fields, restricted ocular motor movement and colour vision disturbances.16 Commonly due to visual or emotional stress, Streff Syndrome is found in young girls aged nine to 12. Treatment with low plus eyewear prescription for constant use has been shown to improve vision
- over time.16
3. Know Your Legal Obligations
While effective communication and careful interpretation of results are essential when dealing with emotional patients, knowing your medico-legal obligations is necessary for proper management.
According to the code of conduct for optometrists from the Optometry Board of Australia, “Optometrists have a duty to make the care of patients their first concern and to practise safely
and effectively.”17
Furthermore, an optometrist is obligated to “encourage and support patients… in caring for themselves and managing their health,” and “respect the right of patients to choose whether or not they participate in any treatment or accept advice”.17
Therefore, while the ability to empathise and communicate is important, and it is up to the discretion of the optometrist to suggest extra services to manage their health, it is ultimately up to the patient to decide whether or not to follow the optometrist’s advice.18
Under section 2.11(d) of the Code of Conduct, if adverse events occur that lead to emotional, unstable and stressed patients in practice, an acknowledgement of any distress from patients must be observed and appropriate support must be provided.17
While action should be taken if a patient poses a risk to health or safety in your practice, patients should not be denied care if reasonable steps can be taken to maintain safety.17
If a professional relationship must be terminated, section 2.13 says, “good practice involves ensuring that the patient is adequately informed of the decision and facilitating arrangements for the continuing care of the patient, including passing on relevant clinical information”.17
As a health professional who works with children, mandatory reporting requires you to report suspected cases of child abuse and neglect.19
Similarly, in the case of domestic violence of adults who are seeking help, refer them to call the National Sexual Assault, Family and Domestic Violence Hotline (1800 RESPECT; 1800 737 732) then report anonymously to Crime Stoppers (1800 333 000).20
Finally, if you believe a patient is showing signs of being emotionally unstable when they come into your practice, it is advisable to have a witness present during the consultation – or, if you can’t arrange that, leave the door open. Furthermore, it is strongly advised to keep a written record (plus a copy) of the consultation and all results, including the date and time they were undertaken. In the event of a lawsuit from a patient, this document would be key evidence to protect you.
Sophia Gerritsma, Debbie Lee and Jonathan Miu are optometry students in their fifth and final year of a Bachelor of Optometry and Bachelor of Science (BOptom BSc) at the University of New South Wales. This is their first published work.
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