Patient Anxiety

Prof. Nitin Verma, Dr. Christine Younan, Dr. Simon Chen

Strong listening skills, honest responses, clear and simple advice, patient engagement and dedicated time… These were the key messages that came back when some of Australia’s leading eye health professionals spoke about helping patients overcome their anxieties.

Having practised as an ophthalmologist since 1983, Tasmania’s Clinical Associate Professor Nitin Verma AM said he has learned plenty of patient management skills over time but the basics remain unchanged.

“The key is to be honest, not to give false expectations. From the moment a patient enters the room, it’s about making eye contact and listening to them. They come to us because they are in trouble – they all come with a story… I ask them to sit down and I give them my full attention. I never look at the computer or take notes, or take a phone call while they are talking. They need to know they are the centre of my attention.”

Remember that a typical patient has minimal understanding of the anatomy or physiology of the eye. Speak to them in plain English and avoid medical jargon…

Dr. Simon Chen says acknowledging patient anxiety is important because patients may feel embarrassed or ashamed.

“I reassure them that anxiety is a normal, universal response to their situation. I often joke that I get worried if a patient is not anxious because it generally means that something is wrong with them,” he said.

Dr. Chen says it is important to ask specific questions about anxiety then address each issue in detail. “Don’t assume you know what the patient is anxious about. For example, prior to cataract surgery, different patents will have different things that scare them the most. It may be pain during surgery in which case I assure them about how experienced my anaesthetist is and how effective modern anaesthetic medications are. I tell them that the team will take extra care to ensure they will have a pain-free operation.

“It may be the risk of blindness if a complication arose, in which case I remind them of how rare serious complications are, then I outline the numerous systems in place to avoid complications and explain that my top priority during surgery is to avoid any complication.”

And then there are the extraneous reasons for anxiety. “One particular patient I recall was visibly shaking with anxiety prior to urgent retinal detachment surgery and it would be natural to assume that she was worried about the impending operation, It was only after direct questioning that she told me she was worried that her dog was alone at home and would not be fed. A brief call to her neighbour to ensure her dog would be looked after was all it took to allay her main concern.”

Some More Anxious than Others

Dr. Chen said some patients are more prone to anxiety than others, particularly those with more serious potentially sight or life threatening conditions. For example, a diagnosis of a cancer such as choroidal melanoma would typically be more anxiety provoking than a diagnosis of cataract. Patients with previous psychiatric problems such as clinical depression, and those who have encountered others with severe visual loss – for instance a patient who has witnessed a parent losing vision from macular degeneration – is more likely to be anxious about the condition than another patient without the same experience.

Assoc. Clinical Professor Nitin Verma said older patients are less likely to be anxious about their problem than younger patients. “Generally the older the patient the more accepting; and the younger the patient, the more anxious… Younger patients are worried about their job. They have a whole life ahead of them, family commitments, financial responsibilities. They worry that they are going to lose their income and often this is the first disability they have had to come to terms with – after all, losing vision is scary. Older patients understand that illness comes as part of getting older.”

Treatment Anxiety

When it’s time to discuss treatments, Sydney ophthalmologist Dr. Christine Younan says it is important to include patients in the decision making process. “To start with you need to have a rapport with your patient, and I believe this involves including them in any decision making process. I always take the time to explain the diagnosis, the natural history (i.e. what is likely to happen if I don’t treat them), all their treatment options and what I believe to be the most appropriate treatment. It is so useful to have colour photographs and OCT images to show patients what is wrong. I believe if patients understand what is going on, and understand why they need treatment, then they are more accepting of it.”

Dr. Chen said simple language is essential. “Remember that a typical patient has minimal understanding of the anatomy or physiology of the eye. Speak to them in plain English and avoid medical jargon.

“Assume the patient has no medical knowledge and speak slowly… Repeat important points often and provide the patient with written information whenever possible. Anticipate common questions and provide answers to them proactively because patients may forget to ask them. After a diagnosis, a commonly asked question is ‘Am I going to go blind?’. Reassuring an anxious patient with the early stages of age related macular degeneration that they are unlikely to ever become completely blind can be very comforting for them.”

Dr. Chen emphasised the importance of encouraging the patient to ask questions. “At the end of every single consultation I like to ask, ‘Do you have any questions?’. This gives the patient a chance to clarify any points of concern, which helps to minimise anxiety.”

A Counselling Process

While 10 years ago intravitreal injections into the eye were rarely heard of, today many people in the broader community are familiar with the technique and ophthalmologists feel much more confident about administering injections.

Assoc. Clinical Professor Verma says this has significantly reduced anxiety that surrounds treatment. “When we started giving injections and you told someone that was what they needed, you had to almost stop them from running away. The concept was foreign for the patient and the doctor as well; I don’t think there was any doctor who’d had enough experience with injections to feel absolutely confident.

“Now 10 years later we find that patients know when they come to our practice that this is the treatment they will most likely receive. They’ve spoken about it to their optometrist, when they are here in the waiting room; they talk to the screening staff about the procedure and with other patients who have been having injections give their observations. Patients also access support and information from groups like Macular Disease Foundation Australia. All of this means that much of the ‘counselling’, if you like, has been done
by the time they see me.

Even so, Dr. Younan said in the early stages of providing treatment, detail is of paramount importance. “I think all patients are anxious before their first intravitreal injection (and I don’t blame them).

“I explain the process in detail during the consent process and answer any question along the way. During the procedure, I explain everything that I am going to do and what they are likely to feel or experience so that nothing is a surprise to them. While no patient likes an injection into their eye, they manage it remarkably well.”

The Impact of Dr. Google

The advent of ‘Dr. Google’ has had both its positive and negative impacts on patient anxiety with the majority of patients eager to self-diagnose even before they see a specialist, then double check the advice they are given for treatment, management and rehabilitation.

According to Assoc. Clinical Professor Verma, this makes it all the more important to be confident when speaking with patients. “Patients come in and talk to us about what they’ve read. That keeps us on our toes – I need to know what’s on the web so that I can reference what they’ve read then give them my views based on experience. I have found that patients are quite happy to forget Dr. Google when you give them information with authority. But you do need to get your facts straight – patients can work out whether you’re talking from experience or not… of course a little bit of white hair also helps,” he says with a smile.

Dwelling on Past Experience

Some patients will present with anxiety due to a poor past experience and Assoc. Clinical Professor Verma says these patients need to be delicately managed.

“When patients refuse treatment you have to get them to really explain why they are refusing. Most often
they’ve had some pain from previous injections, perhaps due to a small corneal abrasion. When I explain
why this would have happened and reinforce the benefits of continuing with injections, most come around and agree to treatment. Once they’ve had a good experience, they realise it’s a harmless nuisance rather than a dangerous complication.”

Anything Can Happen

While normal levels of anxiety can be beneficial in encouraging treatment compliance, Dr. Chen says eye
health professionals must always be alert to extremes of behaviour.

“Severe anxiety can have negative consequences if it leads patients to refuse treatment. One memorable example of this I recall during my training was a pathologically anxious patient who stood up and left the operating theatre mid-way through his cataract operation!”

Case Study: Martha Christensen
Vision loss came as a complete surprise to Martha Christensen who was diagnosed with diabetic retinopathy in 2009 and today has lost significant vision in both eyes.

“I always had perfect eye sight, I used to skite about how good it was,” said Mrs. Christensen, who lives on the central coast of New South Wales. “One day I couldn’t work out whether it was my husband coming toward me – my vision was cloudy. I went to an optometrist who told me I needed to see a specialist. Unfortunately, I ignored the advice – I really thought he didn’t know what was happening.”

“Then my sight started to get worse and I realised something was wrong. Back I went to the optometrist and within 24 hours he had me at a specialist at Wyong.”

By that time Mrs. Christensen’s eye condition had worsened considerably and she was referred on to uveitis and retina specialist Dr. Christine Younan. “Being told I had to go to Sydney was a bit of a shock.

“I expected that I’d be treated, I’d get a good pair of glasses, perhaps some drops and then everything was going to be OK.

“When Dr. Younan told me I needed to have an injection, my first thought was, ‘are you kidding me, a needle in my eyes?’. But she put me at ease by explaining every little bit about the procedure and after the first injection, I thought you beauty, there’s nothing to worry about. She is very patient, very slow, very methodical, wears a mask and gloves. She is ultra-prepared and meticulous about cleaning the eye after the injection, which I’ve come to realise is very important.

“I’ve now had about 20 injections, but I have to say, if it’s not Dr. Younan giving them, I do get slightly anxious…. Even so, I don’t consider the alternative. If there is a chance to prolong my sight I’ll do it.

Even with the treatment, Mrs Christensen has had some bleeds behind the eye which, she admits have been frightening.

“Four years ago I woke up absolutely blind – I freaked out and went straight to the eye hospital. They had me in there for eight days trying to get my eye sight back. I thought it was too late but my doctor at the hospital, Professor Ho, said there was still life in my old eyes. He operated to drain the blood and it was the nicest day when he asked me to tell him how many fingers he was holding up.”

Mrs. Christensen admits to being surprised at how well she has coped with losing her sight and the independence it once afforded. “I never thought I’d be able to cope with this – as you get older you discuss things without anticipating that they could happen to you. I said the worst thing that could happen is I’d lose my licence – but life goes on and it truly isn’t so bad.

“I’ve had good support from Vision Australia, my family and Dr. Younan who keeps me up to date with what is going on, and when I need to have my next treatment. Every time I see Dr. Younan I can’t help but marvel over
her and be grateful for how she is keeping my sight.”

Case Study: Parampreet Singh
Parampreet Singh was a young man when a car accident permanently damaged his left eye, leaving him with cloudy vision and a more subdued outlook on life.

“I had a motor vehicle accident last year in October. I broke my olecranon bone (the tip of your elbow) and my cornea was damaged from a piece of glass that flicked through my left eye.

“After the accident I immediately had blurred vision, but I expected it to improve over the next few days. Unfortunately it didn’t.”

On medical advice Mr. Singh gave the cornea another two months to heal before seeing corneal subspecialist, Dr. John Males.

“I have to admit, I felt bit depressed by that time – my left eye was blurred and I could not see anything clearly, even at a very close distance. The damage that had been done to my vision had affected my self-esteem – I was hesitant about a lot of day to day activities, like playing soccer, going out in the evening and reading – however I was hopeful of some sort of treatment.”

Dr. Males recommended photorefractive keratectomy (PRK) over a corneal transplant, which, he said, would prevent complications.

“My family and I researched the options given to me by Dr. Males and just as he’d recommended, PRK came out best.

“The idea of PRK made me anxious but Dr. Males and his team were really good at comforting and assisting me immediately before the surgery. Dr. Males explained the medical condition and treatment procedure really well and put it into the right perspective. That really took the anxiety away.

With the procedure behind him, and Mr. Singh’s vision returning, he says he feels much more positive about the future. “It feels really sad when you can’t see clearly through one eye, but there are a lot more people in this world with worse medical conditions and problems. I consider myself fortunate enough to have survived a car accident with just a blurred eye and a broken bone.”