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The psychology of the dry eye patient
Take Winnie the Pooh’s approach to taking care of angry, nervous or depressed patients.
Can we talk? We’re all friends here, right? Safe zone and all?
Man, I just had a DAY in the clinic. My first five patients all had dry eye syndrome (DES), all were dramatically better than when they started, and nobody was happy. You take care of DES patients so you know what I mean. There’s no question that all of the developments that we’ve seen have made it easier to take care of DES and other forms of ocular surface disease than any time in history. The reason more people don’t jump at the chance to do what we all do is because, despite all of these wonderful developments, we are still taking care of dry eye PATIENTS.
After struggling through a morning that felt like wading in quicksand, I sat back and spent some time thinking about the psychology of the DES patient. I’ve previously described the archetype of the classic DES patient as a woman between the ages of 35 and 60, married, with children, employed and with some post-secondary education under her belt. While it’s helpful to understand and be comfortable with this demographic, it leaves out a lot of information about the various types of emotional makeup of DES patients, men and women, and how that affects both the patients and us as we care for them.
For guidance in this quest to better understand my patients I turned to the eminent scholar, Winnie the Pooh. (As an aside, for life guidance in general I commend to you “The Tao of Pooh”). Indeed, studying the characters surrounding Pooh not only gave me a deeper understanding of my DES patients, but just thinking about Pooh and his pals finally made me smile after my very tough morning. Let’s spend a little time together in the Hundred Acre Wood, shall we?
Chapter 1: In Which We Meet RABBIT
At SkyVision we joke about taking care of “Linda Blair,” famous for her role in “The Exorcist,” who comes in with her head spinning, hurling invective. While this “Linda” certainly invokes our demographic archetype, she doesn’t really provide much insight into how she’s feeling, at least not in a way that we can translate. Rabbit, on the other hand, is a character that we see every day in the DES clinic. He’s unhappy, and more than that, he’s pretty angry. Rabbit is also a bit of a know-it-all; he reminds me of the DES patients who have been treated at any number of other clinics before they get to you. His anger, and in our case his DES symptoms, have made him somewhat unsocial, and he’s not all that happy to be seeing you.
How does Pooh approach Rabbit with all of his anger and unhappiness? To begin with, Pooh is impossible to insult, no matter how hard Rabbit tries to get a rise out of him. This is key: it’s important for us to have a very thick skin when patients are openly angry about their symptoms. Pooh addresses each of Rabbit’s concerns or complaints and then quickly moves on, not allowing Rabbit to dwell on any particular negative. Pooh moves through all of Rabbit’s issues, big or small, as he hones in on one, single, very positive outcome: Rabbit’s honey pot. This approach works just as well when we are faced with an angry, contentious patient. Don’t get defensive or allow yourself to be insulted by the tone of your patient’s voice. Listen to all of the complaints, acknowledge that you have heard them, and then relentlessly seek to achieve one very positive outcome at that visit.
Chapter 2: In Which We Meet PIGLET
Piglet is a worrier. Everything in the Hundred Acre Wood is very scary for Piglet. He needs to know every little detail about every little thing, and if something changes even a tiny little bit from what he expected that certainly means he is doomed! Even when things are going really well for Piglet he is always waiting for the other shoe to drop. He’s convinced that it’s going to drop right on his head. Sometimes it seems as if all Winnie the Pooh does when he is with Piglet is reassure him that everything is grand and that he’s going to be OK.
That’s Pooh’s lesson for us when Piglet is in our exam chair. The worried patient needs constant reassurance that she’s going to be OK. That she really is OK. Patience and unflinching kindness in the face of her concern is what she needs, almost as much as she needs a refill on her Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan). This is the patient who is going to call with questions about every tiny thing she feels, who is going to be back in your chair with concerns after she Googles “fish oil and prostate cancer,” even though she doesn’t have a prostate gland. After you’ve chosen the appropriate regimen for her and she is showing definite signs of improvement, think of what Pooh does when Piglet is most worried: he holds his hand.
Chapter 3: In Which We Meet EEYORE
When we did our psych rotation in med school, the wise old sage professor told us all that we could tell that a patient was depressed if we walked out of the exam room feeling depressed. Eeyore is depressed. Not only that, Eeyore is a dyed-in-the-wool pessimist. He’s been down so long that bottom looks like up. It’s not all perception, though. Like our down-in-the-dumps DES patients, Eeyore has some real problems in addition to those he creates through his generally negative world view. Hey, the poor guy’s tail keeps falling off. Not only that, but his tail is attached to his posterior by a thumb tack!
Everyone around Eeyore is brought low by his affect. Everyone, that is, except Pooh and Christopher Robin. In the face of Eeyore’s complaining, Pooh, being Pooh, is relentlessly cheerful and hopeful. Sure enough, his positive outlook is borne out each time Christopher Robin arrives to reattach Eeyore’s tail. It’s easy to be brought low by a DES patient who always sees the negative. Our lesson here is that, like Christopher Robin, we possess the requisite skills to fix our patient. For our patient and for ourselves, we must apply Pooh’s ability to always see the positive in even the most difficult situations.
Chapter 4: In Which We Smile
It all sounds so hard, doesn’t it? It’s a little surprising that every day in the DES clinic isn’t like mine the other day. Here, too, we can learn from our friend Winnie the Pooh. You see, the Hundred Acre Wood is filled with many, many more of Pooh’s friends, just like your practice. Do you know how my day turned around after those first few patients? Well, let me tell you about Tigger …