Ophthalmologists aware of need to protect mental, physical health
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Ophthalmology is typically seen as one of the most rewarding careers in medicine.
It is a thriving field that offers the excitement of continuous innovation, a high degree of patient satisfaction, more autonomy and more controllable working schedules as compared with other specialties.
Source: Duke University/Jared Lazarus
However, individual experiences, personal narratives, meeting presentations and studies are currently voicing concerns regarding overwork, increased stress levels and their consequences among ophthalmologists. At the same time, they signal that awareness about the health risks of the profession are increasing, along with the need for ophthalmologists to protect their physical and mental well-being.
“Medicine has changed from being a career where we had a lot of autonomy, a lot of control over our practice, to a more centralized system where we are dependent on others and constrained by the electronic medical record system, what insurance companies will allow us to do, and the hoops we need to jump through to get our patients the care we think is best for them,” Jullia A. Rosdahl, MD, PhD, said.
Rosdahl is a glaucoma specialist at Duke Eye Center and a wellness advocate for the ophthalmology department at Duke University School of Medicine. In collaboration with a clinical psychologist, she has developed resources to educate colleagues on stress reduction, self-care and well-being.
“The interest in this topic in our community has grown gradually over the last decade or so. In 2011, when I was finishing my training, sessions on mindfulness were run here at Duke, and researchers at Mayo had started looking at this in a more systematic way, performing national studies and instituting some interventions. The topic gained traction from there. And then with COVID and the acute stresses on doctors and nurses and the health care system, it became clear that physicians’ well-being is a critical priority,” she said.
High burnout rates
In a study published in 2022 in the Journal of Cataract & Refractive Surgery, Leonard K. Seibold, MD, and colleagues analyzed the results of a survey that showed a high degree of self-reported burnout among U.S. ophthalmologists.
“Among 592 responders, the self-reported burnout rate was 37.8%, so over one in three ophthalmologists acknowledged experiencing symptoms of burnout. And when we broke this down by severity, 65% were mild, but 30% were moderate and about 5% were severe, which would be described as, ‘I feel completely burned out. I’m at the point where I need to seek help.’ So even though 5% was a small percentage, the severity of their circumstances was alarming to us,” Seibold said.
The greatest risk factor determined in the survey was sex. With a burnout rate of 46.2%, women had almost twice the odds of experiencing burnout compared with their male counterparts at 31.2%.
Another major risk factor for burnout was practice type. Physicians working in an academic setting had twice the odds of burnout, and those working in a hospital-based practice had the highest risk of burnout, with an odds ratio of 2.4. Generally speaking, employed physicians reported higher rates of burnout (40.3%) compared with physicians who owned their practices (31.9%).
Factors such as ethnicity, marital status, salary and location did not show a significant association with burnout.
Drivers and symptoms
Factors perceived by respondents as drivers of burnout were poor job satisfaction, high stress, lack of control over workload and increased time burdens for documentation.
“This goes back to the electronic health records. The more time you spend on EHR, the more likely you are to burn out,” Seibold said.
One of the questions was on the use of scribes because their inherent role is to help minimize physicians’ documentation requirements.
“We didn’t show a significant protective factor of scribes, but the P value was .06, very close to being significant. If we had a larger study, I think we would show a benefit to scribes,” he said.
A hectic, chaotic work environment is also likely to result in burnout, and so is poor team cohesiveness, disconnect of professional values or not being aligned well with the department leaders, as shown by the survey.
“Systemic factors are a big driver. We are struggling with bureaucracy — insurance companies, administrative tasks and the EHR are the bulk of the drivers,” Rosdahl said. “There are studies showing that for every hour of face-to-face time with our patients, we are spending 2 hours at the computer. We don’t go to medical school because we want to sit at the computer. We go because we want to take care of people. Quite clearly, there is a disconnect between what we had hoped our professional lives would be like and what they are.”
Burnout often creeps in unnoticed because some of the symptoms, such as irritability, loss of energy and loss of concentration, are often overlooked and misinterpreted as “normal,” transient symptoms of being tired and hungry.
“But one unmistakable red flag for burnout is compassion fatigue, where you don’t feel like you used to about your patients and don’t approach them with the same kindness and compassion. Another one is questioning the value of your work and not remembering how special it is what you do for patients, how much of an impact you can have, along with questioning your skills and abilities,” Rosdahl said.
Young physicians at high risk
Several studies conducted on ophthalmology residents showed rates of burnout that were significantly higher as compared with those of department chairs.
“We used to think of burnout happening to tired, about-to-retire ER doctors, but now we are seeing it much earlier in our career because of the changing landscape of health care,” E. Shanika Esparaz, MD, said.
In the first 5 years as an attending, the risk for burnout is probably at its peak, in her opinion, because of the stress of practicing medicine without supervision.
“You are also burdened with high patient load and administrative tasks. There is not always someone to support and help you with that, like an administrative assistant or a scribe,” she said.
Esparaz is now in her sixth year of practice as a retina specialist, “just over the hump,” she said, and much happier. She experienced burnout about 3 years ago, and it was at that time that she started focusing on wellness.
“In medical school, surprisingly, we don’t learn how to take care of ourselves. There are no courses on proper stress management, nutrition, sleep, exercise, basic things. Hopefully, we are moving more toward talking about wellness and learning about it, but not all universities provide this kind of background,” she said.
Turning crisis into opportunity, Esparaz became board certified in lifestyle medicine and coaching. She did it for herself, but also because she wanted to make her experience and knowledge helpful for other young physicians who need this type of support.
“More and more physicians, unfortunately, want to leave medicine because of burnout. Having spent so much time and energy training for something we are really passionate about, it is worth figuring out how to work through the crisis,” she said “Many young physicians experiencing burnout end up thinking that it is their fault, but it is not. Burnout is a systemic issue, and it is important to realize that there are things that are out of our control. But other things we can control or change or advocate for ourselves. And we can empower ourselves and each other to make change.”
High rates among women
Seibold said that his survey did not investigate the reasons why burnout rates are higher among women than men, but some of his female co-authors provided insight, and other studies have looked more in depth at potential explanations.
“It is a complex, multifactorial issue, but for one, women are more likely to report or acknowledge that they are suffering symptoms of burnout, while bravado often prevents men from admitting there is a problem,” he said.
Other potential reasons highlighted by studies are pay differences, barriers to leadership and a lack of available mentorship. In addition, women may also face issues with sexual harassment and discrimination.
The quality of the relationship that women have with their patients could also make a difference in terms of stress.
“Women tend to spend more time counseling patients, and this may result in increased time pressure and have a negative impact on workflow,” Seibold said.
“It is hard for us to lay down boundaries,” Esparaz said. “We want to help, and it’s hard to say no, not only to our patients, but when we are asked to do another project, prepare another presentation, participate in another committee.”
Studies show that female physicians spend more time on family and domestic obligations than their male counterparts.
“It’s hard, and burnout can happen because you’re juggling your career and your personal life,” Esparaz said.
It is important for women to set boundaries, ask for help when needed, and find ways to delegate at work and at home.
“Let go on perfectionism. You don’t have to do it all,” she said.
The consequences of poor ergonomics
Musculoskeletal disorders due to improper work ergonomics are also a common issue among ophthalmologists, heavily affecting well-being and quality of life.
Nicole Bajic, MD, currently practicing in Cleveland, became interested and involved in work ergonomics after a car accident when she was an ophthalmology resident.
“I was rear-ended and had a cervical disc herniation. I hadn’t even officially started my career, and here I was already having issues. Knowing that ophthalmologists are already at high risk for disc issues, I thought, I’m off to a great start,” she said.
But Bajic also had the strength to turn crisis into opportunity.
“In a way, it was a good thing for me to experience because it highlighted the importance of being aware of posture and ergonomics and also ignited a passion in me to help and teach others about it,” she said.
Ophthalmologists see a high volume of patients on average and are constrained into a lot of unnatural positions.
“Slit lamps were not made with ergonomics in mind. The tables are typically too long, and so we have to lean forward to reach the oculars and see the patient. If we are doing lasers at the slit lamp, we have to flex our wrists or hyperextend them in awkward positions. Doing this repeatedly with our high volume of patients causes repetitive stretching of the nerves and muscle fibers of the fascia, leading to inflammation and pain,” Bajic said. “In addition, when looking at our smartphone, we are using the same repetitive motions that we use when we examine patients, hunching over it with our shoulders rotated forward, our head flexed down.”
This is all compounding the risk for musculoskeletal disorders, eventually leading to permanent damage.
Be mindful about posture
To recover from her trauma, Bajic started physical therapy and learned how to take better care of herself to prevent future injury.
“I did a grand round on this too, bringing my physical therapist with me to share what I had learned with all the attendings and all my colleagues,” she said.
Ophthalmologists should be aware of their professional hazards and be mindful about keeping an upright posture, checking in with themselves throughout the day.
“When you are focused on something, you carry tension in your muscles and take abnormal postures. Check every 20 minutes or so, and take 20 seconds to reset your body, making sure your shoulders are back and down and that you are aligned,” Bajic said.
Changes can be made in the clinic, such as getting slit lamps that are shorter in length or width with adjustable oculars.
“In the operating room, sit down and adjust the patient’s table and the microscope to your height. Turn the microscope away at 13°, seat down, and then you can adjust the patient’s head a little bit toward you,” she said. “Beyond that, at home, work on making sure your posture is correct, and do simple exercises to strengthen and stretch your muscles as a daily routine.”
The ABCs of self-care
To build up resilience and nurture well-being, Rosdahl recommends the “ABCs of self-care.”
“A” is for awareness, conscious knowledge of feelings and emotions in the moment.
“If you understand how you feel, you can potentially make a change,” she said.
“B” is for boundaries that people need to set to protect what they love and value in their lives, at both work and home.
“One example of a boundary would be not checking your email in the evenings or on weekends, so that at those times, you can focus on your family,” she said.
“C” is for community and connection, two important factors of well-being that have progressively been lost, taken over by individualism and loneliness.
“We became aware of this during the pandemic when we could no longer hang out and chat with our colleagues and faculty meetings were on Zoom,” Rosdahl said. “Being connected with colleagues at work is incredibly helpful to know that we are not alone dealing with difficult patients, research not getting funded, an experiment not working, a struggling student, whatever it is.”
She recommended being proactive and creating opportunities to connect, such as scheduling a walk, a coffee or a lunch with colleagues.
Healthy lifestyle choices
Esparaz said the importance of healthy habits is summarized in the six pillars of lifestyle medicine: nutrition, sleep, physical activity, stress management, avoidance of substances and social connection. She recommended consuming more plant-based proteins, fiber and healthy fats and doing 150 to 300 minutes of moderately intense physical activity or 75 to 150 minutes of vigorous activity per week.
“We don’t realize how important social connection is. Medicine can be quite isolating because you are told to work, work, work, study, study, study. But spending time with family and friends is important for our mental well-being. That’s how I worked through burnout, learning and practicing these six pillars. And then I made changes in my career: I went part time and eventually opened my own practice,” she said.
Seibold suggested practicing good ergonomics, staying socially and emotionally connected with family and friends, and engaging in nonwork-related activities. It is also important to have career diversity.
“Whether that’s research or advocacy or teaching, I think that diversity helps to prevent burnout. It keeps you engaged in different ways, and when one aspect becomes more stressful, you can turn to another one. For me, personally, that’s a very effective protective factor from burnout,” he said.
Growing awareness
Systemic issues need systemic fixes, Rosdahl said, and physicians should make their voice heard.
“We have to do it together. It can’t be just one person pushing an agenda,” she said.
If EHRs are a problem, ophthalmologists should give their feedback to EHR companies or internal groups and ask for improvements.
“Within clinics, targeted homegrown interventions are usually helpful. Leaders should encourage their teams to be creative, and when something is not working, let people figure out a solution and try it out. That also gives people back some of the autonomy they are missing,” she said.
At all levels, there is now a much wider acceptance of burnout as an issue, and initiatives to promote physicians’ wellness are growing.
“In our department, we have a physician wellness committee that not only is working for the faculty but also for the residents and the trainees. On an institution level, we are seeing university health systems bring on faculty that are specifically tasked with assessing this problem and figuring out ways to combat it. And we are also seeing this on the national level with the American Academy of Ophthalmology and subspecialty societies. At the American Glaucoma Society meeting last year, the first evening session was solely dedicated to physician wellness and burnout,” Seibold said.
“In health care, we need young leaders to drive those changes. It is particularly important to address this issue with young ophthalmologists because they are the future of our profession and of health care as a whole,” Esparaz said.
- References:
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- For more information:
- Nicole Bajic, MD, of Cleveland Clinic in Independence, Ohio, can be reached at nbajicmd@gmail.com.
- E. Shanika Esparaz, MD, of Envision Ophthalmology & Wellness in Cleveland, Ohio, can be reached at info@envisioncleveland.net.
- Jullia A. Rosdahl, MD, PhD, of Duke Eye Center in Durham, North Carolina, can be reached at jullia.rosdahl@duke.edu.
- Leonard K. Seibold, MD, of University of Colorado School of Medicine in Aurora, Colorado, can be reached at leonard.seibold@cuanschutz.edu.
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