Part One - What I Need to Know
Since elementary school, my heart has been set on a profession in medicine. My mother is a registered nurse and I have always been inspired by her, constantly inquiring about her daily encounters with patients. By around fifth grade, my interest had settled into ophthalmology. There is so much to learn about eyes and so much that unknown, waiting to be discovered. Believing that vision is the most important sense that humans possess, I will feel incredibly accomplished if I can help people who have partially or fully lost their ability to see the world.
A couple weeks into my mentorship at Milan Eye Center and after viewing multiple eye surgeries, I began to question the level of anxiety these patients may feel leading up to their procedure and how the surgeon can work to minimize their concerns. Knowing pleasant experiences are crucial to increasing patient-base, I felt the need to investigate the various methods surgeons practice in order to effectively reduce their patients’ preoperative anxiety. Being able to ease a patient’s mind and make them feel comfortable enough to go through with their surgery is not something they teach you in medical school.
Part Two - What I Know or Assume
Going into my research, I based my assumptions on what I would prefer if I were the patient, just weeks or days away from my procedure. I knew that patient education was going to be a key factor in reducing preoperative anxiety, but I was unsure of how surgeons were able to effectively communicate this information in a way that the patient can fully comprehend. Allotting time for patients to ask questions was another consideration of mine. However, the same obstacle arose once again - providing an answer that the patient can understand. Other than these assumptions, I was essentially uncertain of additional techniques for reducing anxiety and was eager to learn about them.
Part Three - The Search
My first goal in beginning my research was to decide what I wanted my essential question to be. The first source I found was pulled from Magill’s Medical Guide and was about the basics of ophthalmology – the anatomy of the eye, common diseases, and various treatments. The information in this article allowed me to familiarize myself with the concepts of the ophthalmology in order to better understand the instances I am exposed to at my mentorship. I found myself most interested in reading about surgical treatments and knew I wanted my essential question to be based on an aspect of this process. Fast forward to my first experience in the operating room: cataract surgery. I noticed that the patient was comprehensive during the procedure, responding to the surgeon’s orders to look up, down, left or right. Since it is not possible for these patients to be under general anesthesia, I wondered if that played a role in their level of preoperative anxiety.
My next step in my research was to interview one of the surgeons at Milan Eye Center. He was able to give me a lot of great information having 13 years of experience in ophthalmology. Below are the questions I asked, his response, my response, and my reflection of each answer:
1. How long have you been an ophthalmologist?
Answer: “Since 2005”
Response: “Wow, 13 years.”
Reflection: He has many years of experience in the field and I was assured that I would be receiving some great answers to my questions (which I definitely did).
2.How did you become interested in ophthalmology?
Answer: “My uncle who is an anesthesiologist in Canada exposed me to the field and due to his experience, he’s worked with a lot of specialized surgeons. He became aware of the fact that the lifestyle of the ophthalmologist is great and they handle microsurgery and deal with vision, which is one of the most important parts of people’s lives. So, with that in mind he directed me to do some research with an ophthalmologist and I was really inspired by the person I researched with who was not only academically gifted but also cared a lot about his patients. I also knew that I wanted to do some work in third world countries and there are many opportunities for ophthalmologists there.”
Response: “That’s awesome. I’ve also thought about doing third world work.”
Reflection: I thought this was a really great story. I love how his uncle was able to refer him to an ophthalmologist who he became inspired by and can accredit the majority of his interest in the field to him.
3. About how many patients do you operate on during a normal surgery day?
Answer: “On average, about 20-30”
Response: “Wow.”
Reflection: Initially, I thought that was a lot of patients. However, I realized that most of his procedures during the day are cataracts, which generally take about 15 minutes.
4. What are some of the major concerns patients have about surgery?
Answer: “The first major concern that patients have is the risk of losing their vision followed by concerns regarding pain.”
Response: “Understandable.”
Reflection: I think patients are incredibly fearful of having complications with their vision. To me, it is the most important sense, so I can understand and relate to their concerns.
5. What are your strategies for addressing these concerns? In other words, how do you reduce their preoperative anxiety and make them feel more comfortable?
Answer: “Being able to educate patients on the details of the procedure is incredibly important. Conveying confidence in your profession and abilities helps the put the patient’s mind to ease. It is also very important to empathize and be understanding of the patient’s concerns.”
Response: “Yeah, I think it’s very important that the patient knows exactly what to expect.”
Reflection: I liked how he emphasized the importance of education. I think the majority of patients’ anxiety stems from not knowing what to expect.
6. Do patients’ concerns vary with varying age groups? If so, how do your strategies also vary?
Answer: “In general, younger patients are more concerned because they have more of their lives ahead of them. This also puts more pressure on the surgeon, so again, it is important to be confident and answer their questions thoroughly”
Response: “That makes sense.”
Reflection: I liked that he pointed out that the surgeon is likely to feel more pressure with younger patients and stressed the importance of trusting your abilities.
7. How did you initially learn to deal with your patients’ anxiety?
Answer: “It started probably in medical school, working on my own anxiety in order to create a calm atmosphere for patients. And you learn a lot about the patient’s biggest fears right before the operation, so you quickly learn what they commonly are and how to ease nervousness when those concerns arise”
Response: “Sounds like a lot of learning thorough experience.”
Reflection: I liked that he explained that the first step to learning to deal with nervous patients is to work on your own anxiety. I would imagine that being a new doctor is very stressful, but you have to be sure to work on hiding that from your patients.
8. How have your strategies changed during your years of experience?
Answer: “Early education is key. For our cataract patients, we’ve invested in iPads with videos that inform the patient about the procedure that they are able to watch in the waiting area before even meeting with the doctor. We also have a website that shares former patients’ experiences, so the patient feels as if they have already been in the chair.”
Response: “Technology is a wonderful thing.”
Reflection: I love that the practice is able to incorporate technology to educate their patients on their upcoming procedures. The videos give patients a basis for asking the doctor further questions.
9. What are some challenges you have faced with anxious patients and how do you overcome them? Specific examples?
Answer: “I’ve had patients start to cry in my chair out of fear. It’s important to remember to empathize with the patient and understand the root of their concerns. Sometimes, husbands and wives begin to argue but you have to remember that their arguments are just a product of their anxiety.”
Response: “That must be tough.”
Reflection: I could not imagine having a patient begin to cry during their appointment. I liked that he emphasized how important it is to be understanding.
10. Have you ever had a patient not go through with surgery when they really needed it?
Answer: “No, nothing emergent.”
Response: “That’s good news!”
Reflection: I was glad to hear that any severe cases had not gone without treatment.
The second article I read, titled “Preoperative Anxiety – An important but Neglected Issue: A Narrative Review”, was excerpted from the Indian Anesthetists’ Forum. This article explains the many complications that can arise from preoperative anxiety which include difficult venous access due to peripheral vasoconstriction, autonomic fluctuations, delayed jaw relaxation and coughing during introduction of anesthesia, and increased anesthetic requirement. In addition to the complications it can create during surgery, preoperative anxiety has also been correlated with increased pain, nausea, and vomiting in the postoperative period, a prolonged recovery, and an increased risk for infection. (Bansal and Joon 37). This article also includes a section on how to treat and prevent preoperative anxiety, explaining that providing the patient with information about their surgery is a must. The most beneficial outcomes have been reported when patients are shown an informative video which is proven to be a more effective technique than a brochure or a personal interview alone for conveying information to patients undergoing surgery (Bansal and Joon 41). Considering the associated complications highlighted by this article allowed me to realize that reducing preoperative anxiety is not just about making the patient comfortable – it is crucial to a successful procedure. Not only did this article explain why it is important to treat this issue, it provided me with valuable information on the most efficient ways to do so.
My third and last source, "Assessment of Preoperative Anxiety among Patients Undergoing Elective Surgery" from the Egyptian Journal of Hospital Medicine, contains a study performed on patients undergoing elective surgery that assessed the subjects’ level of preoperative anxiety as well as its predictors. Using the APAIS, which contains the statements “I am worried about the anesthetic.”, “The anesthetic is on my mind continually.”, “I would like to know as much as possible about the anesthetic.”, “I am worried about the procedure.”, “The procedure is on my mind continually.”, and “I would like to know as much as possible about the procedure.”, patients were surveyed on a 1-5 scale to assess their level of anxiety 24 hours before their operation. While patients of elective surgery are believed to have lower levels of anxiety, the study reported a relatively high level among the subjects. This survey also concluded that patients were more concerned about the surgery than the anesthesia and reported the highest scores in needing information on the operation. (Almalki et al., 2330). As for the predictors, age group, gender, marital status, previous experience of surgery, availability of family support, and type of anesthesia were assessed. A t-test was conducted to test an association between these important predictors and preoperative anxiety. Statistically significant results were obtained for age group, gender, availability of family support, and type of anesthesia. The patients going under general anesthesia, with younger age, female gender, and little family support reported the highest level of anxiety. (Almalki et al., 2330). Discussing the conclusions of the study, it is noted that the results reflect “…the insufficiency or ambiguity of the information provided to the patients about their surgery” and that “…the healthcare staff should spend more time in the provision of information about the surgery in a clear and understandable matter.” (Almalki et al., 2332). The results of this study are important to my research most eye surgeries are elective and while patients of this kind of surgery are believed to have lower levels of anxiety, this study reports the opposite. This investigation also analyzes the types of patients who are more susceptible to preoperative anxiety and these predictors should be assessed by doctors in order for an adequate plan for reducing anxiety to be established. The results stress the importance of informing patients of their surgery which has been a major finding of my research.
Part Four - What I Discovered
Preoperative anxiety within the field of ophthalmology stems mainly from patients’ fear that they are at risk of losing their vision. Throughout my research, I have been able to conclude that, like I assumed, patient education is the most important and effective method in reducing these concerns. I discovered that the best way to communicate this information is through informational videos, a technique that Milan Eye Center has implemented. Additional approaches to treatment of preoperative anxiety include empathizing with patients, conveying confidence, answering questions in full, and creating a soothing atmosphere. While solace of the patient is a major goal, it is also important that preoperative anxiety is reduced in order for the procedure to progress smoothly, with a diminished risk for complications during and after surgery. Patients going under general anesthesia, with younger age, female gender, and little family support are susceptible to the highest levels and these predictors can be assessed prior to the procedure so appropriate measures are taken to decrease anxiety early on.