Reflections on the Practice of Ophthalmology in a Pandemic – Lyna Azzouz

Mrs. H’s face is frozen, laden in fluster and disapprobation. The bottom half of the 89-year-old woman’s screen is a blur, a smudge. A gravid silence settled between us and, with our screens still on, had rendered the distance separating the three of us incredibly great yet agonizingly small.

As the COVID-19 pandemic descended on us in March of 2020, the world of healthcare was thrown into a frenzy of varied public perception ranging from denial to panic, scarce personal protective equipment, supercharged hospital ICUs and wards, and overwhelmed healthcare providers frantically trying to learn the new enemy as they attended to its victims. The challenge spared no healthcare discipline and while ophthalmology may not be thought of as being at the forefront of this battle, the specialty was heavily affected. If our ophthalmology department was a well-oiled machine, carefully calibrated to operate to the quiet hum of its engine and gears, the pandemic was a dislodged screw that caused a cacophony of clunks, thuds, screeches and eventual painful slowing of the wonderful machine.

At the height of the pandemic, our ophthalmology department deemed it would be best for patients with multiple comorbidities and stable eye condition to conduct their visits from the safety of their homes. Mrs. H was such a patient. She suffered from age-related macular degeneration, diabetic retinopathy, and dense cataracts. In addition to her long-standing diabetes and hypertension, her medical journey entailed a diagnosis of lymphoma, a kidney transplant procedure and an ever growing two-page long list of medications.

Like many of his colleagues, the ophthalmologist I was learning from that day had concerns and reservations about this format of care delivery. While preparing to —virtually— see Mrs. H on a Tuesday in retina clinic, he had confided, “Ophthalmology relies heavily on visual inspection; we use slit lamps, a variety of lenses, and our own bodies to diagnose and monitor patients. Taking the physical exam out of the equation hinders our practice and we don’t yet have efficient means to replace it.”

When we logged into the system to greet Mrs. H, we encountered our first challenge: despite the instructions and technical assistance provided ahead of the visit, our patient was having difficulty connecting. Once she was connected —with our and her granddaughter’s assistance— the unstable wireless connection then created periodic glitches that caused Mrs. H’s voice to lag and her concerns to be lost in technological oblivion. A few minutes into the session, frustration reigned. Mrs. H was dissatisfied; she was concerned about her vision and, upon realizing that a complete physical examination of her eyes was not possible (although she had been informed of it at the time of scheduling), became increasingly irate. “Doctor, I’m going to go blind and all of you are telling me to sit home because it’s dangerous out there? To me, being blind is worse than being dead!” Upon hearing these words, I felt a sharp pang in my heart. I felt our patient’s sense of not being heard and even abandoned. My mind was frantically processing images of the thousands of patients enduring the helplessness that their providers were feeling on the other side of the virtual abyss. The paralysis of the pandemic was tightening invisible octopod arms around every sector: COVID and non-COVID patients, those who attend to their health needs, and much farther beyond.

There came a point where the escalating difficulties and menacing clinic schedule were so formidable that I believed my attending would retort to either scheduling another online visit or arranging for an in-person visit to achieve any progress. To my surprise, with steady focus and inexorable patience, he instructed the patient to switch the phone audio. Once he had re-established voice communication, he proceeded to inquire about her concerns, systemically from most to least disturbing to her life. He set expectations: we had time to address the first two today and will do so to the very best of our ability. The patient then spoke uninterrupted —he listened. After careful ponderance, he decided that the best course of action was to move up her next in-person procedure visit and to include a scan as well. The quiver in Mrs. H’s voice lessened and her expression softened. She seemed far more content now. “Thank you, doctor,” she expressed. “I’m sorry about…earlier. I felt like you guys were forgetting about us, because…because we’re not dying with the virus. But you, you’re always very good to me, even if everything else looks different.”

What she said resonated with me. Despite what the virus had left in its wake, familiar empathy, thoroughness, and care extended by their providers were essential to patients like Mrs. H. I knew that my attending had many more patients to see and a long day ahead —he did not let any of this show through. Poised and composed, he made this patient his priority as he was prepared to do the same for the next patient and the one after and the one after.

Being a healthcare provider was never an easy feat: the fast pace, heavy workload and long hours make the profession challenging. A qualitative and sudden expansion of these challenges became a new reality during these trying times. The luxury of having the choice of not being exposed to the virus evaporated in the face of the commitment to care for the sickest among us. Many lost their lives while others had to continue working as their families and loved ones were afflicted. Every physician, nurse, physician assistant, medical assistant, and more has been integral to the sustained and smooth operating of the healthcare machine —in ophthalmology, hospital medicine, general surgery, and all other disciplines. However, they are not cogs in the machine: they are the machine. Whether in the form of reviving a patient with COVID in the ICU or preserving the sight of patients like Mrs. H through the pandemic, hard work and dedication in healthcare prevail —even beyond audio lags and frozen screens.

Author Description: Throughout my medical school career, I have been fortunate to learn the art of compassionate care from both inspiring patients and ophthalmologists. This essay came about seamlessly as I reflected on the ophthalmologist-patient relationship during the coronavirus pandemic and the way in which empathy and compassion transcend even the most challenging global crises. It describes challenges and adaptations in the ophthalmology world and highlights a patient-provider encounter that is permanently etched into my memory and that continues to fuel my journey as an ophthalmologist-in-training. Finally, this essay was also a way for me to communicate my respect and appreciation for the work and dedication of healthcare workers during these difficult times.

Download a copy of Reflections on the Practice of Ophthalmology in a Pandemic – Lyna Azzouz

Bio: Lyna Azzouz is a fourth-year medical student at the University of Michigan and currently applying for ophthalmology residency . I was born and raised in Algeria (North Africa) and moved to the US at the age of 15. My passions include art, narrative medicine, medical education reform, and health advocacy.