Stress, anxiety and burnout remain hidden challenges in ophthalmology. Two practitioners bring that out into the open and talk about ways that surgeons can confront and deal with them.
Cataract surgeons spend their careers preserving sight, restoring vision and improving quality of life for thousands of patients. Yet when it comes to their own wellbeing, many are somewhat blind.
It is an irony that sits at the heart of modern medicine – the people entrusted with caring for others often struggle to care for themselves, despite mounting evidence that stress, burnout and mental health challenges are widespread throughout healthcare.
For ophthalmologists and particularly busy cataract surgeons, the picture is nuanced. Compared with some other medical specialties, the profession is often viewed as having more predictable hours, fewer emergencies and a healthier work-life balance.
But beneath the surface, significant pressures remain.
“Medicine has its own particular stresses,” says Dr Anne Malatt, a general ophthalmologist based in Lismore, New South Wales.
“You can blind people – that’s a very stressful thing. We live in a very litigious society now, and we hold ourselves to very high, if not impossible, standards. There’s a lot of pressure on ourselves to perform.”
Professor Colin Chan, a Sydney corneal and refractive surgeon and Australian Society of Ophthalmologists (ASO) board member, says stress and anxiety are likely more prevalent than many realise.
“You are making critical decisions – see or not see, blindness or not blindness – every day, multiple times a day,” he says.
“For any profession that involves making decisions very quickly that are of critical importance, that causes a high degree of stress and anxiety.”
Perhaps the greatest challenge is that ophthalmologists often recognise these issues more readily in patients than in themselves.
“One of the things I find that we don’t do very well as doctors, which is ironic given that our job is to look after people, is we don’t look after our own,” Dr Malatt says.
Both Dr Malatt and Prof Chan have become passionate advocates for improving wellbeing within the profession.
Dr Malatt is co-chair of the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) Health and Wellbeing Committee and founder of the wellbeing platform To Medicine With Love.
Prof Chan serves in numerous leadership roles across ophthalmology and regularly mentors younger colleagues while speaking openly about stress management and mental resilience.
For both, the motivation comes from personal experience and from seeing the impact that unmanaged stress can have on colleagues and their patients throughout their careers.
Learning the hard way
Dr Malatt speaks candidly about her own journey.
Early in her medical career, she experienced abusive training environments, struggled with depression and alcohol addiction, and was deeply affected by the suicide of close friends within medicine.
“I’ve had quite a few friends take their own lives over the years.”
Those experiences ultimately led her to reassess how she approached both medicine and life.
“The first thing I did was stop resourcing things that were not healthy for my body, like alcohol, cigarettes and food,” she says.
“I started sleeping properly, going to bed earlier, and being more loving with myself. I stopped pushing myself to the point where I had to resort to something unhealthy just to keep going.”
Today, Dr Malatt ‘s philosophy centres on the sustainability of living “one life”.
Rather than viewing medicine as something separate from life, she sees it as one component of a broader, balanced existence that includes family, hobbies, exercise and personal interests.
“I don’t see my work as separate from the rest of my life,” she says.
“My work is a great part of that, but I don’t work in a way that negates the importance of the rest of my life.”
That has included deliberately adjusting her workload. While she spends four days each week practising ophthalmology, she also dedicates time to a range of other pursuits, including educational projects and a jewellery business she runs with her husband.
“I’ve definitely made adjustments,” she says. “Other people would probably call it work-life balance.”
While awareness of mental health has improved across society, both Dr Malatt and Prof Chan believe medicine continues to lag behind.
Doctors are often reluctant to acknowledge vulnerability, particularly during training when career progression feels uncertain.
“I don’t think much has changed there,” Dr Malatt says. “One of the main problems is no one wants to be open about that in their training because if they’re perceived as struggling, then they get labelled as a problem.
“They worry it could jeopardise their prospects of getting good training positions and even getting a job afterwards,” she says.
Prof Chan agrees that stigma remains deeply entrenched.
“I think the culture of surgeons and ophthalmologists is still very much one where it’s taboo to admit mental health issues,” he says.
Part of that concern stems from perceptions about competence.
“Patients, generally speaking, would overall feel less comfortable seeing a doctor with a mental health issue, or at least having one operate on them,” he says.
Yet he believes that assumption is fundamentally flawed.
“Mental health issues do not correlate with poor performance. Sometimes not admitting to those issues actually results in worse performance,” Prof Chan adds.
Fear of professional consequences can also discourage doctors from seeking help.
Dr Malatt believes concerns surrounding mandatory reporting requirements continue to create uncertainty.
“People live in fear of being reported if they reveal any kind of vulnerability,” she says.
“They tend not to get professional help, and that’s one of the main reasons.”
The result can be a profession where struggles remain hidden until they become severe.
“There’s a lot of doctors who put a lot of internal pressure on themselves,” she says.
“They don’t talk about it. They don’t externalise it. They just keep working and working and working.”
The issue may be lost for many in the cone of silence but it comes through loud and clear in numerous studies and reports.
The ASO 2024 Mental Health and Wellbeing Survey painted a confronting picture of life inside the profession.
A majority of respondents said they were either limited by time when it came to prioritising their personal health and wellbeing, or wanted to prioritise it more but weren’t doing so.
Most were unaware of any mental health resources or support services tailored specifically to healthcare professionals.
One in three didn’t know how to reach out for help if they experienced suicidal thoughts, and more than one in two had lost a colleague or someone close to them to suicide.
Despite those concerns, the vast majority had never called in sick or taken a day off for the sake of their own mental health and wellbeing.
The results reinforced that ophthalmologists often put their patients and family first, leaving their own needs last.
The ASO says it has been using these findings to identify where increased support and advocacy is needed, and to guide the development of tailored resources for its membership.
It says it will be reviving this survey in late June for more up-to-date findings and to find ways to further support members.
In other research, a 2024 Annals of Surgery study by Massachusetts General Hospital researchers and colleagues – a US-based cross-sectional survey of the academic medical community – found that among 622 participating surgeons, including ophthalmologists, trainees, and medical students, 18.4% screened positive for anxiety.
A 2022 UK-based study in the Annals of Surgery found that 87% of surgeons experience surgical performance anxiety.
Another study, from 2020, published in Medical Teacher, examined surgeons’ experiences of anxiety and stress in the operating room and found that these feelings are widespread across all stages of a surgical career.
The researchers reported that stress was frequently linked to concerns about patient safety, the possibility of complications, time pressures, equipment issues and the responsibility associated with decision making.
Importantly, the study found that even highly experienced eye surgeons continued to experience anxiety, although they often developed more effective coping mechanisms over time.
The authors argued that surgical culture should move away from viewing anxiety as a weakness and instead recognise it as a normal response to the demands of surgery.
Also, a recent article published by the American Academy of Ophthalmology (AAO) highlights how operating room stress is a near-universal experience among eye surgeons.
Contributors describe anxiety as ranging from routine preoperative nerves to significant psychological strain following complications or adverse outcomes.
While some degree of stress can sharpen concentration and performance, excessive or chronic stress may contribute to burnout, reduced job satisfaction and mental health concerns.
The article notes that surgeons often feel pressure to maintain a façade of confidence, which can discourage open discussion about anxiety and emotional wellbeing.
Pressures of performance
Although ophthalmology may be viewed as less stressful than some surgical specialties, cataract surgeons face a unique set of demands.
The procedures may be routine, but they are also technically exacting, repetitive and carry significant patient expectations.
A single complication can weigh heavily on a surgeon, regardless of how many successful procedures have come before it.
A 2023 nationwide study of cataract surgeons in India found that stress and burnout remain significant concerns within the specialty, despite the procedure’s high success rates.
Dr Malatt says one of the earliest warning signs of stress for cataract surgeons and the wider ophthalmology sector is losing the enjoyment that initially drew someone into medicine.
“If I feel grumpy about going to work, that’s a huge red flag for me,” she says.
“I love my job and I love my patients. If I’m driving to work thinking, ‘I really don’t feel like doing this today’, that’s a warning sign that something’s going on.”
She believes many ophthalmologists fail to recognise these early signals.
“Being grumpy in theatre, throwing an instrument, becoming abrupt with staff – to me that’s a sign of stress and burnout,” she says.
“But many people just write it off as, ‘That’s how they are’.”
Prof Chan identifies similar warning signs.
“Poor decision-making, poor sleep, feeling tired, not looking forward to what you’re doing, waking up with a sense of distress and not wanting to go to work – these are all common signs,” he says.
The challenge is that doctors often attempt to push through.
“We think we’re strong enough to deal with it ourselves,” Prof Chan says.
“But we’re not trained psychologists. We often have very little insight into ourselves and how we’re feeling.”
Both ophthalmologists emphasise that maintaining wellbeing does not require dramatic interventions.
Instead, they advocate a series of small but deliberate habits that protect physical and mental health over the long term.
For Dr Malatt, the foundations are remarkably simple.
“There is so much research out there now that if you take care of your body in terms of eating well, exercising regularly, going to sleep early and getting a good sleep every night, your mental health is so much better,” she says.
Her advice for colleagues experiencing stress is equally straightforward.
“Stop whatever you’re doing and ask yourself what is going on,” she says.
“Reflect on your life and your work. Is the way you’re practising sustainable?”
Most importantly, she says, don’t try to solve the problem alone.
“Talk to someone you trust, whether that’s a friend, a colleague or your GP.”
Prof Chan’s strategies are similarly practical. One of his most effective techniques is intentionally slowing down.
“If I’m feeling stressed or overwhelmed, I physically slow down,” he says.
“I walk slower. I move slower. If I’m preparing for surgery, I do it in a very deliberate way.”
The approach is based on the idea that clarity improves when people stop rushing.
“When everything is moving fast, the stress can only build,” he says.
Another principle comes from a mentor’s advice to “begin practice like how you want to end practice”.
For Prof Chan, that means resisting the temptation to fill every available hour with clinical work.
“Keep at least a day or half a day free for yourself,” he says.
“Spend time with your family. Do something you enjoy. Don’t work five days a week if you don’t need to.”
And then there is his final recommendation.
“Take a nap,” he says.
“I shut my door at lunchtime for 10 minutes and have a nap. Sleep helps with stress. It makes your mind clearer and gives you more energy.”
Looking after yourself
As healthcare systems become more complex, both ophthalmologists believe greater attention must be paid to clinician wellbeing.
Dr Malatt points to bureaucracy and administrative burdens as significant contributors to stress, particularly in the public system.
“The system is not designed to support the doctors in it,” she says.
“The administration and bureaucracy contribute to a lot of burnout and a lot of people leaving the profession earlier than they otherwise would.”
But while systemic reform remains important, both stress that individual wellbeing cannot be treated as an afterthought.
For cataract surgeons especially, the stakes are high.
Precision, judgement and patient outcomes all depend on clinicians performing at their best.
“The health of your health practitioner is going to determine how well you’re cared for,” Dr Malatt says.
Prof Chan echoes the point.
“If you’re not going to look after yourself, who is?” he says.
“And if you can’t look after yourself, you can’t look after your patients.”
For a profession dedicated to preserving vision, perhaps the next challenge is ensuring ophthalmologists can clearly see their own needs too.
