The "F" Word

Doctors won't talk about it. Patients don't want to know about it. Try doing an internet search on the topic and you come up dry.

It's a subject so taboo in medicine that there may be readers out there who'll want to question the validity or veracity of what I write here. It's the ultimate four-letter-word for physicians: FEAR.

A few days ago a premed student named Jack wrote this comment for me:

"During your work as an anesthesiologist, when was the time where you felt most afraid, if there has been one which sticks out? I ask because im soon to be entering medical school and I feel that fear is a topic which has not been touched on by those advising me."

I'm not surprised about that last part. No one talks about fear in medicine because no want wants to admit a) that it exists b) that it's NORMAL and c) that physicians experience it. People don't want their physicians to be normal, human. Humane, yes, but human - with normal aspects of humanity such as fallibility, frailty, fatigue, and, yes, fear? Not really. I've often felt we're expected to be as faultless as God but without god complexes. I agree with the latter: the best doctors I know have the wisdom and self-possession to have true humility. But strive though we might, how can any of us expect perfection of ourselves, or criticize others for failing to attain it?

True humility accepts imperfection, refrains from passing harsh judgment on it, and instead recognizes where successes come from, where the limits are within a given situation, and, without lapsing into contempt, where there might be room for improvement.

The question is, why this reluctance to admit to fallibility, to error, to fear? It's not simply because human lives are at stake, though naturally the high stakes create high standards. I think there is a deeper problem within medicine, and that is the pervasiveness of hubris and disdain in the culture of medicine, a culture which has deep roots in the DE-humanizing training process, the very system which forms physicians from their embryonic, idealistic beginnings into the clinicians that must go out and meet suffering face-to-face, touch the very margins of some very dramatic and important stories, and sometimes get pulled into the fray without warning. I've seen this culture destroy the very best in people, rip out their still-beating hearts - the ones that contain all their hope and compassion - chew them up, and spit out the bloody mess as if it were worthless trash. It's a culture where the highest compliment a doctor or doctor-in-training can be given is the phrase "Strong work." Strong. Not weak. Finding something difficult is weak. Having needs, physical or emotional, is weak. And being scared, even just a little, is very, very weak. Or so the unspoken message goes.

But the truth is, what we do can be scary. Really scary. I remember thinking on my very first day of anesthesia residency that any of the drugs I was drawing up into syringes that day and administering into people's IV's could KILL SOMEBODY. That is still true today - there is still the potential for any action I take to cause great harm instead of doing good - but at least today I have some training and experience under my belt to allow me to use these drugs as part of a design thought out carefully ahead of time or quickly adapted to a given situation.

The answer to the first part of Jack's question is that several moments stand out in my mind as ones during which I felt "most afraid." Even in the midst of a bustling room crowded with lots of people helping, it's easy to feel incredibly ALONE at the head of the bed, watching a blood pressure go from 80 to 70 to 60 to 50 even though you're pushing pressors and inotropes into the IV as fast as you can, then having to make split-second judgments and life-and-death decisions. There's nothing like watching someone's vital signs tank, circling an ever-widening imaginary drain, the cardiac rhythm waveform shifting and getting ominously squigglier before your eyes, as you ask out loud if the code cart is in the room.

Interestingly, during moments like these I don't find myself asking other fear-based questions like what will I tell the family, what will my colleagues think, what if I lose this person, what if nothing I try works. So far the fear has acted as a spur to action - let's try this; get help, get an arterial line in, try another approach, do, do, do. It's only later, when the crisis is over and there's time to think, that the emotional after-shocks come. The what-if questions. The I-should-have ruminations.

The scariest moments, though, aren't even ones like these in the operating room. For me, despite my background in pediatrics, nothing is scarier than a newborn needing to be resuscitated. (Well...maybe a pregnant woman with a difficult airway is scarier,or at least as scary...but that's about it.) I am very comfortable with children. I doctored children for a while before I started doctoring all ages. But when a voice on the overhead system at the hospital says, "Attention all personnel. Attention all personnel. Respiratory stat to labor and delivery," I still go into fight or flight mode. I run up to the floor to offer help. I know what I need to do. I have lots of help around me, and I know they know what to do too. But I see a lifeless-looking, tiny little infant as grey as ash, whose limbs flop back down to the bed when lifted and released, whose chest shows no sign of respiratory effort - all very, very abnormal signs - and my heart races. Still. Even though I've seen this before. Meanwhile the parents are behind us, mother perhaps still receiving sutures after the delivery, father nervous or in tears, and lots of people crowd a tiny little space where we're supposed to bring this baby out of trouble in its first few minutes of life on earth. We all do what needs to be done, outwardly composed, business-like in the urgency, but inwardly, speaking for myself at least, SCARED the whole time.

There are those who say admitting to fear weakens one's performance at these events. I say it's weak to deny a very normal emotional reaction, and perhaps even dangerous. I say we can control our responses to fear without having to suppress it, because it can be an ally, maintaining in us a healthy respect for the importance of the task at hand. I say the day my heart rate stops going up when an airway is difficult, when a patient is in septic shock on the table, or when a child's oxygen saturation drops like a stone, put me out to pasture, please. Because that's the day I've spiritually stopped doing my job as a physician.

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Years ago when I was exploring my own moral formation I made a list for myself of qualities I see in spiritually highly evolved individuals and qualities I would expect to see in spiritually stagnant, unevolved, or stunted individuals. I came up with the first list by thinking of exemplary people, like my in-laws, and friends I admire, then flipped all the qualities around to come up with the second list. One list was essentially the mirror image of the other, and I found a lot of me fitting into the spiritually unevolved side, unfortunately. This is what I jotted down:

The Spiritually Evolved Person…
-Tends to be forgiving, see the best in others, and be accepting of what others can offer.

-Responds to people’s comments / needs / objections with the desire to be better and to serve

-Sees every person as one of great worth and believes all have equal rights

-Works hard
-Has a deep sense of gratitude

-Knows “it’s not about him/her”

-Knows happiness and misery are chosen

-Rolls with the punches – often with a sense of humor

-Takes nothing personally

-Is not reactive and is slow to anger if at all

-Does not pass judgment or need to blame

-Considers others' needs as valid and at least as important as his/her own

-Makes others feel welcome

-Forgives

The Spiritually Unevolved Person...

-Tends to be critical and to look for things to criticize, to feel irritation or anger at others' imperfections, and to look down on those who might have faults or failings to forgive

-Cannot bear to have his/her imperfections or mistakes pointed out or discussed and may in fact feel he/she is beyond reproach

-Feels superior

-Is lazy

-Has a deep sense of entitlement and/or complains a lot

-Feels everything is “about” him/her

-Feels that others / external circumstances make him/her miserable

-Whines, throws a tantrum, or acts like a martyr when things don’t go his/her way

-Takes everything personally

-Is reactive and is often easily angered

-Judges harshly & blames readily

-Thinks his/her own wants take priority over others’ needs and may be incapable of being considerate of others’ needs or see them as important; lords it over others

-Makes others feel alienated or rejected

-Punishes

If the culture of medicine could be personified, the resulting incarnation, I think, would have a lot of the characteristics on the second list - scorn, arrogance, judgmental attitudes, unsupportive perfectionism. By contrast, a lot of the people who pursue careers in medicine aspire to behaviors and ideals such as kindness, cooperativity, compassion, and forgiveness. I think if we could talk about fear and fallibility without being judged, criticized, or blamed, the world would truly be a better place - not only for doctors but also for patients. There are already efforts to bring discussions of medical errors in this direction...but change comes gradually and incrementally.

One individual who has begun to work for change in "the system" is an extraordinary physician who was involved in a devastating medical error but had the courage to face the experience, in all its loneliness and pain, and use it as a springboard from which to start transforming the way the world of medicine responds to adverse events. I admire this man's heroism. Please read his story here.

"I wanted you to see what real courage is...It's when you know you're licked before you begin but you begin anyway and you see it through no matter what." Harper Lee, To Kill a Mockingbird

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Addendum, June 12 2008:

Quietus Leo over at The Sandman has written an incredible post in response to this one with some insights of his own regarding physicians and their fears. I want to highlight an excerpt from his closing paragraph because it really hits the nail on the head:

"The only thing that disgusts me more than incompetence in a physician is vanity. Hubris is born of fear. Fear of exposure, fear of failure and fear of showing weakness. When you see a vain person, scratch the surface (one may need an ice pick) and you will discover a coward. Not a coward in the sense of external bravery, but one who won't face his/her own failings. Such a person has stopped growing, learning and improving."

Amen, amen, amen. May I never lose heart or the ability to see myself honestly and learn to become better.