Fear and Loathing in Health Care

“There’s no need to fear – Underdog is here!”

Before I started my surgery internship in 1982, a resident told me to read 3 books: House of God, by Sam Shem, a semifictional account of his first year as a medicine resident at a Boston teaching hospital; The Right Stuff, Tom Wolfe’s portrayal of the test pilots who would subsequently become the Mercury 7 astronauts; and Hunter Thompson’s drug fueled, gonzo journalism missive Fear and Loathing in Las Vegas. My resident wanted me to understand the culture that I was about to immerse myself in – one of high energy, hard work, the need for confidence, living a bit on the edge, and the recognition that all this would be scary.

In House of God, the protagonist learns how to keep his patients alive and avoid being chastised, deals with his fear that he’ll hurt someone, loses his idealism, has a few memorable adventures in the call room, and subsequently changes specialties to psychiatry. The test pilots in the 50’s and 60’s had tremendous skill and bravado, and recognized that they could well be killed doing their job. But they were the best of the best. Their fear was covered by the attitude that if someone augered in – it was because they didn’t have enough of “The Right Stuff.” But when you got inside their heads, not only was there drive to succeed, but also fear and doubt. Alan Shepard was heard muttering “God, please don’t let me screw this one up,” prior to the first Mercury launch. Such studied confidence is vital in any high risk profession, and for those that combine that with skill and realistic insight, the results can be spectacular. The late Hunter Thompson was the National Affairs editor for Rolling Stone. His books involve completely immersing yourself in an experience, usually while under the influence of numerous drugs. He traveled to Las Vegas to cover a convention of District Attorneys dealing with the “The fear and loathing caused by the drug problem in America.” The combination of polarized attitudes, in the backdrop of a Las Vegas, leads to an interesting study of pushing limits.

Fear, even if we don’t recognize it, pervades health care. Patients are afraid – they cede control to others and are uncertain of their future. They may not openly acknowledge it, until something triggers it (see blog “Self Determination.”) As a provider, before I went to Haiti, I was asked if I was afraid of the violence or if I could handle the extent of the disaster. Perhaps because I am older, and my children are grown, I didn’t fear as much for my own safety. I’ve also shared with you that by working with other remarkable volunteers, we were able to deal with whatever we saw.

The adversarial nature of our tort system creates anxiety and fear, and impacts on the patient /physician relationship. Politically, as the health care reform debate played out, both sides used fear to influence their support base. “Death panels” vied with “Losing my insurance because I have cancer.” Because fear is a basic human emotion, just like joy and passion, it can powerfully influence behavior. How we chose to handle fear can define how we live our lives.

We all deal with fear differently. Some become overly arrogant, never admitting to a second thought, and subsequently forging forward to a disaster. Others are paralyzed by fear, and do not take any chances, achieving and experiencing little. Perhaps the best tactic is to recognize that the fear you feel is a sign to be a bit more aware, a bit more prepared, and a bit more willing to reach out for advice, enlightenment, and support. When you are able to integrate fear, both your own and others, into the overall experience, and balance it with planning, confidence, and a little bit of faith, the rewards outweigh the risks.

…or you can call Underdog.