post by Dr. Jeremy Fish, MD
Uncertainty. The unknown. The mysterious. It is impossible to contemplate these without experiencing some level of fear. Neuroscience has taught us humans will choose a bad situation over an uncertain one. People trapped in abusive relationships know this all too well. Abusive people and bullies use the fear of uncertainty to keep people trapped in terrible situations. Let’s face it, when it comes to fear, our minds are filled with adrenaline and ill-placed dopamine – triggered by our alarm bell, the Amygdala — and our instinctual selves are triggered into fear-based mind-set, which makes Flight, Fight, or Freeze our go-to responses. Yet, we spend millions, maybe billions of dollars a year pursuing activities that stimulate our fear – sky-diving, horror movies, suspense thrillers, roller-coasters, rock-climbing, mountaineering, adventure vacations, traveling to exotic places, eating new foods, to name just a few. So, somehow, we all know ways to enjoy the fear of uncertainty in the right setting and in the right ways.
Today, we face very high levels of uncertainty. Terrorism, unstable political structures, severe doubt in government and invisible foes like COVID-19 abound. Our current invisible tiny foe is jumping from person to person, killing some and not even noticed by others. Our frail and elderly are at particular risk. Our ancestors called these events plagues and pestilence – acts of a higher power punishing us for our wrongdoing or misbehaviors. It often led to permanent ex-communication from society -- a heavy price for catching an illness. Although we are far more sophisticated now and have science demonstrating a tiny, invisible particle, coated in proteins and filled with strands of RNA in a pattern consistent with previous viruses of the Coronavirus (crowned) genus, we remain truly human and so must respond with fear to invisible foes that might kill us or our loved ones.
So, what is the difference between fear we wish to escape and avoid and fear we seek and enjoy? In general, it’s what we choose to mix with our fear. For many of us, we are naturally drawn to adding anger to fear. That is the pathway of rage, revenge, persecution and negative conspiracy theories with an apocalyptic ending. For others, we are able to add hope, confidence, and delight to fear, creating an environment of suspense, anticipation and positive conspiracy theories with a happy ending. Yet, I surmise, most of us ramble through both, bouncing between catastrophic and hopeful scenarios, talking with friends and family to try to make sense of what is happening and regain some sense of control and safety.
The good news is we have a choice how we respond to fear. For those of us who find anger available when fear strikes, we can transform our heightened emotional state into passionate purpose and achieve things we thought impossible, drawing others to our cause. These folks we often call heroes, people who move toward danger and uncertainty with courage and create great new movements and organizations to transform something frightening (HIV infection) into action that changes the world for good (ACT UP). Health care was forever changed in a positive way by the HIV pandemic, mixing patients’ rights with civil rights into a powerful new dynamic that gave birth to shared decision-making and patient-centered care to name a few.
For those of us who add a dash of hope and confidence to fear, we experience the thrill of the ride, the delight of a suspense novel, the hope for a better future. We likely call these folks optimists, visionary leaders, good neighbors, team-players and inspiring storytellers. They help us manage our fear and follow them to accomplish wise actions together, model sharing food when food is scarce, right now they are going door-to-door handing out masks, gloves and resources to help our elderly get the resources and care they need. They are having children write lovely cards to elderly people they may never meet, providing them companionship and comfort in the midst of fear. We seldom call these folks heroes because their acts are often smaller, more personal, quiet, humble and are about relationships and community-building. It’s often hard to pin-point one person who is responsible for what is happening. It’s like a cascade for the common good … pretty soon that crabby neighbor no one likes is expressing gestures of neighborly love and thoughtfulness. You may not have noticed, but we have many of these folks in our quiet little learning community here at John Muir Health Family Medicine Residency. Out of fearing leaving someone out, I will not attempt to share the specifics of the many lovely stories that are happening here every day. The resident who is finally able to connect with his or her most challenging patient, one who no-showed the last 20 visits, but somehow picks up the phone and begins to share her story. The staff person who makes the extra effort to contact the elderly patient who is fearful she has COVID-19 but can’t get tested because her symptoms are not bad enough. The residency support staff who offer to take on that challenging project and learn new skills so she can help us get through the crisis. The faculty who stretch to make sure every resident has a learning experience whenever possible while many of our clinic training sites are closed. Those residents who step forward and volunteer to help in whatever way they can, focused on getting to a better place rather than complaining about a frustrating current reality. Our wellness team is finding new ways to engage us in our own well-being and self-care.
How do we learn to enjoy uncertainty? For me, it is learning to stay curious, open, flexible and adaptive. I allow myself to think about the catastrophe that might come. I also make sure I allow myself to think about the hopeful future that might also come, to find the silver lining in the midst of the cloudy days. I notice the positive. I reframe what frustrates me into something that inspires me. For example, I spent the last 5-½ years leading the creation of a residency program that was finally looking complete, three years of structured curriculum, amazing residents, staff and faculty. Happy patients getting great care in our residency practice. Our financial future was looking bright. We had a fantastic Match. For those of you who don’t know, March through early June is historically the quiet time of year, the time for regaining energy and getting ready for the new class. The residents are humming along, gaining confidence and feeling ready for the next year of training. Well, COVID-19 decided to invade our little, finally stable residency and has now disrupted our period for rejuvenation and readying for the new class. had to cancel my vacation with my son, wife, friends and our dogs – a vacation I’ve been looking forward to for months. So, that is a story of frustration, disappointment, disruption and potentially despair. Yet, years of experience and reframing have taught me to search for the positive reframe and positive sense of meaning and purpose.
What is that for me? It is all of you, stitching together all those hopeful, inspiring small stories into a giant fabric of optimism, suspense, delight and confidence that our residency learning community is full of amazing people who step up to assure our program will take it to the next level. Our adaptation to our current reality is one of the most inspiring experiences of my life and gives me great hope and confidence that our program will be strong and successful for many years to come. We abound in team-players who are rapidly re-designing and executing changes to our program in real-time. Some residents, patients and faculty are beginning to hope we can translate this crisis experience into new and positive changes to how we train our residents in the future. We have all discovered something new. We can take care of a large number of patients by phone, sometimes better than we could by face-to-face visits. It’s helping some find out things about their patients they never knew, see the medicines in the bathroom to truly verify medication reconciliation is happening. That barking dog, wow, didn’t know he was the center of my patient’s life, how can I take care of her without knowing that? Some are finding phone visits a helpful way to set boundaries around how long the visit is and how many topics can be discussed, somehow finding it easier to set those boundaries by phone than in person. We are learning new things in new ways. We are finding the silver lining in the storm clouds of COVID-19. Doesn’t mean we are happy COVID-19 came to town; real people are getting very ill and dying. We understand that and are also somberly preparing ourselves for a wave of illness to come crashing through our health system in a few weeks. Yes, much remains uncertain, yet one thing is certain to me. We will grow through this experience together -- we will make our program better than it was, we will learn new ways of caring for ourselves and our patients.
Fear (not my favorite emotion) blended with hope, confidence and delight can bring us wisdom, innovation and inspiration. Blended with anger, it can bring us passionate purpose, achievements beyond belief and heroes to inspire and protect us.
Uncertainty, not my favorite experience. Yet, navigated with wisdom, friends, and community, an opportunity for growth, innovation, curiosity and new ways of life.