This blog post explains the background to my talk in Dublin at the SMACC conference. This talk, entitled ‘Things that scare me’ is a waypoint on a journey that I’ve personally experienced. I believe it’s a journey that many of us have either taken or are on and I hope that this talk will help my friends and colleagues navigate that path. Please visit the SMACC website to watch the original video from SMACC1 and visit BroomeDocs2 to listen to the background story explaining my personal journey which I sincerely hope may help other who find themselves in challenging circumstances.
In our clinical lives there are situations that challenge us, situations that cause us to feel stress and situations that actually scare us. It is good to recognise the difference and, challenging as it might be, it is good to accept that there are things that scare us. Challenges, situations, problems that bring us to that place where we are truly afraid. How we are affected by these situations is of grave importance. How we manage these situations is difficult but, in a non expert but experiential way, I would like to offer some thoughts on the matter. What scares you?
Things that scare me as a paediatric surgeon probably come as no great surprise. Tiny, premature neonates who require emergency surgery for perforated necrotising enterocolitis are a major challenge. They are a challenge to everyone involved not the least because they appear to exist in a physiological place completely different from the rest of humanity. They can have a pH of 6 point something and still be alive. They can have a biochemical picture that frankly terrifies anaesthetists with little experience of such infants. And they can have a coagulation picture that simply doesn’t make sense. They can just bleed. And when they do, that frightens me.
As surgeons we like to believe that we know what we are doing. Torrential bleeding during the resection of a massive tumour is where things are can wrong. Often, all that can be done is a major clamp placed rapidly across everything to deliver and resect the tumour. At that point, finding things not as they should be, frightens most surgeons.
Our careers are precious. They are the pinnacle of years, often decades of training. They define us. They are what sustains us, what provides our livelihoods and often those dependent upon us. Without our careers our lives would look completely different and many of us are unable to conceive of life without them. When our career is significantly threatened, particularly by forces of our direct control, that scares us.
And yet the challenge of this piece is to ask you, right now, to consider precisely: what in your line of work scares you? It is likely to be different from the things that scare me, as fear is deeply personal. My challenge to you is to see that fear, recognise that fear and name it.
Specify it. Right now. See it right in front of you. What scares you?
I’m here to tell you that it is ok. It is ok to be scared. It’s okay to be scared because being scared is actually a reaction to something that represents a significant threat to you. It is a challenge more than we think we can handle. Being scared is a recognition that you perceive a problem, a limit to your skills or a shortfall in your ability, a place where you are deeply comfortable being you. And that situation, in itself, is ok.
Researching this, I am aware of all sorts of amazing resources available in the #FOAMed world on stress. There are podcasts, workshops, blogposts and self help groups all dealing with stress and its management. I cannot recommend them highly enough for those of us who work in stressful situations. To be perfectly honest, the things my colleagues in Emergency Medicine, prehospital and critical care do every day would give me an incredible level of stress, let alone specific situations. And that’s an important fact, stress and fear are very individual. Most of us have learned strategies for dealing with stress. More than this, as Chris Hicks pointed out in his talk at Blood and Sand (2015) last year, there probably is an optimal level of stress for excellent performance where we are sufficiently stimulated but in control to deliver effectively. That is where training helps us to recognise the effects of stress, develop strategies to manage it and train for success.
I want to talk about FEAR, when we are way into the red zone.
Fear is complex, but basically it all happens in the thalamus. Whatever the sensory input of our fear is, that one, right now, the one you are trying to push out of your mind, the sensory input goes to the thalamus. The thalamus sends out information in two directions. The fastest is through the amygdala where our rapid response is activated via the hypothalamus to immediately respond, response without thinking. It’s all about the sabre toothed tiger thing. No time to think, just react. The hypothalamus fires off the Sympathetic Nervous System which brings about readiness for flight or flight. All of which is good for a fight but not necessarily so good for dealing with an acute clinical emergency.
This massive stimulation due to fear affects how we physically perform: fine motor tasks become almost impossible; the tachycardia and hypertension give us that pounding headache; crazily our visual acuity may actually be increased but always at the compromise of peripheral vision, all we can focus on is the specific problem; while activity outwith our field of vision is obscured; we become unable to take in task relevant cues either verbally or visually; our working memory is blunted; our cognitive processes become blurred; we overreact to perceived challenges and threats; we extrapolate as part of the longer view of the threat and it leaves us unable to trust other people or their decisions or even to trust ourselves.
The effect of our fear on others is also real; it is contagious. As social animals we perceive and react subconsciously to other people’s emotions. Fear within a team environment means people are no longer predictable, normal routines and practices don’t work, reactions and decisions vary particularly when the team member expressing fear is a senior. The fear spreads and the group exhibits the same fear often with no understanding of the process that has brought them to this. Fear spreads amongst a group. The evidence is clear from studies that poorer outcomes occur not due of lack of knowledge or of training but due to poor communication and teamwork precipitated by fear.
Fear is a big problem. We all have things we fear and they make us and the groups we work within behave differently.
Fear ”lives” in the amygdala. It is hard wired because learning to fear predators and threat slowly and gradually confers little evolutionary advantage If you damage the amygdala in rats they will just walk up to a cat with no “fear” and get killed. Clearly the medical things we are afraid of are not hard wired. They present threat due to many different reasons- the majority of which are due to conditioning. The reasons for our fear are complex. They involve all sorts of things from simple learning, negative reinforcement, reflection, exposure, chance, gossip, hearsay, extrapolation and even fantasy.
If fear lives in the amygdala, the moderation of that fear comes from the hippocampus. It appears to be the source of conscious recollection.It advises us that despite the initial shock things weren’t as bad as you originally perceived and you can tone down the fear response. This is how we learn not to be afraid. A situation that terrified us in the past and no long does so is due to the effect of the hippocampus.
So, what can be done to manage fear?
Now, I really am no expert, merely someone who has been afraid. I’m not here offering complex answers or a particular training course but principally a single personal reflection. Fear is real but there are things we can all do to mediate its effects. Please make sure you look after yourself in whatever way works best for you. I think the most important thing we do regarding fear is to acknowledge it, name it, and accept that it exists. It then becomes something tangible that we can begin to deal with it. It would be valuable right now for those reading this to name that fear.
In considering whether you can name this fear it is important to recognise that doing so is not a sign of weakness. It is not a sign of poor training. It does not mark you down as a person who is untrustworthy or lacking ability. Rather, it marks you as honest, as real.
Now consider how you would feel if a colleague shared with you their fear. Would you see them as weak? Would you consider them now to be poorly trained? Of course not. Now consider how you would react to that person. Would you walk past them, ignore them or criticise them? No, your response would be to stand with them. When you are experiencing fear, try not to ruminate and be judgemental of yourself. Be curious about the fear, explore it without judgement or criticism.
"Things that scare me." Not an easy topic to share but valuable I believe. I am no longer afraid. https://t.co/TBWcCZiXvH
— #hello my name is Ross (@ffolliet) December 5, 2016
And that simple step is, I believe, how we start to counter fear. Of course there are more complex strategies and protocols and workshops to deal with this but the first thing about fear is recognising it in ourselves and in others. It is about accepting the humanity of what we do, the reality and the brutality of what we do, that it is ok to be afraid and that our colleagues understand and support it because they too have in their own place been afraid. We don’t criticise it, mock it or even ask what it is, we just recognise it. And in that recognition fear loses so much of its power over us.
Those who stand with us when we are afraid and offer their confidence in us where we have little in ourselves are significant people to have around.. The catastrophising voices in our heads can be replaced by the voices of those who stand with us. The voices we then hear when we are afraid are our chiefs, our heroes, our peers and our colleagues and our friends. Sometimes they are there in person, sometimes just in our head but those are the voices we should learn to listen to when we are afraid.
Please take a moment now to consider how you manage what has happened in reading this blogpost or listen to the podcast. Your mental wellbeing is fundamental and caring for that is essential. We each have our own approaches. In the same way we care for patients it is important that we care for ourselves. If this has raised difficult issues please take time to speak with someone you value recognising that we all have issues of fear in our lives. It is a sign of insight to recognise fear and not consider it weakness. You and your well being are so important, please look after yourself.
Fear is real. It affects how we perform. But if we accept it and stand with each other, it will change.
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