Two main fears sneak up on me at work.
One
I say this somewhat jokingly, but the sentiment is true: I’m terrified of killing my patients. I’m afraid that a medication I forget to order, or a lab result I fail to see, or a loose knot I tie in the OR, is going to leave my patient gasping for air, unconscious, or bleeding to death. I’m afraid of both unintentional misses and wrong calls — the former of which feels inexcusable, and the latter, inevitable. But of course, “misses” are inevitable too. I’m only human and often, I’m a fairly sleep-deprived, overworked shell of a human. There will be signs and symptoms that get past me, and problems I fail to recognize quickly enough to act.
This particular brand of fear has made its way into my dreams. I sleepwalk alongside my mostly made-up errors, and wake up abruptly, short of breath. I flick on the light hoping to dissipate the fog between dream and reality, trying to recall if I really gave Mr. M the wrong dose of epinephrine (I’ve never even written for epinephrine in my awake life) or if Ms. T’s blood pressure was really 50/10.
Sometimes in this liminal state, I will panic thinking I’m late for work and get halfway dressed to go to the hospital before realizing that the 11:30 on my clock refers to PM, not AM. As I come to my senses, I let out a huge sigh of relief, and collapse back into bed. When I eventually wake up to my alarm at 4:00 AM, my one-leg in a scrub pant tangled up in my sheets is the only sign that something went awry overnight.
Two
The other big fear I face at work has nothing to do with patient care, and everything to do with my own self-esteem. I’m both accustomed to and still afraid of workplace embarrassment. While the surgical needle has moved countless ticks toward a more supportive and professional training environment, there are still plenty of old-school practices at play — plenty of days that residents get chewed out or demeaned.
This week I did three back-to-back cases with a Real Surgeon who’s known for letting residents start the case, but the moment we do something wrong — or even just something he doesn't like stylistically — he mumbles “Oh for f**ks sake,” grabs the instruments from our hands, and then proceeds to lecture (scold) while he finishes the rest of the case. Halfway through a long tirade about how my hand movements “do not inspire confidence” because I “gnaw at the tissue like a rat,” I looked around the room and realized that the scrub nurse, circulating nurse, and anesthesiologist — all older women — were fully tuned into my public shaming. I caught several sympathetic eye rolls as I repeated, “Yes, sir. Understood.” At the end of the case, when the Real Surgeon left me alone to close the superficial skin incisions, the air in the room shifted. The circulating nurse put on a Dua Lipa song over the speaker and the scrub tech asked me where I grew up. We chatted as I pushed needle and suture through skin, bringing the edges together in a neat line.
In our next case, I was terrified of “gnawing” at the tissue so I took my time, drawing sharper, more precise cuts with the scalpel. “Good,” The Real Surgeon said, “Much better.” My mood lifted for a few seconds like a slowly inflating balloon before it popped: “Jesus Christ!” he burst out. I was moving too slowly this time. Before I could pick up the speed, the instruments were already out of my hands.
This is just one of many examples of the type of shame we face as residents, which most often airs on the very light side of the shaming spectrum — impersonal, skill-oriented, relatively gentle berating compared to what our predecessors in surgery faced. But even in less abrasive environments, the fear of answering an anatomy question incorrectly or of not knowing the next step in an operation prevails — not only because my knowledge gaps can impact my ability to care for patients, but because being wrong in front of a room full of people is naturally embarrassing. For some, that’s the stuff of nightmares.
***
I’ve thought a lot about how both fears — that of failing my patients and that of letting down my superiors (and myself) — impact my learning, my performance, and my day-to-day experience. I’ve repeatedly wondered: Does fear help me become a better doctor?
I can’t find a lot of good data to answer this specific question, so instead, I’ll stick to my personal evidence on the matter: For me, fear is highly effective at the right dose.
At the right dose, it’s as simple as this: I’m appropriately afraid of killing my patients and I’m sufficiently afraid of looking dumb in front of my peers and superiors. Therefore, I study a lot. I review anatomy and diseases in textbooks. I mentally walk through operative steps and double-check my post-surgical plans. I comb through patient orders to make sure everything is just as it should be. In these cases, fear ultimately drives better care.
But at too high a dose, I can be pushed past the threshold of productive fear, and into the territory of sleeplessness or into a concerning indifference that reminds me of a teenage-like defense response to being repeatedly told you’re wrong. After hours of being made to feel inadequate, I start to feel hopelessly inadequate and stop trying to improve altogether. I enter a kind of numb state where I can’t be hurt by insults, but also no longer respond positively to any constructive feedback that may be embedded between criticisms.
***
In reflecting on the “right dose” of fear, I’m reminded of Greg (not his real name), a senior resident I worked with as a medical student. Greg was incredibly warm, jovial, and always had this big, almost goofy smile on his face. When I was a med student, Greg made me feel welcomed into surgery and showed me that there’s space for humor and softness in a field with some pretty sharp edges.
Once, I observed Greg and a Real Surgeon do a four hour-long operation on the bowel, throughout which the Real Surgeon tore him to shreds. I recall angry grunts, colorful language, and some personal attacks during what felt like the longest four hours to me. But with every remark, Greg responded with his standard smile beneath his mask and the most earnest “Oh, I see! Thanks!” At the end of the case, when we were left alone to close skin and clean up, I asked him how he did that, how he could manage to respond with gratitude while being so blatantly and harshly demeaned. He told me that after nearly seven years of training, he genuinely appreciates all feedback, even when sandwiched between insults. “But isn’t it kind of scary?” I asked, “Being yelled at for four hours straight?” He laughed at my question. “Not anymore.”
Years behind Greg, I’m not quite there yet. I don’t see every harsh comment as an opportunity for growth and I still shake in my clogs a bit when being scolded. But I can see how fear can both motivate and discourage efforts to improve, and I hope to one day achieve the right dose: enough fear to keep me on my toes, but not so much to push me to the ground. I hope that in the future, when faced with an unnecessarily high dose of harshness, instead of going numb, I will eventually be able to smile, thank the Real Surgeon for their feedback, and then go home and sleep soundly through the night, cementing the lessons learned that day.
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