“Fear is beneficial. It happens for a reason. Everything we have in our heads is evolutionarily beneficial for the most part. The benefit of fear is it allows you to predict the evil sh*t that's going to happen and avoid it.”
This is another episode from Rob Orman's Stimulus Podcast. Rob is my best buddy and the best interviewer in the business. In this episode, we discuss:
The distinction between carrying fear and being afraid
-
Good doctors carry fear with them. Those who don’t carry a healthy dose of respect for the risks of their actions can be dangerous.
-
Fear should be your friend. It should be one of many internal voices that you listen to and to which you decide whether you want to regard or ignore.
-
Fear should not be your limiter. “If fear is your primary internal theme, then you're afraid. And that's a problem.”
The importance of embracing the idea that sick patients don’t take a joke
-
The sicker the patient, the less room you have for error. Be very careful.
The Five Fears
1. Scott’s fear number one: lawyers
-
This is a healthy fear as long as you use it the right way. Shared decision-making and good documentation help to keep this fear positive.
-
It’s a bad fear if it prompts you to practice defensive medicine and do things that patients don’t need or want (such as order unnecessary tests or procedures).
-
When you document, be sure to show that you thought of the life-threatening diagnosis and why you did not think it was the cause of the patient’s complaint.
2. A common fear that Scott does not personally experience: being an imposter
-
This is the inner voice that says negative things about your performance and capability of getting the job done.
-
Scott’s mindset has always been to assume that his baseline skill level at anything is zero until there is external calibration. With this cognitive assumption, he has never had an inner voice speaking negatively to him.
-
In emergency medicine there are plenty of opportunities to externally calibrate your skill set (eg. following up on patients to see if your diagnosis was correct or keeping a log of your first-pass intubation success rate).
3. Fear of Monday morning quarterbacking
-
This is a useful fear to have because it allows you to foreshadow what you're going to experience tomorrow and the chance to fix the situation today.
-
While Monday morning quarterbacking can yield strategies for improvement when done in a positive fashion, it can also be done badly and be an opportunity to serve insults.
-
“The fear of Monday morning quarterbacking should drive your documentation more than it drives your practice.” And if you can anticipate what the Monday morning quarterback is going to harp upon, it should drive you to take actions to have the appearance of due diligence.
4. Fear of procedural complications
-
Procedural complications can be prevented by breaking them down into distinct micro skills that can be individually mastered.
-
No matter how adroit one is at procedures, having a certain level of fear of the potential complications is healthy. That fear makes you question whether the procedure is truly necessary, or whether it would be safer done in another setting such as the OR.
-
“This fear has never stopped me from doing something that's indicated, but it has stopped me from doing things that weren't indicated.
“Many of the safe emergency physicians have a negative inner inner voice. They're fearful of the complications, because they don't think they're good enough. That's somewhat healthy. There's another group that thinks they're the master of everything with no external calibration. Those people are dangerous.”
5. Scott’s final fear: a patient dying on his watch
-
This fear puts Scott in his flow state. It motivates him to “play a much better game” than he would otherwise.
“This fear of death winning is the most healthy fear of all. It crystallizes everything and makes me think at a different level.”
Shownotes by Melissa Orman, MD
Additional New Information
More on EMCrit
Additional Resources
- EMCrit 371 – Iodinated Contrast Issues: Part 2 – Contrast Reactions - March 24, 2024
- EMCrit Wee – Zentensivism with Matt Siuba - March 15, 2024
- EMCrit 370 – Extracorporeal Therapies for Toxicology & Poisoning #ExTRIP #NephMadness - March 8, 2024
Absolutely brilliant dialogue guys. This is some incredibly important stuff that no one ever really talks about and you nailed it. Felt 100% of that.
thank you so much for those words, Sam!!!
Could not agree more. We are generally well versed in the medical aspects of indications and contraindications, but when it comes to the Human Factor we forget how important 1)Positive Attitude, 2)Communication, 3)Teamwork, and 4)Situational Awareness really are. Something that I also learned through years of practice is that when you don’t know what to do, DON’T DO ANYTHING! STOP AND GET HELP!!! My M.D. never fell off my badge proceeding this way, and patients always benefited. Lastly, for those of us who have many years of practice, we must promote Reverse Mentoring, listening and respecting our young professionals sharing… Read more »
Great talk. For residents who say “if I never do procedures, how will I be ready in an emergency?” In training, just because you hand off a procedure to surgery or anesthesia doesn’t mean you have given up the learning experience or “reps”. Go to the OR or stay in the room, watch, do visualization. If your attending is too concerned with YOU seeing THEIR patients, then they don’t have your best interests at heart. You get out of your training what you put in.
Great thoughts. I think another word that has utility here is “humility.” Humility is the little voice that tells you, “you might be wrong.” An experienced, skilled resuscitationist should be confident and ready to spring into action, and the further they reach in their career arc, the fewer situations will trouble them and the fewer people around them will be in a position to question them. But there should always be a leak in that impervious wall of confidence. No matter how certain you are that you’re making the right decision, you should always allow the possibility — truly, legitimately… Read more »
I think an interesting addition that I would love to hear more on is the idea of fear as a spectrum. In this discussion fear is addressed as a more dichotomous variable (e.g. “you need to have fear” or “those who don’t have fear”) and a little bit on how it’s tempered by the presence of other emotions (e.g. “If fear is your dominant emotion…”) but I’d be interested to know about everyone’s thoughts on the spectrum it can cover. I’ve been a student, and teacher, of martial arts for years and one of the things that I like to… Read more »
Fantastic dialogue Scott & Rob! This talk is motivational to be more reflective, calculated and rational in thinking! I must say that where I work as a junior doctor relatively unsupervised in South Africa the 5th fear rings true most of the time & it definitely puts a person “in the zone” during a resuscitation/ critical situation. I have to add that as a paraglider and enjoying other high intensity activities (and I would hope to think I’m no “meatdick” :D) it’s good training where you experience critical situations that require intense focus & calculated actions – similar to that… Read more »
Hello, Very enjoyable episode. If you do the ‘usual’ and it goes poorly that is fine but do something different and if it goes poorly it is a big deal. Nail on the head. Felt this when my transport program launched a prone transport protocol. I still recall getting a text message from a colleague the first time we transported prone. I was picking my son up at school and I felt ‘fear’ (Fear of procedural complications & Fear of Monday morning quarterbacking). It was the right things to do but if it went sideways that may be the end… Read more »
Arrested just a few minutes into the podcast… Narrator: “…you are like the Syd Vicious of critical care… You say things that some people would find outlandish – some people would find really exciting…and people want to adopt it – and listen to you. I’ve done this hundreds of times – you have hundreds of podcasts. I’ve taken what you’ve said – applied it immediately to care and – I think – saved lives…” Excerpt from email exchange with my dad follows Nov 2012 Hi ya Pop, Well they’ve been working me pretty good at work for a few days… Read more »