Fear and Loathing in Health Care

In this new year, it is easy to become overwhelmed by multiple events that seem beyond our control and perhaps feel a sense of doom. On reflection, much of this is fear. Fear is a powerful emotion that drives behaviors.

As healthcare leaders, we must acknowledge that fear is pervasive in Medicine. Our patients fear whether their illness will be cured and that they could be financially bankrupted due to inadequate coverage. Our front-line providers have feared for their lives over the last year, a fear that is thankfully being mitigated by vaccination and falling COVID-19 numbers. Our practitioners feel concerned about whether they can fully care for their patients and always have the lurking threat of litigation hanging over them.

If we are honest with ourselves, many of us fear that we cannot provide all that is necessary to help our constituents or that we are inadequate to the task of servant leadership.

Before I started my surgery internship in 1982, I was both excited and scared. Confiding in a resident, he told me to read three books: House of God, by Sam Shem, a semi-fictional 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 from 1971 – 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 ’50s and ’60s 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 augured in – it was because they didn’t have enough of “The Right Stuff.” But when you got inside their heads, there was a drive to succeed and fear and doubt. Alan Shepard was heard muttering, “God, please don’t let me screw this one up,” before the first Mercury launch. Such studied confidence is vital in any high-risk profession, and for those that combine that skill with realistic insight, the results are spectacular. The late Hunter Thompson was the National Affairs editor for Rolling Stone. His books involve completely immersing oneself in an experience, in his case, 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.” In the backdrop of Las Vegas, the combination of polarized attitudes leads to an interesting study of pushing limits and seeing two alternatives, yet concurrent, realities.

As a provider, before I volunteered in Haiti after the earthquake, I was asked if I was afraid of the violence or if I could deal with the extent of the disaster. Perhaps because I was older and my children were grown, I didn’t fear as much for my safety. But there was intense doubt about how I would handle what I would see. I learned that by depending on those around you, fear was shared and diluted.

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 continues to play out, both sides use fear to influence their base. Medicare “Death panels” vied with “Losing my insurance because I have cancer.” Based on a long history of racial disparities and distrust, those that would benefit most from the COVID-19 vaccination are also more likely to refuse it.

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, a bit more willing to reach out for advice, a different perspective, and support. When you can integrate fear, both your own and others, into the overall experience and balance it with planning, confidence, and a little bit of faith, your abilities as a leader are enhanced.

Harry C. Sax, MD, FACHE
Regent for California – Southern
harry.sax@cshs.org

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