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Second Opinion

Second Opinion: Be Smarter Than Your Brain

Leap, Edwin MD

doi: 10.1097/01.EEM.0000395422.32764.c1

    Everyone is a drug seeker. Why does everyone want to be on disability? I'm so tired of lies. Great, another lousy shift. I wonder who will die tonight? I'm so sick of suffering. I'm so weary of misery and loss. I hope this never happens to my family. I'll probably get sued. Being sued nearly drove me crazy. This job never gets easier, only harder. I have to find something else to do. I can't go on this way. I think I'm going crazy. I don't have any more compassion. People hate me now.

    These are only a few of the wonderful thoughts that float through the minds of emergency physicians these days. Sure, not every physician has them. But I know our specialty, I know our colleagues, I hear from doctors around the country, and I see that fear, frustration, and anxiety are common themes.

    Older physicians fantasize about career changes; younger ones are often blindsided by the hard realities of practice outside their training programs (where their work hours and staffing do not necessarily reflect the world beyond).

    We are crushed by regulations and overwhelmed by holding patients. We are often put in situations where we are set squarely between the devil and the deep blue sea:

    Spend more time with your patients. See them faster.

    Don't let the psychiatric-hold patient escape. Why are you using so much staff on psychiatric patients?

    See chest pain immediately. Why didn't you see the board member's ankle injury as fast as the chest pain?

    In all of this mess of emergency medicine, we often find ourselves frustrated and bitter. But is it only because of our situation? It is admittedly daunting. But is our unhappiness merely the result of the things imposed on us? Or could it be more complex than that? Lately, I have come to wonder if our thoughts are perhaps worse enemies than even lawsuits, regulations, or satisfaction scores.

    I began to realize this in December when my wife was diagnosed with cancer. Immediately following her diagnosis, my thoughts were like a runaway train headed for a washed-out bridge. All I could see was darkness and fear.

    While that may be initially understandable, those thoughts were dysfunctional, hopeless, and miserable. I spent every evening sleeping by the fire, as close to her as possible. I wanted to watch movies, eat, and sleep. My children, accustomed to a fairly unshakeable father, saw me begin to unravel.

    These thoughts also began to spill over into my work. I was constantly filled with anxiety as soon as I walked in and logged onto the computer. Every patient I saw represented my wife. Every tragedy represented fear. Everyone with cancer was a metaphor for her. Every CT scan made me think of her next study. Every phone call to a consultant reminded me of her specialists. Each time I delivered bad news, I replayed the bad news that we had received. And everytime the radiologist said of my patient, “That nodule needs to be worked up later,” I began to feel nervous.

    But was any of it rational? In point of fact, no. My thoughts extrapolated and extended my wife's illness to every situation I saw. In fact, her situation is different from many. And she is, as she pointed out, as healthy as ever except for her malignancy. My thoughts, my fears, ran away from me.

    I spent a lot of time imagining the worst. Was that because I could see the future? Hardly. Anyone in emergency medicine knows that our collective skills at prophecy and prognostication are marginal at best. I remember the patient who had an aortic dissection from his aortic arch to his iliac artery. We transferred him to a referral center. A couple of weeks later he was back in the ER for another complaint, and said he felt a little sore but was recovering well from his dissection. I had him dead. God had other ideas. The same with my patient Ken, a police officer with a myocardial infarction, cardiac arrest, and 45-minute resuscitation. He was cyanotic from the chest up when we finally transferred him to a regional center. When we called the next morning, he was sitting in bed, drinking coffee with his wife.

    Does that mean bad things don't still happen? Of course not. Does it mean we have no reasons for fear or frustration, for anger or annoyance? Hardly. It doesn't even mean we shouldn't have exit strategies from our stressful jobs.

    But it means that our thoughts, to the extent that they hinder us, have to be controlled and often redirected. When we envision tragedy, we have to learn to envision hope instead, because both are rational possibilities. When we imagine our oppression or misuse by others, we must learn to consider our blessings, our hopes, and the good people we care for and work with. When we think we can't go back to work another day, we have to consider the laughter we share with co-workers, the provision our job makes for our families, the lives we can affect or save, and even the vacation that lies ahead.

    We must not be the victims of unregulated imaginations because our imaginations are fed by negative images, drawn from a specialty where bad things are very common. But the problem is that bad things, the kinds of things we see in emergency departments, aren't actually that common … except to us. We work in the land of high-test, 200-proof misery, which constitutes a terrible selection bias for our minds to process.

    We are only beginning to explore the impact of thought processes on our practices. The field of heuristics, the way we make decisions, is relatively new to medicine. And it's important to understand how and why we make bad decisions, how our minds betray us.

    It is equally critical, however, that we learn to explore the impact our thoughts have on our own lives, which also ultimately affects our interaction with loved ones and patients, and our career longevity and satisfaction.

    I have discovered that my thoughts can be controlled, and they have to be filled with good things. For each person, those good things may be slightly different. As a Christian, I am trying to focus on prayer and on the words of scripture to point me in directions of hope and meaning, despite trouble. For some it may be the wisdom of other faiths, or beautiful music, art, poetry, comedy, good memories, or future dreams.

    Whatever you use, please remember that you are not a hostage to your thoughts. You may be smart, and your mind incisive, but it is still, in the words of Gollum, “tricksy.” And every day you must take it in hand, shake out the dust, open the windows, and fill it with good things.

    You owe it to yourself, your patients, and your family to be smarter than your brain. And ironically, to sometimes ignore your thoughts for your own good.

    Comments about this article? Write to EMN at[email protected].

    Dr. Leap:
    is a member of Blue Ridge Emergency Physicians, an emergency physician at Oconee Memorial Hospital in Seneca, SC, and an op-ed columnist for the Greenville News. He is also the author of three books, Working Knights, Cats Don't Hike, and The Practice Test, all available at . He welcomes comments about his observations, and readers may write to him at [email protected], and visit his web site and blog at
    © 2011 Lippincott Williams & Wilkins, Inc.