Lose Your Fears: Part I, Fear of Failure

It has been a while since my last post and I have been quite busy back at the UVa Hospital taking part in a Transition Course as way to prepare 3^rd year medical students for rotations in the hospital. It has been  an experience so far to say the least and perhaps, most significantly, due to the fact that we have spent more time talking and working with clinical nursing students over the past week than we have in the first 2 years of school combined. While that in of itself is a problem, the reality is that now we are at least being exposed to interprofessional trainings and workshops that will ultimately reflect our true work environment.

As part of these numerous workshops and recent discussions regarding Palliative and End-of-Life Care (I just finished Atul Gawande’s book Being Mortal) and have been inspired quite passionately to pursue a proper education and exposure to palliative medicine, I have come across three major fears that we can all benefit from losing. While this may pertain and has been constructed from my experiences within the medical profession, I believe strongly that anyone can benefit from releasing his or her fear of these 3 major things. I will tackle the first fear in this blog post so stay tuned for Parts II and III.

The first and probably most debilitating fear is the fear of failure. Fear of failure is rampant in medical culture, most predominantly Dr. John Madriola and Atul Gawande write about this seemingly contradictory philosophy where in medicine, doing nothing is seen as a failure and categorized as nearly equivalent to death. Doing nothing and the process of dying can be liberating, engaging and entirely “successful” endeavors when approached from the perspective that one is actually doing the right thing. In order to fully appreciate and implement performing medical excellence, one simply has to utilize an adaptation of Atul Gawande’s five questions from Being Mortal in situations beyond just the end of life.

1. What are your goals for life?

2. What are you afraid of?

3. What are you hopes and dreams- what do you aspire to do?

4. What tradeoff’s are you willing to make in order to get there?

5. What is your idea of true happiness, or more practically, describe your ideal day?

If as a health care practitioner, you ask these five simple questions, as Gawande notes, the correct path towards achieving the patient’s identified goals often becomes quite obvious. With the individual invested into the process of hopefully achieving his or her desired health outcome, there is essentially almost no way one can judge this as a failure.

Need an example? Let’s take our average 65 year-old recently retired male with CAD, HTN, DM II who is overweight, doesn’t exercise, lives a predominantly sedentary lifestyle and eats a SAD inflammatory diet. Traditional medicine would call this man a failure is he: 1. Dies of a CVD event or from CVD related complications, 2. Does not maintain a HgbA1c below 6.5% 3. Does not maintain a blood pressure below 140/90 4. Does not maintain an adequate lipid panel- best practice should utilize a TG/HDL <3. 5. Imposes an undue, chronic burden on the healthcare system in relation to financial and social welfare.

Now, while I totally agree that a chronically sick American population is certainly the most harmful issue facing our overall social welfare, the brutal reality is that this collective is made up of individual “failures” within the traditional system and only by addressing the individual can we eventually hope to improve the whole.

So let’s apply our 5 questions and see how we can avoid practicing medicine from the fear of failure, and empower the patient to see that indeed there are other metrics to use when it comes to assessing successful medical care.

What if this person’s hopes and dreams are to simply be alive to see his grandkids grow up; What if his biggest fear is dying from a MI without being able to say goodbye to his family; What if his primary goal is to spend time writing poetry and short stories now that he has finally retired; What if he is willing to adopt some minor changes to his lifestyle and diet while routinely seeing a doctor to assess metabolic markers of health; What if his idea of the perfect day is sitting on his porch, watching the sunset with his grandkids on his lap, telling stories of how he used to be the fastest runner in his high school?  Do you see that all of those metrics of success or failure we identified in the traditional medical system neither provide a direction for improvement nor a meaningful framework in order to help this man?

So from this understanding what could a plan for improvement be:

1). Assess current medications and optimize blood pressure control, lipid levels, blood sugar and inflammation in order to stabilize his levels- notice that this does not involve adding new medications, enforcing an expectation for these markers to be lower or improved and, if anything, should involve removing medications to relieve any potential unwanted side effects he is currently experiencing.

2). Find out how he is currently spending his time, where does his family live, who are his social supports, is he satisfied with the time he is spending with his friends and family, what are the barriers to achieving his goals for being with his closest loved ones

3). What are his major hobbies, what does a typical day look like, how much time does he spend pursuing his writing, is he willing to adopt an equal amount of movement, walking, house chores for time spent writing? Does he utilize any technology on a normal basis?

4). Is he willing to modify his diet by adding more fibrous vegetables, eliminating a majority of processed and packaged food and simply spending more time cooking and preparing real food meals? Is he willing to follow-up with the medical team with his dietary progress by tracking meals, body weight and overall happiness during this transition? Can he commit to seeing/communicating with a physician on a regular basis to aid in his journey?

5). Most importantly how can the medical staff be of the most use to him? What practically would provide the best support for the patient? What does he see as reasonable goals for weight loss, activity, engagement with his family? How can we minimally disrupt his life in order to provide the best quality of life possible?

So we can see, there is so much beyond practicing in a world full of the fear of failure, from the abnormal lipid, blood sugar and blood pressure values, to the lack of adherence to a strict dietary protocol, to an inability to take all prescribed medications, to complete ineptitude in engaging in the necessary exercise regimen. As a medical student, I have lived this world, lived with this fear of failing, of innumerable expectations, felt the embarrassment of being unknowledgeable and seemingly unworthy of the task. Instead of thinking, why am I not capable of achieving an outcome, we should be asking is the desired outcome really what I should be striving to achieve?