Dreams

Many large mammals seem to dream. Photo from www.tanzaniaparks.com

Earlier this week I dreamed that someone from my residency program--it wasn't anyone I know in real life--plunked down a piece of paper in front of me with a dollar amount. (About two month's pay.)

"We'll give you this much to buy you out of your contract," the person said. They didn't want me to be an intern anymore and were going to pay me to stop working for them.

In reality, I would never be confronted with that kind of choice; I'd be fired or I wouldn't. But the dream made the prospect of being fired even more dreadful: I had to choose to be fired, and take the money; or refuse to be fired but not get the money while knowing that my bosses wanted to fire me anyway. I realized this in the dream, and began thinking, "This is terrible--they're going to stop me from being a doctor, they don't think I can be a doctor, but I've worked so hard to be one, I want so badly to be one"; and then I woke up suddenly with a terrible feeling. I quickly realized that I'd been dreaming.

"I'm doing fine," I thought to myself, in the dark of early morning, Ms. Dr. Hemodynamics and the Hemodynamic Cat sleeping soundly in the bed as I woke up and looked around at the real world. "That's not what's happening." Or rather, it wasn't what was happening in my actual life, where my bosses do not seem displeased with me. But clearly some portion of it was happening in my emotional life, my submerged world of fears.

Later that week, I led a presentation about a particular case, designed to start a discussion among interns, residents, faculty and guest experts about how to think about a patient's problem, and the issues it brought up. I did some work I didn't absolutely have to do on the presentation, and I hope it showed. Anyway, two faculty members told me I'd done a good job.

In the most literal sense, I have never dreamed of such a thing. I have imagined it or hoped for it in the daytime, and I have experienced it before. But I don't remember ever waking up from a dream in which one of my bosses or my teachers had just told me I'd done a good job, even though that happens much more often than someone firing me. Maybe I have those kinds of dreams. Maybe I just don't wake up from them with that startled dread that makes me remember a dream. Or maybe fear requires more overnight processing than hope or optimism do.

Freud said dreams represent narratives of wish fulfillment. I don't buy it, or not exactly. I read The Interpretation of Dreams in a film class when I was seventeen, and in retrospect I think it may remain more important for filmmakers than it does for clinicians.

I don't think I want to be fired from my job, or bought out of my contract. And I'm not prepared to do the interpretive backflips Freud and his followers required to turn that common kind of dream into a narrative of some kind of unconscious wish. It's a dream about a fear, which in the organization of the mammalian brain has got to be at least as powerful as a wish. If the brain is going to spend a lot of processing power on learning, fear is probably a better way of organizing learning for survival than wishing.

I'm a person of my era, not Freud's, and in my simple-minded way of thinking about dreams, I think of dreams as the brain reprocessing the material of the day--the intellectual material and the emotional material too. Whether they are wishes or fears, they get processed.*

Maybe the common ancestor of people and chimps slept in a forest, dreaming about her fellow apes turning on her for stealing fruit she didn't steal, horrified as they advanced towards her, shocked by this unreasonable turn of events; then, I hope, waking to find herself among peaceful family members. Now my great ape brain dreams about my bosses telling me I'd better fire myself from my job. If my dream has its ancestral predecessor, both of us apes--the ancestor great-great-great-grandmother ape and me--would be dreaming ourselves a deep social lesson, processed and then wired through many redundant circuits, which says, "Don't anger the apes around you."

For me, at least since junior high school and probably before, countless dreams have reinforced variations on this theme. Whatever imagined events these dreams are processing, their emotions and narratives surely help me be a more or less polite and socially appropriate person during waking hours. And that kind of dream creates such a powerful dread on waking that it is hard not to imagine that its mechanism must be deep and ancestral, dating back to that great-grandmother ape dreaming many millennia ago.

***

For practically every patient I admit to the hospital, I put in an order for "vital signs per routine"--which means they get woken up at night and early in the morning. People in the hospital also get woken up by their roommates, or their roommates' televisions; or worst and often most disturbingly of all, by other patients, delirious, their hallucinations representing a waking state of dreaming, or a dreaming state of waking, screaming "HELP ME!" or "GET AWAY FROM ME!" or "DON'T TOUCH MY PENIS!" across the hall again and again.

Once in a while you meet someone who can sleep through it all even without a lot of sedative on board. With one recent patient like this, I came to think that he'd spent enough time in hospitals that he'd figured out how to sleep while in a hospital room, including what had clearly become a nearly instinctive ability to fend off medical interns in the morning and keep sleeping despite their questions, pokings, and proddings. (This is not an easy task.)

Alone among my patients, this man was likely having dreams, full dreams, rich dreams. Did they make him better? Did they help him figure things out? I'll never know. I just hope that if I appeared in his dreams, I was never one of the apes who was hurting him.

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*Considerably less simple-minded descriptions of this kind of processing can be found in this article in Science for those who have access to it through local or academic libraries.