Friday, October 26, 2007


Many large mammals seem to dream. Photo from

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.


*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.

Monday, October 8, 2007

Fear is the mindkiller, part 3

My slogan for internship: "I will not fear. Fear is the mindkiller"--from Dune. But there seems to be no getting around fear.


I've been feeling burdened lately. I had the day off on Monday, and I was at a grocery store in a wealthy neighborhood getting myself the best coffee in town. I was there because I felt that with everything I'd been through in the previous week, I deserved a treat.

A young mom wearing some outfit that a skinny person would wear to yoga (the pants were tight and stretchy, not loose and concealing) had run into someone she knew. "Oh, I'm a little stressed right now," she said. "The kids are starting sports, and they're in school now, so lots going on, it's been a little bit overwhelming."

I wanted to turn to her and say, "Are you f***ing kidding me? Seriously. You're at the gourmet store buying $20 a pound cheese and hanging out with your kids, and what you have to say for yourself is you're stressed?"

Then I reminded myself that maybe for her motherhood does count as 80+ hours a week doing a terrifyingly high-stakes job, and although I do have to say that taking kids to soccer practice and the gourmet cheese store doesn't sound THAT stressful, what do I know?

Anyway, I realized that my reaction to her was not about her. It was about my stress, and how annoyed I was that someone else would claim to be as stressed as I am. In other words, I'm starting to feel sorry for myself. It was inevitable that it would start sometime--self-pity is probably the one thing that almost all medical interns have in common at one point or another--and I now recognize that it has started.

But I have always been willing to work reasonably hard, and for long hours. And there are many things about the work that is interesting and challenging in all sorts of good ways. So it isn't the time or the work that makes me feel burdened and sorry for myself. It's the fear.

I have a low-grade fear that never really disappears, like watching a scary movie while the main characters are driving around doing something innocuous. You know something bad is going to happen, but you’re not sure what.

I make mistakes all the time. Most aren't a big deal, and the few mistakes that could have become more worrying were caught by other people. There are only one or two mistakes that can still haunt me. The worst one came very early on in internship, when I didn't recognize an acute problem as it was beginning, until it required more serious intervention than it might have if I'd recognized it earlier. No one blamed me for it. Like many intern mistakes, it was an error shared by several people. And the outcome of the patient's hospital course was unlikely to have been any different as a result.

When I came back to the incident a couple of days later in a check-in session with my attending of the time, he said, "This is why you do residency. You just have to see it often enough to recognize it. If medicine was all things you could learn in books, we could just turn you loose after medical school. You can go ahead and feel bad about it, and in fact, you should, so it won't happen again. But this is what residency is about." He said that I was right on track for where I should be in terms of my skills as a physician.

I guess I took his advice: I didn't let the mistake stop me from coming to work the next day. But remembering that morning can still clench my stomach with a special force. No matter how much I reassure myself or other people reassure me that such mistakes are part of the normal course of my development, mistakes still frighten me.

It's mostly just the most recent mistake or two I've made that I remember at any given time, though, because the main reason the more inconsequential mistakes matter is that they remind me of my potential to create harm. That clutching clenching weight inside my abdomen, the horror of the near-miss, returns even when I think about the smallest errors. It's not usually the errors themselves that make me feel that way; it's the fact that I continue to make errors.

For the first couple of months the excitement of being a doctor, and the new confidence I have as an intern that I didn’t have as a medical student, was enough to compensate for this sensation, enough to keep my energy and enthusiasm high. But recently I think that constant sense of near-miss or about-to-hit, that chronic fear, is starting to exhaust me a little bit.

I don’t want to get rid of the fear, because it makes me a better doctor as I make my lists and check them twice. But I want to figure out a way to live with the fear. I don't think it stops with internship. There are doctors I see who look totally relaxed, but they've been doctors for a long long time, and anyway, I'm not sure they should be as relaxed as they are. What's worse in a doctor than overconfidence?

In other words, fear is necessary. But it is also burdensome. More than the hours, more than the work itself, fear is what makes me feel like this is especially hard. Fear is what makes me feel secretly sorry for myself. Fear is what makes me tired and irritable; fear makes me hate some mom in a grocery store. My task for the year is not only to become a good doctor. It is learning how to live with the constant fear of being a bad doctor.

Musical break: Senegal Fast Food

Listening to Manu Chao's new album on this rainy day off from the hospital, I went to his website and found this song ("Senegal Fast Food") he did with Amadou & Mariam--not on the new album, which like this song is both infectious and addictive. The plot of the video sneaks up on you, especially if (like me) you only get 1/10 or 1/15th of the French.