On Worry

On Worry

By Eric Warm

Here’s a question: if you were a patient, would you choose a doctor who sometimes wakes up at 3 AM to worry about a decision he/she made about you, or a doctor who never does this?

And, if you are a physician, which of these doctors do you want to be?

Worry is both a verb and a noun. You can “allow your mind to dwell on difficulty or troubles” or you can have “a state of anxiety and uncertainty over actual or potential problems.”

The true art of medicine is how we deal with uncertainty. Evidence-based medicine is great. If there’s evidence – do it. But what if there isn’t?

Some of us worry. Some of us worry about worry.

In this week’s grand rounds a neurosurgeon showed us 10 videos of pituitary surgery he had recently performed. He worked in incredibly tight spaces with a high degree of risk – a slip of the hand could lead to blindness, exsanguination, death. I didn’t ask him, but I’m quite sure his worries are much different than mine (an internist). 

Internists have slips of the mind. And for me, my mind sometimes realizes this at 3 AM.  Once I woke a patient up at home because I thought she was going to get hypoglycemic on an insulin regimen I prescribed. We laugh about this now, but I wasn’t laughing then.

If the 3 AM wake-up call happens to you, I offer the following suggestions (these are in no way evidence-based):

  1. Realize that many people worry about their decisions at times. Ask someone you admire. I’m sure they’ll have a story to tell.

  2. As you care for patients during the day, be deliberate with this thought: am I going to lose sleep over this decision? If the answer is yes, do something right then that can reduce your worry.

  3. When you do wake up, consider the following:

    1. Determine if your brain has actually thought of something new – sometimes it does. Make a plan to get it done (maybe wait until dawn, though).

    2. Determine why you are worrying – is it something you didn’t/don’t know? If so – find it out, or have a plan to find it out – don’t stew in your bed. (If you use a computer or phone, put the blue light filter on).

  4. Realize that doctors play the odds. We give the best advice we can, but if there’s a 98% chance of a good outcome with a given decision, there’s a still a 2% chance of a bad outcome.  Angioedema with an ACE inhibitor? Guillian-Barre from flu shot? Perforated colon from a screening colonoscopy? Everything has risk. In general, we should bet with house money, but this is the most difficult worry for me – should I have suggested the 2% option in this particular case? If you guess wrong, try to avoid hindsight bias (the tendency to overestimate your ability to have predicted an outcome that could not possibly have been predicted).

  5. Worry is common but it should not paralyze you. If it does, get help.

As for the question of which doctor we want to be – I’m not sure we get to choose.

What I’ve learned: sometimes worry helps. Mostly it doesn’t, but that doesn’t have to be a failing.

As Mark Twain said: “I’m an old man and have known a great many troubles, but most of them have never happened.”