The first time I was truly afraid of a patient, I was standing in an outpatient family practice clinic in Detroit. If you’ve ever felt mind-numbing fear, you know that it creates a dividing line between that moment and the next. Strange details imprint on your brain, like the heft of the chart in your suddenly damp hands, and the musty smell of an exam room suddenly grown tinier. Grown men have told me that part of the attraction for going to war is learning if they have what it takes when confronted with the fear that is part and parcel of combat. When we watch movie characters stumble into bad situations, we have the prescience that comes with being an observer, and tell ourselves that we would never, ever go into the dark house after the psycho or get in the car with the charming serial killer. In actuality, how often do we do dangerous things and not realize how close we stand to the precipice? As my childhood friends will tell you, I had what I considered a charming unawareness for these types of situations (until, of course, I became a mother), and perhaps it came from my innate belief that all people are good. When I was younger, I traipsed into places and talked to people that now I would never let my children associate with, but again, I really didn’t think anyone wanted to hurt me, and I trusted that I would know it if they did, but perhaps that was hubris or plain dumb luck that I never got hurt.
This time though, the analytical, writer part of my brain was coolly noting that, for once, I was actually not only assessing the situation accurately, but also responding in what I thought was a very calm and non-threatening manner, though the other animal instincts in my brain that had made the fine hairs on the backs of my hands prickle within the first 2 minutes of meeting this patient, were screaming “Run! Get out of there, right now! Do not pass go, do not stop! Get out!” It was like, and I kid you not, the good buddy in movies, you know, the sensible one like Velma, or actually more like the hyper-panicky one Shaggy, tapping on my shoulder and whispering “I don’t think this is a good idea.”
Having grown up in the suburbs of Detroit, in a town where everyone looked so familiar I would have trouble placing the face as being someone I knew from church, the gas station, school, or work, going to PA school in “the city” was exciting to me. I knew I’d be exposed to situations I’d never experienced, and like my combat veterans, wondered if I’d have what it took. I wasn’t afraid of the crack addicts or gang-bangers. I was afraid that I wouldn’t know how to react, wouldn’t have what it took in the face of an emergency to do what had to be done–chest compressions, suturing, bandaging, reading EKGs accurately. I thought I’d be most afraid in the ER at Henry Ford Main, or during my psychiatry rotation where I was on the inpatient consult service for Detroit Receiving and Sinai Grace, because of the out of my control aspect of those situations. In an outpatient clinic, I naively thought, at least you could kind of predict what kind of day you were going to have. Appointments are scheduled, and you can predict what kind of patients you will see, unlike in the ER, when you can have a heart attack, gunshot wound to the hand, and head cold all walk in at the same time. It was a controlled environment, I thought, and control of my environment is key.
All of us desire control. It begins when we’re learning how to talk and walk. This is where the terrible twos (and threes and fours for some of us) get their name. The desire to exercise our will on the environment is innate. We want to be able to choose our path. We want to believe that we have control, though in reality, we have very little. Today is Friday the 13th, a day many fear, though most of us find it superstitious. We scoff at people who would have “silly fears” of things like the number 13, but in reality, don’t we all pause for just half a second, if we have an interview or date that gets set for Friday the 13th or we’re placed in hotel room #13? It doesn’t stop us from continuing on with our lives, but given the choice, just to be on the safe side, wouldn’t we change the date or room number, if we could?
As children, many of the sayings that we grew up with enforce those beliefs: Step on a crack, you’ll break your mother’s back–so we avoid walking on the cracks, just in case. It’s part of the mistaken belief, these superstitions, that we can control our destiny. We believe that by following all the rules, we can control our circumstances. As children we pray, if I promise to do all my homework next time, please let me pass this test. As adults we pray, if I promise to be a better mother, please let her be OK. Fear is irrational, it compromises our illusion of control, because it shows us how little power we actually have. When we see through the eyes of fear, nothing is in our control, and that is the most frightening thing.
The unkempt woman in the musty exam room looked right through me. All of us want to be seen, truly seen for who we are, and when others do not see, it can be frustrating, and make us doubt ourselves. When she did not respond to me, I wondered for a brief second, did I not speak loudly enough? I had read her chart before coming in the room. It was supposed to be a routine follow-up for her annual gynecological exam. Her list of medications gave me clues to what was missing in the 1 sentence description of why she was there.
“Have you been taking your Clozaril?” I asked.
“My mother has blue hair. Do you see them? People walk on buses,” she said.
Being alone in a room with a schizophrenic patient off her medications is not a place for a green PA student. My very first rotation was psychiatry on the inpatient wards. Ingrained in us were several rules: Make sure to always be between the patient and the exit. Make sure that someone knows where you are at all times. Make sure that you wear long hair pulled back so a patient cannot grab you. I had seen schizophrenic patients on their medications, discharged them home to the loving care of family or friends, after seeing them admitted off their medications, when they could not distinguish between their reality and ours. Most were not violent, but what was frightening was their inability to see us. To them, I could have been a 300 lb body builder threatening to take away their most prized possessions, and as anyone who’s ever been threatened knows, fear will make us strike out to protect ourselves.
Fear will take a perfectly reasonable person, and turn them into a knife-wielding, gun-toting, hate-speech throwing part of a mob like those we’ve seen on the news. It turns off the reasonable, logical parts of our brains, and takes us back to the child we all were once, vulnerable and at the mercy of others. When we point our fingers at others, tsk at the behaviors that we, of course, would never engage in, scoff at superstitions and phobias, we forget to look at what prompts them. We forget to look deeper. We forget to ask ourselves what are they really afraid of–and what am I afraid of that I am too blind to see them for who they really are.
“You know what? I think I left your bloodwork outside. I’ll be right back,” I lied, and briskly walked out of the room, straight to my preceptor’s office, and explained the situation to him. I never saw that woman again, but I’ll never forget her eyes or the trembling of my hands afterward. Have you ever been truly afraid? Do you have any phobias or fears that may seem irrational to others? I’d love to hear about them. I discovered an irrational fear of heights when I climbed up on a ladder to explore an old B52 bomber, and could not make my legs work to climb back down the ladder I had just ascended 10 minutes prior.
Today I am grateful for reminders that all of us have fears that lie behind the facade of control we all cling to. I am thankful for the friends who kept me from making irrevocable mistakes in my innocence when I didn’t have enough fear, and hope my children will have such good friends as they make their way through a world filled with too many choices.