The Risk of Preparing for the Worst

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I was watching an English Premiere League game the other day (as I am wont to do). Tottenham Hotspur had secured a comfortable lead in the first half over Brighton and Hove Albion. They were cruising. Their play was infused with confidence and creativity. They were enjoying themselves. In the second half, though, all hell let loose. Brighton scored an unexpected goal. Then, Tottenham started messing up all over the field. Poor traps, missed passes, awful shots, and breakdowns in defense. The confidence, the creativity, and the joy were gone. The players who had been moving about the field with the fluidity of a Baryshnikov became stiff and leaden. Sure enough, Brighton tied things up. Now the Tottenham players were in a panic. Their game completely fell apart. Brighton scored another goal and could have put in several more. As it was, Tottenham lost three to two.

Catastrophe in Medical Care

I am sorry to say, I have witnessed this type of dramatic shift in fortune, this complete switch from supreme success to catastrophe, in the neurosurgical world. A big, serious brain operation goes wonderfully. The patient and their family are delighted and heaping praise on the team. Then something happens. It could be a minor perturbation of the patient’s homeostasis. An unexpected shift in electrolytes, a small mucous plug in the lung, a low-grade fever. But it sets off a chain reaction—often feeding off the patient’s co-morbidities. Smaller problems compound themselves. Then the big problems hit: a DVT, a pulmonary embolus, seizures, infection, or hemorrhaging in the operative field. Now it’s an all-hands-on-deck, five-alarm disaster with the team fighting desperately to pull the patient out of a precipitous nose dive.

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Celebration Avoidance

For said reasons, we would almost never celebrate a success, a surgery gone well, a patient taking a turn for the better, a job well done by the team. Instead, particularly in a situation where things seemed to be going super smoothly, we intentionally put ourselves in a state of high alert. Waiting for the boot to drop. Considering, anticipating, and preparing for anything and everything that could go wrong, that could destroy a happy outcome, that could take a patient from the road to recovery and send them careening down a steep, icy chute to severe disability or death. So we searched, we scoured, and we heightened our senses for any subtle sign, any slight indication that the situation at hand was going to deteriorate. So that we might jump on it, put the fire out before it had a chance to ignite. Catch and extinguish a catastrophe when it was nothing more than a minor annoyance.

And well we should, right? That was our job, correct? All that pre-med rat race, the four years of medical school, the seven years of residency, perhaps a fellowship or two, licensure, board certification, and continuing medical education, was to raise above just being technicians to being disaster clairvoyants. Survey the field night and day and suss out the indicators of impending doom. Train our brains to see the bad stuff. No matter how subtle. Train our brain to anticipate everything deteriorating to hell. To expect the 2-0 game to implode.

A Useful Skill

I’m sure that this is a useful skill in many industries. Any, certainly, where lives are at stake if the worst is not considered, not anticipated. But I would guess the same goes in many other businesses. In this lightning-quick, hyper-competitive economic world, I suppose a company can be riding high, obliterating the competition, when fortunes turn on a dime and the company is hemorrhaging big money. In fact, one of my best friends was employed by a major company for the sole purpose of presenting worst-case scenarios to all actions taken by the c-suite.

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The Downside

A useful skill, for sure. But can there be a downside? Well, we know from the neuroscience world that the wiring of our brains is not static. It changes from second to second at the synaptic level. Use a collection of connections a lot, and the synapses are multiplied and strengthened. Use them very little, and they downregulate and may even be pruned away. So what happens when we constantly reinforce catastrophe-anticipatory circuitry and deprive reward circuitry? Yes, we build up our flight or fight centers, our stress management centers and weaken our enjoyment centers. Do it enough and we indeed get very good at anticipating the worst. We develop a sixth sense for bad stuff. Many of us in medicine can walk into a patient’s room and know immediately their status—particularly if it is about to deteriorate (much to the bafflement of med students and residents).

But, at the same time, we strip our success sensors. We fail to notice uplifts, to recognize joyful occasions, to anticipate happy outcomes. We become numb to everything positive. We force ourselves into an anhedonic state. And it carries over to all our interactions, all our activities in and out of work. A surefire pathway to burnout.

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Collecting Uplifts

So, what can we do? We certainly don’t want to lose our sixth sense for impending disasters, but it would sure be nice not to cancel our ability to derive pleasure from our days. It becomes critical, therefore, to program our brains for both. The job will make us do so for the negative; we have to intentionally do the work for the positive. We have to tell ourselves and remind ourselves to notice the good stuff, drop the negative superstitions, and celebrate our successes. We can still keep an eye out for the surprises.

In a medical setting, positive things are happening around us all the time. Patients get better. New technologies and medications are brought into play. Patients and their families are thanking us. Teams congeal and function like well-oiled machines. But we all too often sail by it all. Always on the prowl for the bad stuff. I’m sure something similar happens in all industries.

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So try this exercise that I have advocated before. Carry some sort of reminder to look for and write down five to 10 positive things that happen in your day. Do so every day for at least a month. Train your brain to have a sixth sense about the good things happening around you. Reflect on your list at night. Share it with colleagues, family, and friends. They don’t have to be dramatic saves. They don’t have to put your company into the Fortune 500; they just have to be positive things. A song, a smile, a thank you. It won’t take long, and you won’t have to seek them out. They will come to you because you reinforced those synapses, those pathways in your brain. Or perhaps in your soul.