Reflections on Life, Being Human, and Medicine Archives - Page 10 of 51

My patient was a reconsult in the ICU. This was a patient my colleagues had seen the prior week. They had provided input and then signed off (left his care to the Intensivist). He had a complex combination of health problems including heart failure. The ICU team called us to come back and provide further input.

There was not a lot for me to add. I dutifully reviewed his chart and his imaging studies in depth. I then went in to talk with and examine him. He was in his 80s. He had recently suffered a stroke. His speech was slow. He was not completely oriented, but he still tried to maintain his dignity and his identity. His wife and daughter were there and were almost too attentive. They anxiously participated in my history and exam of the patient. They seemed to hang on my every word. I didn’t have a lot to add to his care. I thought of making a quick exit from the room and moving on with my day.

And then I didn’t.

Something happened that changed the whole scene and honestly changed my whole day.

I looked again at my patient, and then at his wife and daughter, and the whole scene in the room. It made me think of my Dad. In that instant, I thought about my father, his times of illness and his times in the hospital. How would it change how I viewed things if the man in the bed were my father? In order to understand I decided to (in a sense) pretend he was my father. Not fully pretend – but just enough to look at him and try to picture my patient like I would have looked if it were my Dad in the hospital bed.

This changed things A LOT. Suddenly there was more to the man who was in front of me in the hospital bed. I could see beyond. I could imagine what he was like before age and illness had changed him. I looked into his eyes and then turned to look at how his wife and daughter looked at him. It was then that I truly could understand. They didn’t see an elderly frail, weak man with so many medical problems. In their eyes I saw reflected a younger, stronger man. I saw someone who worked hard. I saw a solid secure person who was the one that they leaned and relied on.

As a child, I remember being amazed at my Dad. He could do or handle anything. I would struggle to lift the bushel crates of apples (about 50 pounds). My Dad could stack two bushel crates together and then lift both of them over his head. He would do this so that he could stack them in the cold storage higher than any of the rest of us.

My mind drifted to more memories of my Dad. I thought of him navigating the small little forklift around moving boxes of apples in tight areas. He had to wrap a pull rope on the engine to get it started. If it wouldn’t start, he could fix it. He was confident. He could fix anything or do anything that he needed to do. If it needed to be done, he would just do it. I remembered listening to him talk with my grandfather. Together they would work through complex decisions about running the farm.

I thought of him as a high school teacher. He was always calm and always in control. He never seemed to get flustered. He loved to laugh and would get a twinkle in his eye at times. He was a solid reliable figure in the school. Everyone loved and respected him.

My Dad passed away last November. His cancer had aged and weakened him before he died. But when I think of him, I don’t remember that stuff. Instead, I remember him as the strong and robust man who could do anything.

I looked once again into the eyes of my patient’s wife and daughter. The scene was so different than what I initially saw when I first walked into the room. Their facial expressions, their attentiveness, and their questions now all made sense. They could see so much more than what was obvious. I looked back at my patient, and I slowed down. There was indeed so much more there. I suddenly didn’t want to leave the room. My long list of patients and work yet to do didn’t matter as much. We talked more. As we did, I learned more about him. He was truly frail and not able to tell me much, but he didn’t need to. The four of us could now somehow together see a much more full and complex understanding of who he was.

When I left his room, I was honored that I was allowed to be a part of his medical care. I felt better. I’m not exactly sure why. I think part of it was a feeling that what I was doing was important. I had purpose. The person I was taking care of was important.

I decided that it was good what I did in my mind that day. I resolved that I should do it more. Who is the person beyond the hospital and before the illness? What is their world like? What was their world before?

Since that day I have continued my game. I refuse to just see who they are in the hospital bed. Instead, I pretend they are people who have been important to me. Let me be clear. I don’t assume that they are the same as my family or friend that I remember. But if they were, how would I want a doctor to see them, to talk to them, and to care for them? In this thinking of the depth and complexity of my family or friend, I am able to push myself to see more.

Today I was consulted on an 89-year-old with heart failure. She was hunched over and asleep when I went into the room. I woke her to talk with her and examine her. She was small and frail. She had a prominent kyphotic (bent over) deformity of her spine. She was confused. She didn’t provide a lot of information to me.

I paused a minute. I imagined my grandmother. My grandmother was a strong farm woman in her day. I thought of all that she was and meant to me and my family. I stopped. I pretended that this patient was my grandmother. This changed the entire scene for me. Suddenly there was a lot more going on. My patient was complex with a long life and lots of details to her past. It would be amazing if I could somehow learn more of who she was. I was determined to do the best that I could to help her just like I would have wanted others to do for my grandmother.

And so, sometimes I pretend they are my father.

He was flying his F/A-18 Hornet when it happened. His aircraft could fly at speeds up to 1,190 mph. It could climb from the ground to its maximum altitude of 50,000 feet in under a minute. It must have been an incredible experience to be in control of all of that power. He said he was cruising at normal speed admiring the beauty of flying when it happened. His legs went numb. He flew back to the base and took off his flight gear. The sensation didn’t go away. He went to see his flight surgeon. They examined him. They ordered tests. They didn’t find a cause.

He was sent to The United States Naval Aerospace Medical Institute (NAMI). There he underwent additional tests. He was sent to see all of the different specialists at NAMI. I met him when he came to the psychiatry clinic.

Each prospective flight surgeon gets training in all the aspects of flight medicine. One of the very important areas was psychiatry. I was a flight surgery student doing my rotation in psychiatry at the time.

Our lead psychiatrist conducted a thorough interview with the aviator. We met to discuss and think about his case. Later all of the flight surgeons at NAMI met to review his case. This meeting is called a Special Board of Flight Surgeons(SBFS).^[1] A SBFS involves all of the flight surgeons assigned to NAMI. Each medical specialty had a chance to examine the aviator and provide commentary as applicable.

The meeting started with one of the doctors presenting the details of our patient’s case. The neurologist spoke next. He assured us that they could find no neurologic basis for his symptoms. In fact, his symptoms did not fit any sort of anatomic pattern that would make physiologic sense. It fell next to the psychiatrist to talk. He felt that the symptoms were because of a mismatch between the man’s true personality and what he was pretending to be.

Isn’t that an interesting concept? Is it possible to create problems by pretending to be someone or something that you are not? That strikes a chord in many of us. We worry that maybe deep down we are just pretending.

The psychiatrist continued to talk. He spoke of the how the aviator felt the incredible pressure to take on a certain persona in order to fulfill his duties as a “top gun” type of jet naval aviator. The truth was, he wasn’t Tom Cruise. In trying to pretend he was, he had created such an intense psychologic stress that it was presenting itself as physical symptoms. He had been able to do it for a period of time. He succeeded in flight training and in his initial tours of duty. Eventually however the disconnect had caught up with him.

The psychiatrist finished his presentation by stating that he felt that the most descriptive diagnosis was, “Insufficient Narcissism.”

Narcissism is defined as “the pursuit of gratification from vanity or egotistic admiration of one’s idealized self-image and attributes.^[2]

Narcissus was a figure in Greek mythology. The beautiful nymph Echo fell madly in love with Narcissus. Narcissus however refused her advances. Instead, he gazed at his own reflection in a pool of water and when he did, he fell in love with himself. Narcissus then “lay gazing enraptured into the pool, hour after hour” without moving. Eventually the unmoving Narcissus was transformed into a flower (the narcissus).

We all know people a bit like this. These persons carry themselves bigger than life. They have extreme confidence. They really value and like themselves. They don’t really listen to or pay attention to criticism from others. Think Tom Cruise, Kim Kardashian, or Kanye West. As you do you will begin to get a picture.

Like Narcissus many of these persons can be both successful and at the same time cause tremendous damage to themselves and those around them. Pride is listed as the cardinal sin of the seven deadly sins^[3] for good reason. Pride can and does cause lots of problems. “Pride goes before destruction, and a haughty spirit before a fall.”^[4] “One’s pride will bring him low, but he who is lowly in spirit will obtain honor.”^[5] “For you say, I am rich, I have prospered, and I need nothing, not realizing that you are wretched, pitiable, poor, blind and naked.”^[6]

Narcissism is generally bad. A diagnosis of insufficient narcissism was a bit audacious. Is that really a thing?

In our training we learned a lot about the psychology of a naval aviator. We learned about personality types that causes some to succeed while others would fail. We learned about the confidence that it takes to go flying at very high speeds even though you know that if you make one slight mistake you could crash and die. In flight training we talked about dying all the time. Before every flight we would brief about what could go wrong. By the end of their first tour of duty, most naval aviators have lost at least one colleague or friend. For them to go back and climb into their airplane and not just fly it, but push it very hard, takes a unique personality. They need to have a self confidence that causes them to believe that even though others have failed, they will not.

I have thought about this when I look at our political candidates. It must take a certain degree of narcissism to become a politician. They need to believe that they can succeed and win. They need to be able to ignore or not be harmed by the inevitable and continual opposition and criticism that they will face from their opponents.

It creates the question, “Is there such a thing as a healthy narcissism?”

On the opposite end, we talk about the “imposter syndrome.” “Imposter syndrome is loosely defined as doubting your abilities and feeling like a fraud. It disproportionately affects high-achieving people, who find it difficult to accept their accomplishments. Many question whether they’re deserving of accolades.”^[7]

The idea is that some people who are very qualified and very successful still struggle to acknowledge the reality of their abilities. They often feel like they are “faking it.”

The ideal state would of course be to have a realistic understanding of yourself including your abilities as well as your limitations. The truth is that this requires a delicate balance. You need to know your limitations and strengths, openly and honestly, but you should not be limited by them. You should be able to push forward with confidence. At times you should be able to push forward, pretending to be Tom Cruise complete with aviator glasses and a powerful motorcycle screaming at high speed toward the sunset. It is not that you are being fake, but you’re smartly working through what you are able to do, and what you want to do and taking on just enough of a dose of narcissism to push to achieve your dreams.

In our training about the psychology of the naval aviator we discovered it is not just about training a bunch of narcissists. It is actually a lot more complex than that. We learned that most aviators put on some degree of a façade. They take on the persona of the overconfident never doubting jock. Inside however most are highly intelligent, intellectual, and often obsessive compulsives who have trained themselves for the role of an aviator. When they put on their flight suit, they also put on their persona of the super confident aviator.

It might help you to understand by thinking of the opposite extreme. I think of a teenager who when talking to an adult apologizes in how they talk. They look down. They don’t really say what they are thinking. They are way too timid. They don’t have to be. They would do so much better if they just believed in themselves a little bit more. It would be so much better if they would greet you with a firm handshake, look you in the eye and naturally talk to you.

I am not encouraging vanity. But I am wondering about the power of a little bit of appropriate confidence.

I’m not an athlete. But at one point in my life, I decided that it was okay to do things, even if I was not good at them. If I really wanted to do something, I was going to do it even if others could do it better. I am not a great golfer, but I still go golfing. I was never trained as a writer. But I enjoy writing my blog.

Do you want to paint? Then do it!

Do you want to write? Then do it!

Do you want to learn to sail? Then do it!
Do you want to learn to fly? Then do it!

Do you want to give the speech? Then do it with confidence!

Do you want to succeed at your career? Have you been trained? Then don’t apologize for it. Do it.

The SBFS concluded that our aviator patient needed time. They were going to keep him out of the cockpit and have him go through a series of counseling sessions. They didn’t know what the result would be. Perhaps he would be able to better understand himself, and then decide if he could or would be able to put on the aviator persona again. If he did he would need to do it by choice. It was possible that the persona would be too far of a reach for him, and his naval aviation career would be over.

I don’t know what happened. Honestly either would have been an acceptable outcome. He didn’t have to be something that he didn’t want to be. He could move on to other areas where he could be successful. On the other hand, he might have been able to come to terms with his subconscious struggle with “imposter syndrome.” If he did, hopefully he could take on the role of jet naval aviator again in a healthy way.

You don’t have to be something that you are not. But it is also okay to push yourself a bit to do and be the person that you want to be. You don’t have to be the best at something in order to do it. Go ahead and try it. You might be better at it then you give yourself credit for.

Insufficient narcissism? Maybe that is or is not really a thing. Narcissism is generally bad. But appropriate confidence and taking on things even if you worry that others might be better at it? That is perfectly fine.

Go for it.

^[1] https://www.med.navy.mil/sites/nmotc/nami/arwg/Documents/WaiverGuide/NMOTCINST_1301.1K_SBFS.pdf

^[2] https://en.wikipedia.org/wiki/Narcissism

^[3] https://en.wikipedia.org/wiki/Seven_deadly_sins

^[4] New International Version, Proverbs 16:18

^[5] New International Version, Proverbs 29:23

^[6] New International Version, Revelation 3:17

^[7] https://hbr.org/2021/02/stop-telling-women-they-have-imposter-syndrome