Several years ago, I went to fix something that was broken on the front door to our house. To be honest it had been broken for a long time. Sarah had been asking me to fix it but for one reason or another I repeatedly forgot about it. She would periodically remind me and ask me to fix it when I could. On this day I had some free time. I was doing some work around the house when it occurred to me that I still needed to fix the door. I went and got my tools and was able to fix it without too much problem.
That was when Sarah got upset (frustrated).
This story is not about a “Sarah problem” by the way. She had patiently waited for months. She had kindly asked and reminded me to fix it over a long period of time. The interesting thing is that she didn’t get frustrated during the months of waiting. It was not until I started working on it that she got upset.
Let’s pause to consider the two perspectives. We will do it kind of like they do in the old sitcom television shows.
The camera zooms in on Mike with a confused and thoughtful look on his face. You hear Mike’s inner voice start talking, “I was a good husband. I used my free time to think about our home and the needs of our family. On my own initiative I got my tools and went to work on fixing the door to the house. I was sort of impressed at my handyman skills. I was able to get it fixed without too much fuss. It looks pretty good, if I don’t say so myself. I thought I would get a lot of praise and kudos from my family for the good work I had done. Instead, my wife was frustrated. I don’t get it. Wasn’t she happy to have me get it fixed? Would she have been happier if I had just continued to ignore it? You try to do something good and in the end, you have a frustrated wife. Sigh…”
The camera suddenly shifts. You now see Sarah’s face. She is trying to not be frustrated as she thinks to herself, “I love Mike but sometimes he can drive me crazy! We had something broken on the front door to our house for months. I have been patiently asking and asking and asking him to fix it and he had not done it. I have not wanted to nag him about it and so I have been very patient and just would periodically and gently remind him. Today he went to fix it and it really didn’t take him very long to get it fixed. Why did he take so long to fix it in the first place? If he could have done it this easily, why didn’t he just do it when I first asked him to? I don’t know why this can seem to frustrate me so much. Now that is fixed, however, I realize how long he ignored me as I had to keep asking him to fix it. Sigh…”
To be honest, Sarah has a point. I really could have and should have just fixed it right away. My months of procrastination did not make the job any easier. In the end, it didn’t really take me much time to do the job. I love my wife. I would never intentionally ignore her or things that are important to her. In this case, I honestly would just get distracted and forget about doing it. I really need to do a better job of paying attention to getting things done that she needs me to do around the house.
This is not a particularly poignant or dramatic story. It turns out however to be a really valuable lesson and one that I see play out over and over again in my medical practice. Let me explain.
Recently I was rounding in the ICU. My patient recently suffered a serious heart attack. She became very ill and ended up requiring a temporary artificial heart pump to keep her alive. She had multiple teams of physicians, advanced practice providers, and nurses caring for her. She had high risk and complex stent procedures done. There was a period of time when we didn’t know if she would survive, or if she was going to need to be considered for heart transplant or a ventricular assist device. Eventually she started to get better. We were able to wean (reduce the doses of) the potent medicines that were raising her blood pressure and making her heart work harder to keep her alive. We were also able to wean and then remove the temporary heart pump. She was and is getting better.
Today she broke down in tears and frustration.
There it is again. Sarah wasn’t frustrated until I started working on fixing the front door.
My patient wasn’t frustrated before. When she was going through procedure after procedure, was feeling very sick, and things were really scary she didn’t complain at all. Now that she is getting better, she is frustrated and upset.
But I am an experienced clinician. Or perhaps it is because I am an experienced human being, because I wasn’t surprised at this. I have seen this so many times that I have come to expect it. I call it the “Crest of the Hill Anxiety Syndrome.”
I routinely tell patients that the hardest part of a hospitalization is the last few days of their stay. I have had patients in the hospital for several months and not have them complain or get upset at all until about 3 days before discharge. Sometimes it gets so bad that the patient will threaten to leave AMA (Against Medical Advice). I have more than once been called to urgently go see a patient who is insisting on going home just a few days before it is really wise for them to do so.
The first few times this happened it puzzled me. The patient has been in the hospital for 6 weeks going through a life-threatening illness and a complex treatment regimen and now they are upset and threatening to leave? What gives?
And then I chuckle and remember Sarah and the front door.
I have written about the power of “hope” before. Remember that “hope” is not an “I wish, I wish, I wish,” but is instead the concept of shifting our thinking to focus on good things to come. By focusing our attention on the future, we can better tolerate the present. Hope is an incredibly powerful tool that can empower us to endure really difficult times. The crest of the hill anxiety syndrome is partly related to this. It seems that when “hope” is far off, it is abstract. It is something to be dreamed of but not something that is reachable. When, however, it is getting close to becoming a reality, it becomes so real that it can create incredible anxiety and frustration.
It is perhaps a bit like Tantalus.
Tantalus was a god who did all sorts of things that he shouldn’t. This included stealing from the gods, revealing secrets of the gods to mortals, and even killing his own son and making a soup out of his son’s body to test the god’s omniscience. As a punishment for his actions, he was condemned to stand in a pool of water beneath a fruit tree with low branches. Whenever he would reach to pick some fruit, the branches would raise up and pull the fruit just out of his grasp. Whenever he would stoop down to take a drink of water, the water would recede so that he could not get a drink. Whatever he desired would be visible but just out of his reach.
Our patients have been dreaming of a time when they will be able to go home. They will be able to see their own house, rest on their own sofa, sleep in their own bed, and eat their own food. They will no longer have to put up with the noise, pain, food, and indignity of the hospital. As they get close to going home, the reality of it starts to get so real to them that like Tantalus they want to reach up for it and grab it. Suddenly, the same old hospital food is unbearable. It seems like there is no way to make their hospital bed feel comfortable. They are sick of watching whatever is available on the television or reading whatever books they have. Every blood draw is one more frustration and pain for them. They suddenly feel the weight of all that they have endured at the same time as they are not able to get what they want.
Being able to see the light at the end of the tunnel is incredibly encouraging. It brings hope and promise for the good that is coming. But as the tunnel goes on and on, suddenly the walls can begin to feel narrow, confining and claustrophobic. The air begins to feel thin and unbearable. The light at the end of the tunnel that once brought hope and encouragement now brings just an oppressive awareness of the reality of tunnel that they are in.
They are like Tantalus and able to see but not able to have what they want.
I dare to dream that we are in the last major COVID-19 surge. Omicron is 4 times more contagious than the original SARS-CoV-2 strain. Fortunately, it seems to be more prone to attacking the airways rather than the lungs. This is all good news and bad news. The good news is that it seems that people are not getting as sick as they were with the delta strain. Do not get me wrong, some people are still getting horribly and incredibly ill. People are going to die of omicron. But the percentage of people who catch omicron who get very sick appears to be less than with delta. Hospitalizations and deaths since omicron (at least so far) have not risen as quickly as the increase in the number of people getting Covid. That is the good news. The bad news is that it is so contagious that a LOT of people are going to get it. I have heard some experts speculate that this means that the vast majority of our population is now either going to be vaccinated or get omicron (or both). This means that eventually the level of immunity in the community will become very high. If a high percentage of people are immune and unable to get infected, the community prevalence will drop.
There is a snowball effect that goes both ways. If community prevalence rises, people are more likely to catch COVID (there are more people to catch it from). That raises community prevalence even more, making even more people likely to get infected and so on. It also goes the other way. Once more and more people are immune, they are less likely to catch COVID. If people are not catching COVID, the community prevalence drops. That means that there are fewer and fewer people spreading the disease. That means that even fewer people will catch it. As fewer people catch it community prevalence drops progressively further, and the disease begins to go away.
Maybe (just maybe) this is the beginning of the end of the horrible parts of the pandemic. We are going to have to live through several weeks yet of a LOT of people getting sick, but maybe after that, things will get better. There might be a light at the end of the tunnel. But there is also a lot of tunnel left (several weeks likely). As it gets closer, we might begin to feel frustrated. We might begin to feel the “crest of the hill” syndrome.
Now is not the time to “leave AMA.” The next 4-6 weeks are going to bring an enormous surge of people getting COVID (it has already started). We anticipate that businesses (especially our hospitals) are going to struggle with problematic staff shortages. We are already seeing a tremendous increase in test positivity. Large numbers of people are contracting COVID (700,00 – 800,000 people per day in the US). Even if they are not getting as sick as they were with delta, the numbers of people who are off work is (and is going to continue to be) a big issue. Now more than ever is a time for you to be sure to do whatever you can to keep yourself and your family safe (masks, distancing, booster shots, etc…)
When I looked at my patient in the ICU today, there were tears in her eyes.
I smiled a reassuring smile at her. “I hope you know that what you are feeling is not a surprise to me? You were so sick earlier this week. You are getting better now. It may seem odd, but this phase of your illness is when I find that patients have a hard time coping. I know it is frustrating. I am sorry for all that you have been through and what you still have to go through. It is okay for you to be upset. It is really quite normal to be frustrated.”
She looked up at me and her eyes brightened. Her daughter nodded, “See Mom? This is what I was trying to tell you.”
I thought about telling them a story about the time that I fixed the broken part on the front door to our house.
One reply on “The Crest of the Hill Anxiety Syndrome”
great writing/thoughts again!!