Stuck on a nail

A man pays a visit to a friend. As they sit on the front porch talking, the friend’s dog lies beside them, twitching and wimpering.

“What’s wrong with your dog?” the man asks.
“Oh, there’s a nail sticking up in the spot where he’s lying,” the friend replies.
“Why doesn’t he move?”
“Oh, well, I guess it doesn’t hurt that much.”

Perhaps you’ve heard this little parable before. I love it because at first it’s seems ridiculous . . . and then I start realizing all the ways I am like the dog; stuck on a nail.

I know I should, but . . .

But not really stuck in an obvious sense; there’s a choice that’s not being made. He could move but he doesn’t. Why do we resist change even when we know it’s the right thing? Why do people choose to stay in abusive relationships? Why do people choose to persist in destructive habits? We want a better life, and we know how to get there – why don’t we just do it?

You would think that discomfort and the stress that goes along with it would be motivation enough. But something strange happens when the discomfort is either bearable (a single nail) or unavoidable (nails everywhere). Rather than escape it, we cope with it; the stress becomes chronic. This has interesting consequences.

Lessons from stressed mice

Like humans, healthy mice are active, curious and social. But when a mouse is stressed it’s behaviour changes; it becomes withdrawn, lethargic and anti-social. Stress triggers the release of adrenaline and cortisol – aptly named “stress hormones”, they prime the mind and body to fight or flee. They raise blood pressure, suppress our immune systems, and, perhaps most importantly, inhibit rational thinking. In mice and in humans, stress impairs our ability to solve problems.

Good vs. bad stress

To be clear, not all stress is bad; stress that is moderate, predictable and matched with the tools and abilities to cope with it can be hugely productive. Think of the stress of learning a new skill set, earning a degree, resolving a conflict with a loved one, or building a company – these are challenging endeavours worth every bit of stress involved. In fact, stress, under the right circumstances, is necessary for our survival.

But stress is meant to be temporary, punctuated by rest, reward and rejuvenation; and stress that is productive can be managed. Writing this blog is stressful: I had never designed a website, I knew nothing about WordPress plugins, and the prospect of writing and publishing our personal lives for the world to see is more than a little daunting. But I take breaks, your comments and emails fuel me, and I have complete control over my own learning process.

What happens when the stress is not temporary, not predictable, and not manageable?

Side effects

In medicine there is a drug called prednisone that we have to use frequently. It is essentially synthetic cortisone – a stress hormone. This might sound funny, but we use it mainly for a side effect: it is a potent anti-inflammatory and in the right circumstances, it can be extremely useful. But it’s also toxic. In the short term it can cause fatigue, agitation, insomnia, hypertension, and a host of mental health symptoms. In the long term it causes suppression of the immune system, cardiovascular disease, weight gain, osteoporosis, ulcers, and muscle loss – just to name a few.

A short course of prednisone is unlikely to cause much harm, just like acute stress that is managed and resolved is unlikely to scar you. The problem is long-term exposure. It’s not just harmful, but the longer it goes on, the worse we are at dealing with it.

Chronic stress can come in many forms: a bad marriage, poverty, a dysfunctional family, a bad job. When insecurity, emotional strain and lack of autonomy are the norm, it’s a mistake to think that the pain is only temporary; the stress damages us – mentally and physically.

Learned helplessness

In the late 1960’s and 70’s Martin Seligman conducted some groundbreaking animal studies in which he subjected dogs to painful electric shocks. One group of dogs had a safe area they could move to to avoid the shocks. Another group did not have a safe area and, thus, had no control over the painful stimulus. Same stress, but one is manageable while the other is not.

The interesting part is what Seligman did next. He took the dogs from the second group and put them in the first scenario. What do you think they did when the shocks started? Normal dogs immediately take action, try things, learn; these dogs layed down and whimpered with every shock. They had learned that their actions had no effect and so they stopped trying. Seligman called this, “learned helplessness”.

Similar studies have been carried out in humans with similar results.

Is burnout actually learned helplessness?

I can’t help but see parallels to burnout. We toil for years at jobs that are inherently difficult while being pushed and pulled to meet this metric, adhere to that guideline, cope with a system so strained that we are forced to perform below the standards of our patients and ourselves. The wait times are too long, there aren’t enough beds, the suffering goes on and on and our patients look to us for solutions that, too often, we don’t have. Shock after shock in a cage with no safe area. After a while you lose the will to fight. You lie down and whimper. It’s not the whole explanation, but it’s a piece of the puzzle.

Unlearning helplessness

Not everyone who endures stress becomes depressed or burned out. Those who don’t are, through some combination of genetics, circumstance and life choices, thought to be more resilient. Resilience is a touchstone word these days. Traditionally it’s been thought of as a trait, relatively fixed: you either have it or you don’t. But it’s not like that. Resilience is a skill – something you can learn and practice, an advantage you can pull out when you need it.

I can’t tell you how to be resilient because I’m just starting to understand the nature of the problem, but here are my thoughts:

Get off the nail, at least for a little while
Getting out of medicine and putting myself in new and interesting situations has allowed me to see things in new and valuable ways.

Cut myself some slack
I needed to understand that my frustration at the craziness of the system was understandable and even justified before I could move on.

Think of options
Change departments, start a side-hustle, travel the world for a year . . . entertain the possibilities even if you don’t follow them; it’s about the choice mindset.

Forced optimism
When you’re so used to the negative thoughts, it’s a challenge to see the glimmers of hope that still exist; this is a skill I need to work on.

My bet is that, like the dog on the porch, we are all laying on our own nails: poisonous situations that are holding us back, yet we persist in enabling. To me it’s both morbidly fascinating and brilliantly liberating to understand how human this is. And now the work begins to find a better way.