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 But when a mouse is stressed it’s behaviour changes; it becomes withdrawn, lethargic and anti-social.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.

14 Comments

  1. I love this post Matt. I suppose we all have the option to get off the nail. It’s how we choose to do so. I am forever the optimist.
    Miss you guys and look forward to catching up in person before too long. Love to you, Lindsay and the boys!

    1. Darn you optimists and how easily you maneuver off of your nails!

      Really looking forward to seeing you guys again too 🙂

  2. Thinking about those dogs, I’m wondering about the role of the other dogs in encouraging and inspiring those with learned helplessness…. In human relationships there’s the potential to “lend ego” it’s something that a partner, a friend, a therapist can do to help someone who is down in the dumps… a kind of ‘Hey, follow me – Let’s do this together’. This is probably another important item in the bag of tricks: Remembering to be open, honest, talk to friends, and allow them to give you some new perspective. We’re all in this mess together.

    1. Ooo, interesting, Marla. If I recall correctly, soon after the initial experiments, Martin Seligman himself found that he could only get the “helpless” dogs to avoid the shocks by physically moving their legs for them; he had to retrain them to take action. I think you’re onto something really important there – tap into whatever social networks and do something – anything – together.

  3. As a fellow doc, everything you discuss about getting off the nail makes so much sense. This is such good advice for everyone. Excellent post and I will share this post with some friends that I think will really benefit from it. I enjoy your blog and I hope you will continue it even when you move back to Canada and start the boys homeschooling and go back to ER medicine.

    1. Thanks, RocDoc. When I started thinking about the connections between learned helplessness and burnout, the pieces started falling into place. It’s so important to realize that chronic stress actually twists our perceptions so that we see fewer options and, at the same time, inhibits our ability to take action. So, the very people who are best suited to fixing the system are mentally, emotionally and physically injured, and impaired from doing so. I hope that the better we understand the problem, the more likely we will be to find solutions together.

  4. Matt,

    Beautifully articulated in the way that only you can pull off. I have a hematoma from hitting my head against the bar each time you raise it.

    Also brings an interesting corollary to mind that you may identify with. In the same way that the dog on the nail has her view of possibilities constrict, taking the nontraditional path can come with a widening of possibility.

    Case in point: friend I interviewed (posting soon) was on an academic fast track to success with years invested in a career she loved. On having her first child, she realized unexpectedly that she needed to be home more. Totally threw a wrench in her plan and forced her to change paths after much internal conflict.

    Once she took the road less traveled, she started to notice all sorts of faint paths in the wood. She decided to home school. Began coaching folks who home schooled and hosting conferences. The same passion for teaching and service found a new outlet.

    Her account of it rings true with the idea that once you say, “Why can’t I do it differently than everyone else?,” it creates a virtuous cycle of fearlessness and willingness to question how things are done in other spheres of life. Suddenly the world is pregnant with possibility once more.

    Not a bad way to live, as you and your family have demonstrated.

    Fondly,

    CD

    1. Great insight, and I can’t wait to read your blog post. Sometimes I think success is determined not by the number of answers we have but by the number of questions. It’s the questions that reveal our options. Asking the right question at the right time has the power to unlock miracles: landing on the moon, the Internet, Lindsay agreeing to marry me . . .

      As you are pointing out, we ask questions when we’re open and engaged. We don’t do it so easily when we’re suffering. So, how do we exit that spiral? Personally, I can’t think of any way that does not involve some kind of connection with other people: hearing their stories, having meaningful conversations, perhaps trusting them to guide us on that road less traveled.

      As always, thanks for the thoughtful comment.

  5. What a lovely post. You and CD are gifted writers.
    I was always rip-cord ready no matter what I did. I understood sunk costs. If I did not like something after a while, I would change it.
    This applies to work only. I am the opposite when it comes to relationships. Thank goodness.
    After a while, I was not afraid of change at all. I kind of looked forward to it.
    I always understood that nothing I did was irreplaceable work-wise.
    I hope you will find a happy arrangement for yourself.

    1. Thanks for the comment, Dr. MB. I guess that was part of the motivation to write the post: to figure out why some people are more “rip-cord ready” than others. Perhaps it’s our innate wiring, perhaps it’s self-training, and perhaps it’s due to the stress-cortisol-learned helplessness axis . . . likely a combination of all of the above and six other factors I am ignorant of!

      Certainly, one of the ways we can be more nimble in life is to work towards financial security as aggressively as possible, which is something you and CD have written about very eloquently.

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