How I Manage Fear As A Hypochondriac Doctor: Jim Down (Transcript)

Here is the full transcript of physician Jim Down’s talk titled “How I Manage Fear As A Hypochondriac Doctor” at TEDxManchester 2024 conference.

Listen to the audio version here:

TRANSCRIPT:

A Tropical Disease Emergency

In 2009, a tropical disease doctor pushed a trolley with a very young, very sick man on it into the intensive care unit where I work. The first thing the doctor said was, “It’s not VHS,” which was unusual, but also, I have to admit, a bit of a relief to me because I couldn’t for the life of me remember what VHS stood for. But the guy was sick, and so we wheeled him down to one of our bed spaces and I heard the story.

It turned out he was a British aid worker who’d been taken ill in Mali a week before with fevers, shakes, and sweats. “Oh, and it’s not malaria either,” the tropical doctor said to me. For some reason, that triggered a memory in me and I went, “Oh, of course, VHS, viral hemorrhagic fever.” This guy, Ebola and its mates, which are viruses that put the fear of God into clinicians like me because not only are they often fatal, they’re also incredibly contagious.

So I thought I’d just double-check. “It’s definitely not VHS?” “Absolutely wrong country.” “Good.” So we set about trying to stabilize this poor young man with our shiny machines, and it was going okay until about an hour later when he started to bleed heavily from everywhere. By the time a student nurse arrived with a message from the tropical diseases consultant, there were about six of us around the bed up to our elbows in blood.

I remember she read nervously from a piece of paper, “It might be VHS, so please take appropriate precautions.” These are appropriate precautions. This is how we were dressed. Very sadly, this young guy, despite our best efforts, passed away about an hour later.

A Late-Night Phone Call

At two o’clock the next morning, I received a phone call from a consultant virologist. Now, to put it in context, I have never been called by a consultant virologist at two o’clock in the morning, before or since. Even during the biggest viral pandemic the world has seen for a hundred years, never in the middle of the night. So I pretty much knew what was coming.

“VHS?” I asked. “Afraid so,” he said. “Lassa fever.” And I can still remember that sinking feeling in the pit of my stomach as I wondered whether I’d caught what had just killed this poor young man.

If I’d been told this when I applied to medical school, to be honest, I probably would have done something else. Because I am in no way a brave person. In fact, quite the opposite. I’m an absolutely committed hypochondriac.

Medical School and Early Career Experiences

The only time at medical school that I really relaxed was when I did obstetrics and gynecology. At last, some illnesses that I definitely didn’t have. But this isn’t the only time that I’ve been nervous about my own health at work. Way back in 2000, I was a junior doctor working in Stevenage when a train crashed just down the road outside Hatfield.

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Within minutes, I was bundled into the back of an ambulance, clutching an orange bag with the words “paediatrics” written on it. I am not a pediatrician. I can’t tell you how much I am not a pediatric doctor. I’m not even a very good parent.

But as it turned out, by the time we got to the scene, the only task for me was to, unfortunately, certify the deceased, which was horrible obviously. But as we made our way from the first fatality down the tracks, the police approached us looking fairly agitated. They came up and said, “The current thinking is this could well be a device.”

I’m afraid I didn’t have any idea what they were saying until they added, “In which case, there could very well be a second device.” “You mean, a bomb?” I asked very coolly. They nodded, and I ran down the tracks and certified the rest of the deceased and legged it out of there as quick as I could.

Encounters with Dangerous Situations

And then in 2004, I stabbed myself with a needle that I was convinced was contaminated with HIV. And in 2006, we admitted this guy, Russian dissident, Alexander Litvinenko. Again, unfortunately, we didn’t know what was wrong with him until, you know, after he died about four days later.

But after I’d spoken to his extraordinary wife and gone out and given a shambles of a press statement, I was taken aside by a woman from the government and she took me into an office and she said, “We know what killed him. Radioactive polonium 210.” Now, I don’t want to give you the impression that I never understand a word, and if anyone ever says to me at work, “But I’m afraid again, don’t worry,” she said, “Massive dose. He didn’t stand a chance.”

“Right. Oh, and it’s a secret. You must not tell anyone. There’s far too much at stake.” “But what about the staff?” I said, “Are they not at risk?” “They’ll be absolutely fine as long as they wore the universal precautions.” These are our universal precautions, and I just worry that they might not be robust enough to deal with weapons-grade radioactive polonium.

So along with my colleagues, I collected 24 hours of my urine and sent it off to be tested for radiation. A week later, I received a letter from the health protection agency that said, “Dear Dr. Down, your polonium levels are of no concern to us.”

The COVID-19 Pandemic

And then of course, COVID hit in 2020, and being me, I assumed that I’d catch a massive dose of it from my very sick patients and almost certainly succumb. Obviously, that didn’t happen, but I did see suffering and death on a scale that I have to say I’d never even imagined from a virus that both horrified and baffled me in equal measure.

And when it finally petered out about 15 months later, I was haunted by some of the patients I’d seen and some of the decisions I’d made.

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But I didn’t really know what to do with it. So I just sort of muddled on until a non-COVID patient came in who changed all of that. She was a very sick woman who came in one evening, and I spent the whole night with her trying to work out what was going on while I also tried to stabilize her. But unfortunately, we didn’t get to the bottom of the diagnosis until the morning, by which time our small window for definitive intervention had passed.

Now there were lots of reasons for that, and it almost certainly would have made no difference. But when she died five days later, I blamed myself completely. And when I went home that night and went to bed, rather than sleep, I spiraled into a crippling state of anxiety.

I was basically overwhelmed by negative thoughts about myself, about my abilities as a doctor, about all the things that I should or might or could have done that might have saved her life. And over the next few days, I became incapacitated by this. I couldn’t eat. I couldn’t sleep. I couldn’t sit still.

The Psychological Toll

But when I went to the park for a walk, I became enraged by people who were joking and messing around. And I couldn’t work either because my confidence had evaporated. And I was paralyzed by this weird sense of paranoia. For some reason in my head, I believed now that the patients would be out to trick me and catch me out deliberately and the staff would either be pitying or judging me.

And I thought that if I did go back to work, immediately something awful would happen again because the sense of shame and guilt were overwhelming. And I needed help. And I was lucky because I work in an amazing NHS hospital, and I often think perhaps the message here is that, you know, this could have had a very different ending, this story, if I didn’t work in this brilliant hospital.

Because when I had my crisis, I was offered help immediately, not just from friends and colleagues and my amazing family, but from professionals, from psychologists and psychiatrists. And as these people steered me back to health, it became obvious to me, of course, that the real risk of doing the job I do is not all those physical threats I’ve talked about, it’s psychological ones.

For me, that shame, the feeling of not being good enough and anxiety. And as I talked to more and more people, it became clear that my anxiety was to a large extent based around one simple thing: uncertainty. I hate uncertainty, and so I’ve been trying subconsciously to eradicate it from my work.

Dealing with Uncertainty and Risk

I’ve been trying, although I didn’t realize it, to spot fires on the horizon and either stamp them out or work out how to swerve around them before they got out of control. And in some ways, of course, that had served me reasonably well. I’d avoided, you know, major disasters at work, but now I could see that my approach was completely pathological and also unsustainable.

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Reducing anxiety is a very important part of it. Reducing risk and mitigating risk is fine, but that’s not fine if it slips quietly into avoiding risk. Because in my line of work, that essentially means practicing defensive medicine, i.e., working in your best interest to protect yourself, maybe without even realizing it, rather than looking after your patients.

But of course, the reality is that you can’t do that. You can’t eradicate risk from your work. It’s an illusion that you can protect yourself. And once that illusion is shattered, there’s nowhere to go. And my problem was that I didn’t realize this until I’d hit rock bottom.

So I’m talking to you today, I guess, because I think, in a way, this can happen to almost any of us. Because uncertainty and risk are the price we pay for responsibility, particularly when that responsibility is not matched by an equal level of control. I can’t control who comes into my intensive care unit, but once they do, I have to look after them. They are my responsibility, and sometimes that is not going to go well.

Managing Anxiety and Moving Forward

That inherently makes me anxious. But now, I proactively manage the symptoms of my anxiety. I use exercise, simple things, exercise to clear my head, I use antidepressants because they give me some objectivity and distance from intrusive thoughts, and I use clichés, obviously, cold water swimming, that kind of thing. But I also now try to take a balanced approach to my job.

I can’t be laissez-faire or reckless, you know, I mean, people might die, but neither can I sit and spend my days ruminating about what might have been or what might be in the future. Risk is always going to be there. And if we’re going to flourish, if we’re going to grow, if we’re going to live, if we’re going to perform to the best of our abilities, we have to work out a way to be open about that, to accept it, and to manage it so that when things go wrong, and they will go wrong, we’re all in the best possible state to deal with it. Thank you very much indeed.