The new season of "Dear Dr. Horton” is here! Send the anonymous questions that keep you up at night to a real former Dean of Medical Student Affairs, Dr. Jillian Horton, and get the perspective you need with no fear of judgment. Submit your questions anonymously through this form, and if your question is appropriate for the column, expect an answer within a few weeks!
Dear Dr. Horton,
How do you address concerns with friends over questionable coping methods, when they are highly educated nearly-doctors too? My roommate has always had body image issues, but I did not know how deep they were rooted. In fact, after a recent psych block, I am pretty sure she has an eating disorder. I'm just not sure how to address it. Nothing seems to be falling apart in her life. Any tips on how to address uncomfortable suspicions that are unconfirmed? Without offending my friend?
Dear Tip Toeing,
Have you ever heard of the invisible gorilla?
In a famous psychology experiment, participants are asked to watch a video clip of two basketball teams and count the number of successful passes. (1) Most people get the right number of passes. But they miss the person in the Gorilla suit who literally moonwalks through the game. Why? Because they’re not looking for a gorilla. And we have a hard time seeing what we are not expecting.
My colleague Ron Epstein uses this concept to help physicians go off autopilot and become more observant (2). It’s a helpful construct for understanding cognitive error as well. But I think it has another, more personal application. When it comes to physician suffering, I think there are a lot of invisible gorillas in the room.
The first thing I want to commend you for is noticing. Too often in medicine, we’re blind to the suffering of our peers. Sometimes this is because we are struggling to contain or manage our own suffering. Sometimes it’s because we assume that nobody struggles the way we struggle. And sometimes we assume our colleagues are “smart” enough to be able to identify when they are in over their heads, and we share the fallacy until things have spiralled totally out of control, or worse, until it’s too late.
This is a fundamental paradox of life in medicine...that being a doctor means you always have insight into your own health. It’s true that being a doctor can be helpful if you are trying to decide if you have a virus. But there’s no reason to think it’s particularly helpful if you are trying to decide if you have an illness that is characterized by cognitive distortion. Meanwhile, the people around you may mistake your intellect for insight…words that are not synonyms. And before you know it, the invisible gorilla has pulled a Godzilla and torn up not just the basketball court but pretty much everything else in your life.
I had some very hard times in my residency, times when a gorilla followed me into every room. For years afterwards I used to wonder: didn’t my friends know I was in over my head? Didn’t they see my suffering? Wasn’t I worth the discomfort of saying something? I grieved this abandonment; it was a sadness that stayed with me for at least a decade. But then, in the years that followed, I missed these same signs in my own friends, and sometimes in my residents and students, and I wondered how I could have been so blind.
Life has taught me that my friends didn’t abandon me. In fact, they were often watching me closely…closely enough to know I never missed a pass, that I always kept catching the ball. They thought performance was the metric that would measure whether I was alright. That’s how they missed the gorilla.
It doesn’t absolve them, or me, or any of us of the responsibility for taking better care of each other. But it helps give us a framework for how we have failed so miserably as a profession when it comes to judging the wellbeing of people around us. We have to start looking for gorillas.
Tip toeing, you’ve noticed something amiss. There’s a moonwalking gorilla in your rented apartment. Maybe you’ve talked to it a few times and it laughs and tells you it’s not a gorilla, it’s a seahorse. Or maybe it’s barked like a dog, in the hopes of throwing you off its trail.
You have a choice. You can pretend it is a seahorse, or a chihuahua, and you can become party to the cognitive distortion.
Or you can sit your roommate down. You can show her this post. You can tell her you wrote this letter, because you’re worried sick about her.
Be prepared for anything. Gorillas are unpredictable. Enlist the help of friends, family, trusted faculty, and school resources, to help get through to her. Will that make the gorilla angry? It might. But my experience is that in processes that don’t preclude a degree of insight, most people welcome true expressions of caring and concern. Some people have been wrestling the gorilla on their own for so long that it is a relief to know that backup has finally arrived.
Even if things go the other way, would you rather have an angry friend or a dead friend? And what would any of us want or expect our friends, family and teachers to do if we had an illness that could impair our judgment, insight, willingness, and ability to seek help?
I think we would want them to be brave, to step up, to help us send that gorilla packing, so we could get on with our lives.
- Epstein, R.M. Attending. Scribner, 2017. P 17
Dr. Jillian Horton is a general internist in Winnipeg, Manitoba. She was the Associate Dean of Undergraduate Student Affairs at the University of Manitoba from 2014–2018 and now directs programs in wellness and medical humanities at the Max Rady College of Medicine.
She writes a column for CMAJ Blogs called Dear Dr. Horton: cmajblogs.com/category/dear-dr-horton/