One theme that I stress repeatedly in these essays is that when doctors and patients communicate, they are often in different places, different head-spaces. Whether it is anxiety or fear or emotionalism, patients often approach a situation differently than a trained health care professional. Yesterday, I watched a horror movie1 and I realized that, from a professional’s perspective, patients seem to act like people in horror movies. So, I thought I would try another writing experiment and consider what lessons we can learn about patients from watching horror movies. Rest assured, those with delicate constitutions, that this essay will not have any gore or violence, unless you consider the way that I, at times, torture the English language.
While there is an amazing array of different horror movie subgenres, most adhere to at least one or two common tropes. The most universal of them is that panicked people make bad decisions. One might argue that the entire genre would not exist, if, in the first ten minutes someone said, “Nope, getting drunk with the sorority girls at an abandoned and haunted mental facility is a bad idea.” I, like a lot of people, have watched a horror movie and screamed at the screen, “Why are you running upstairs when the front door is RIGHT THERE?!?” The problem is, in life like in horror movies, any plan or expectation or rational thought can melt away when confronted with something completely unexpected. Sitting on our couch, we can ridicule the decisions these people make, but would we really be better in that situation?
When I moved to Southern California, I learned everything I could about earthquake preparation. I had water and canned food, and I knew what to do to protect myself when an earthquake hit. I was not obsessed or phobic; I just wanted to take care of the easy stuff. Then one day, I was walking down the hall at school and I heard a roar, like a truck was driving up to the building and the whole building started shaking. I was prepared for this moment and when it hit, I stood there like a deer in the headlights. It was not that I was frozen in fear so much as it was my brain not functioning fast enough to catch up with current events. By the time my brain told me what to do, it was all over. I failed my real-world practicum in earthquake survival and I immediately knew it. Later that same night, I was in my underwear laying on my bed reading [don’t judge me] when an aftershock hit. It felt like a truck ran into my apartment building. It took less than a second, but all I could think about was me running onto the street in my underwear right when the TV camera crews would show up. From that moment on, I considered showering in my clothes so I would not get caught with my pants literally down. Or put more succinctly, as Mike Tyson said, “Everyone has a plan until they get punched in the face.”
Some health events come out of nowhere, but often we can see storm clouds on the horizon before the diagnosis—and odd lump, a moment of dizziness, a loss of appetite. Whether it is borne of prudence or delusion, we will calm ourselves by saying we don’t know until we know. But steeling ourselves against the possible is different than steeling ourselves against the actual event. And how we THINK we will behave does not always represent how we DO behave.
When my friend was diagnosed with multiple sclerosis, there were warning signs. But until those words are spoken and that diagnosis is released into the universe, she was hoping it was all just a bad dream or countless other less ominous diagnoses. What happened after that diagnosis did not reflect the countless discussions we had before that news was official. Instead, she made a lot of bad decisions. I am not judging or shaming her for her actions. In this new universe where any moment for any reason an MS episode might flare and take the eyesight in one eye or her ability to walk, her decision-making focused on living in the moment. She had lost the disease lottery, so when experimental drugs2 appeared for her to try, she was more focused on the negative side effects than on the potential for relief. Calm, rational, thoughtful conversation would not change her mind. While some can overcome the initial panic, everyone will have that blue sky moment when they hear nothing that anyone is saying, as their brain concocts the most insane worst-case scenarios in processing the new reality. If you are with someone like that, you know you cannot with brute force change their mind. You can be supportive and quietly relentless, but they need to come to you.
In the horror movies of the 1980s, where no summer camp or slumber party was safe, there were rules about who lived and who died. Some were moralistic, as the pot smokers and those engaged in premarital sex were always killed off. But everyone who died, put themselves in harm’s way. They read from the creepy spellbook, they opened the box, they tempted fate by denying the existence of Freddy, Jason, or Michael. In short, they asked for it. As a viewer, we could take comfort in the fact that we would never make that mistake so we would never get killed. Of course, we shared this schadenfreude that they played stupid games and won stupid prizes. In modern horror, though, people get set upon by demons, monsters or serial killers through no fault of their own. They were minding their own business and trouble went looking for them. Even worse, sometimes people get into trouble by actually trying to help or do some good only to learn that no good deed goes unpunished. Here, as a viewer, you don’t get the comfort of judgement, because there, but for the grace of God, goes you. Not every bad thing has a cause and effect and good people who do nothing wrong die.
We like it when we can trace an effect to a cause. You did not manage your diet, so you got diabetes. You did not manage your diabetes and now you have lost your leg. While some may approach this with a big spoonful of “you made your bed, now lie in it,” many are more interested in making sense of the bad thing because predicting outcomes means that we can control outcomes. You disrespected the witch and she turned you into a toad. You didn’t quit smoking and now you have lung cancer. I would never make that mistake. This desire to have the world make sense doesn’t work in healthcare. Right now, there is a ninety-year-old alcoholic on a barstool in Wisconsin chain-smoking who won’t die until his wife clobbers him with a frying pan. Meanwhile, my father quit smoking sixty years ago, went swimming every day, ate right, and had no excess weight on his frame. One day when getting ready for a swim, he heard a pop and discovered that he had cracked his kneecap. His kneecap cracked because he had undiagnosed cancer that made every bone below his waist as brittle as dry pasta. We like it when we can trace the cause and effect. We hate it when it seems to make no sense and too often healthcare makes no sense.
This lack of sense or fairness, in horror movies like in life, generally produces one of two suboptimal responses. Some will hate the lucky ones. They will inexplicably turn on survivors because someone they cared about did not make it. Others will say that none of it matters and either freeze in inaction or adopt a screw-it-you-only-live-once mentality, leading to poor choices. If we cannot predict effects from causes, what is the point of rationality?
Another common trope in horror movies is that the protagonist is on their own. Either help, like the police, is unavailable or incompetent. If experts are available, they will almost certainly give you bad advice, either because they are not smart about the right things, or, they are aligned with the bad guy in some way. You are alone and can trust no one. People who are facing healthcare trauma or death feel alone since they often feel like no one knows what they are going through. The physician may care, but at the end of the day, they get to go home. Sometimes it is true that a care team is not taking the patient or family into account as they plan.3 This does not make them wrong or evil, just not good at listening.
When medical reality does not match medical expectation4 it also opens the door to those who will feed on the “experts are incompetent” feeling. These are the “what the medical establishment doesn’t want you to know” crowd. These people want you to trust no one (except themselves), because everyone else all out to get you. While a rational person will ask why this miracle cure is not more widely-used given its genius, the isolated and alone will crave any quackery because, well, they feel isolated and alone.
Finally, the OG of horror tropes is that the monster never dies. In the 40s, even if they did die, they would return with Son of… or Bride of… or just have Return of… By the 80s, they didn’t even bother with killing the monster at all. Sure, the monster got burned up, drowned, or shot (or all three), but when you turned around, the body was missing and the sequel was set. In healthcare, any successful solution comes with concern about its return. Remission is a reprieve, but it often doesn’t feel satisfying. There is always that lingering doubt with cancer, or the absolute knowledge with herpes or shingles, that it will come back for a sequel. You might be confused why someone who survived a heart attack would be depressed, but the cardiac blues are a real thing. Even when a bad thing is vanquished, patients will often still be looking for the other shoe to drop.
What is the overall takeaway, outside of the fact that I watch too many movies? Too often, we don’t understand the motivation and mentality of patients facing chronic diseases. They seem to be happy when others would be sad, or sad when others would be happy. They make odd decisions. We know that they are struggling to be rational, but at the same time don’t know how to engage with them in that struggle. We always find ourselves navigating between allowing a patient to feel their feelings but not let them descend into despair. Horror movies like real life don’t always have happy endings.
OK, that was fun. Maybe next time, I will explore what healthcare can learn from watching sci-fi movies. Like the fact that someone should really develop that wand that doctors use to wave over broken bones or chronic kidney disease that heals patients instantly. Technology is awesome and can never lead us astray!
1I am not name-checking the movie because it was only OK. If it thought it was very good or excellent, I would name it, but I won’t receive shade for watching an slightly below average horror movie.
2This was before all the MS drugs now advertised on TV. This was a time when there was no treatment.
3My 99-year-old grandmother with dementia fell and broke her hip. Everyone knows that this is a death sentence, but the ortho surgeon booked a surgery suite for the following week to fix the hip. Not sure why he wanted to risk his numbers on a woman who would almost certainly not survive the anesthesia. It didn’t matter, as she was dead four days when the surgery day arrived.
4I will joke that “TV cancer” is awesome. Sure, it is scary at first, but it always gets cleared up in 47 minutes.
PX Matters with Joseph Snipp 
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