Remember that our patients frequently feel a lack of control

I recently went to an “admitted student day” with my eldest son at the university he plans to attend in the fall.  On our campus tour, our guide pointed out a block on the ground in the center of campus (which incorporates a symbol of the university) that no one steps on because “stepping on it will cause you to fail your first exam.”  In the winter, it is the first spot to be shoveled out after it snows so that no one inadvertently steps on it.

There is no evidence whatsoever that there is any element of truth to the story.  Of course, it’s difficult to do a double-blind, placebo-controlled study, but perhaps it could be done with blindfolded students in thick, rubber-soled shoes, taken in zig-zag-y paths either around or on top of the block, prior to their first exams.  But I would think that only those disinclined to believe such stories in the first place would participate in the study, since no one would want to fail an exam if they stepped where they believe they shouldn’t step.  The not-stepping-on-the-square is different than protecting the symbol from spray paint or other vandalism by rival colleges.  And people wear this symbol on their socks (which get stepped on, obviously) and on the seats of pajama pants (which get sat on), so the not-stepping-on-it isn’t really out of respect for the symbol.  It honestly stems from fear and discomfort arising from a superstitious story.

A remarkable number of otherwise critically-thinking individuals choose to participate in this superstitious behavior.  Many who do so say that even though they don’t really believe the story, “it couldn’t hurt.”

But that kind of thinking and behavior can hurt.  It ingrains a habit of following superstition and kowtowing to irrational fears  Of ignoring fact.  Of ignoring evidence.  Of ignoring science.  And then people make excuses for the superstitious behavior and try to rationalize it: “I just felt like I shouldn’t step on it,” or “I did it out of respect to people who believed it.”

Full disclosure: I hold an undergraduate degree from this particular institution of higher learning.  And I remember walking on the block.  On purpose.  Before my first exam.  Because I did not want to have to worry about having to focus on where I stepped, and I knew that if I gave in to the story at the beginning, then I would end up becoming a slave to the superstitious behavior.  And I did not fail my exam.  But I remember feeling uncomfortable each time I stepped there (which I did frequently over my years in attendance, purposefully).

I want to explore that discomfort.  Again, I really don’t think it’s a “respect for the symbol” issue, as I and my schoolmates never had any problem stepping on, sitting on, or eating over any other versions of that symbol.  I have no doubt that if the story were “step on it and you’ll get an ‘A’ on your next exam,” that it would be the most trampled upon spot on campus.  Or that if the “don’t step on” spot were 3 feet to the northeast of the block, that the northeast nondescript area would be avoided.  My unease really was a bit of a sense of fear.  That I was doing something “wrong” that somehow tempted fate.

Never mind the fact that I understood very well that attending classes, doing the reading, doing the problem sets, asking questions when I didn’t understand something, and studying were the factors which would determine my grades on my exams.  These factors have a proven, cause-and-effect correlation with exam performance.  I know that.  And I knew that then.  And yet the unease …

I think some of this unease has to do with a sense of control (or lack thereof).  I can control whether I do the reading, the homework problems, the studying.  But I cannot control what the professor will choose to ask on the test, whether it will focus predominately on subject matter I understand or on subject matter that’s more difficult for me, or how well others do (which affects the grading curve).  Believing a superstitious story (or acting on it) is an acknowledgement that some things are beyond my control, and it’s an action to try to take a bit of control over the uncontrollable.

And yet this lack of ability to control everything is precisely the reason it is dangerous to fall into the superstitious behaviors.  They have the ability to make us feel like we have control when we don’t, and to make us neglect the factors over which we really do have a lot of power.  The superstitious behaviors can indicate that we’re giving up on the provable, the scientific, the rational behaviors.  And we need to remind ourselves not to do that.  We need to make sure that the fear doesn’t take away our power of rational thought and behavior.  We need to remember that although the rational behaviors do not produce infallible results, they are still supremely more reliable than the superstitious, especially when they are not simply “rational,” but also studied and scientifically/factually verified.  We need not to allow a tiny amount of uncertainty or discomfort to outweigh a preponderance of evidence.

Doctors need to remember that their patients frequently feel a lack of control.  And that patients experience fear.  We need to understand the tendency of many people to feel superstitious.  We need to understand the feelings that drive people to seemingly irrational behavior.  We need to remember that once a seed of fear is planted, it can sprout roots and gain hold.  We need not to roll our eyes when people express fears about vaccines, but we need to acknowledge the sense of unease that a human has when he or she feels as if he or she has incomplete control in a situation, and the fear that person has when someone has planted a seed of doubt and suspicion.  The more we understand our patients, the better we can communicate with our patients, the better we can relate to our patients (and our patients to us), and the more likely we are to be heard and our advice followed.

And all of us need to think about what we are afraid of and why.  When there is overwhelming evidence, for example, of the safety of immunizations and the science behind them, we need to think about why we would be afraid of a a repeatedly disproven risk, why we would allow the roots of that seed to take hold once we have figured out that it’s a weed, not a flower.  We need to think about why we feel compelled to buy special water with a “memory” of a magic herb and grow suspicious of “Western ” or “traditional” medicine.  Or why we are afraid to step on a specific square on the ground.  And we need to force ourselves to step on that square, so that we reinforce our resolve not to become slaves to irrational thinking and behaviors.  The fact that we do not have 100% control does not mean that we should throw up our hands and disregard a preponderance of evidence.

It’s scary not to have complete control.  But every human is faced with such reality.  It is incumbent upon us not to allow that fear to assume de facto control.

Abigail Schildcrout is founder, Practical Medical Insights, and blogs at DocThoughts.

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