On anxiety in medicine

One thing we don't often talk about but which keeps so many people back from their lives is anxiety. I mean, of course, not the anxiety we all feel at understandably threatening or fearful situations; I mean anxiety which affects the way we live our lives, how we express ourselves, how we work, and our health. The best way someone explained anxiety to me is like asthma: your body is responding to a fairly harmless substance as if were something extremely dangerous; your body launches a response aimed at this harmless thing and the response itself hurts your body more than the harmless thing ever could!

Imagine a military battalion being on edge awaiting for an enemy strike. Suddenly a white sheet of paper gets flown into your team's territory, the area you're meant to be protecting. The area has been quite for so long, peace was declared years ago, but your troops remained on guard as if it was still in the midst of war. When the harmless piece of paper gets flown into your troop's protected area, no one knows what's going on and no one has time to think it through. Instinct kicks in. Fire!!! The troops launch an attack. Bullets go out, grenades, bombs, all and every weapon available is used. Eventually everything goes quite and you evaluate the damage: there's giant craters and fires burning throughout your own territory and your team's supplies are exhausted. What to do now? You restock your supplies (this costs your government money, time, and effort). You rebuild the areas of your territory that were damaged, and as you do so you curse that stupid piece of paper that brought all this about. You hate him now... Then one day another piece of paper will enter your territory again. And guess what? You will do exactly the same thing! You've come to believe that the enemy IS that piece of paper. The reality is that the real enemy is that jerk who let your troops keep believing there was still a fervent war going on, and the fact that you have now forgotten to think and evaluate each threat as it arises and are acting purely on instinct.

Anxiety works exactly the same way. The reason it arose was probably no fault of your own: you've probably lived through a war that required you to be on edge all the time. But now what? The circumstances changed and so must your thinking, otherwise you risk causing your own self more harm than the anxiety/worry/fear is worth.

In my job I meet a lot of people who give up on their own health due to anxiety. Sure, there are sometimes when I see the bravest of patients who present to me asking specifically for help to deal with the anxiety which they've realized is destroying their lives. I'm not talking about those people - they've already done the hardest part: they recognize their problem and have sought help for it. These people have victory guaranteed because they've already overcome the greatest obstacle! The people I am, however, wanting to discuss is those who still cannot identify their problem and believe their ill health is due to bad doctors, bad medicines, bad surgical procedures, etc.

Sometimes I see patients who refuse surgery for, for example, skin cancer. Why might they do that assuming they already know that cancer is a bad thing and they don't want to have it? Because the plastic surgeon who would remove the skin cancer from his face was a bastard and he wants nothing to do with him. Ok, so I suggest another surgeon. The second (and later third and fourth) is also a bastard! Wait, wait, wait, what's going on? Eventually I find out that the patient is really terrified of having surgery on his face - and until he gets over his fear of facial disfigurement every surgeon will keep being a bastard! I've seen the same time and time again with patients who have gynaecological problems, gastroenterological problems, cardiological problems, haematological and almost every other type of medical problem. I've had specialists ask that I please re-refer patients after they've had psychotherapy to deal with their anxiety. It ends up delaying treatment, and some patients go on to refuse treatment altogether.

What can I do? Many patients you just can't convince that it's not that every doctor is a bastard or has mistreated them. You can ask the questions and have the evidence right in front of them that this person has a debilitating anxiety problem but same as you can bring a horse to water but can't make him drink it, you just can't help those who refuse to acknowledge their greatest problem. What I sometimes do is tell my patients about these troubled army troops that keep attacking benign enemies and end up causing themselves greater harm than the "enemy" ever could. Do you think these troops might benefit from some retraining to help them better evaluate the enemy and launch and adequate response when it's due? Yes? I'd like to do the same for you, and I know just the person to help you with some retraining. This person's role is called a psychologist. Seeing him is not a sign of weakness but rather about redirecting your strengths where they're actually needed.

It is always such a shame to see people walk away with gynaecological cancers, thyroid cancers, valvular heart disease, severe renal failure, etc. who keep telling me that they'd rather die than see another horrible specialist. What I hear is 'I'd rather die than deal with my anxiety'. It's such a shame.

On "the boat people"

Someone asked me the other day what I think about refugees, specifically the illegal immigrants that enter Australia on boats and are intercepted by Australian authorities. These last specifiers are important because they make this situation particularly unique. It’s no secret, and I consider this absolutely nothing to be ashamed about, that I entered Australia as a refugee from a war-torn country. I, however, find it difficult to form an opinion about the so-called “boat people” given that my family and I all entered the country legally on a comfortable passenger plane, were granted permanent resident status immediately on arrival, were escorted from the airport to a furnished and fully-stocked home in inner-city Brisbane, and received so much governmental support with negotiating a new country and a new language. The illegal immigrants I was asked about, although both refugees, are in a such completely different scenario that I find it personally hard to put myself in their shoes… And yet, so many people who are so much less qualified than even myself find it too easy to comment on “the boat people”.

A colleague once asked ‘why don’t illegal refugees from south-east Asia and other countries do what people from wealthier countries do?’ You know, just buy a plane ticket and come to Australia on tourist visas which they can then overstay and support themselves and escape the authorities however best they can. She suggested this would solve the issue of the Australian government having to process these illegal immigrants’ after-arrival applications to remain in Australia as refugees. Then Australian taxpayer’s money also wouldn’t be “wasted” on arresting and then housing refugees in detention centres, etc. Well, if you’re a citizen of certain countries, it’s actually quite difficult to get a tourist visa to Australia to overstay, and thus getting on a boat for illegal migration is much cheaper and easier despite all its inherent dangers. Well, this colleague suggested, why don’t the boats filled with illegal immigrants just get turned away or their passengers put on planes back to their own countries of origin before their stories/reasons for migration are heard. The reason for that is that would give the Australian government a bad human rights record… Oh yeah, it might actually be a violation of human rights.

So what do I know about refugees? I know that it must be a difficult decision to make to migrate to a country where the only certainty is that it’s not your own country (ideally for the better). When my family lived in El Salvador, people were migrating illegally into the surrounding countries, mostly northbound to the U.S.A. Around the time we left for Australia, the majority of people migrating illegally into the U.S.A. were leaving for the same reasons we were: seeking refuge from the hardships of war, the threats of death, and the intense poverty. Only a very very small minority were leaving “just for the hell of it”, and I believe perhaps no-one migrated illegally with the intention of hurting North-American citizens on their arrival. I also believe these broad categories/reasons remain true of all people who choose to migrate into another country. Why did my family migrate legally when others chose to do it illegally? Because we could. Why did others do it illegally when they could have done what my family did? Fear, lack of knowledge, I don’t know. I just don’t know. And I think that that’s the thing, that it is extremely hard to even imagine what it takes a human being to go through to make the choice where they consider it a lesser danger to hand over non-refundable money to an illegal human trafficker in order to board a shabby boat for a rough sea journey to a place you’ve never been to that speaks a language you don’t understand. How horrible must the other options have been?!

How do I feel about the “boat people”? A great curiosity to know their stories. And a wish that no person in this world had to suffer the hardships that lead most people to seek refuge in another country.