The heaviest burden is great potential

I have severe performance anxiety and fear of failure -- or is it fear of success?

Published May 12, 2003 7:45PM (EDT)

Dear Readers,

First, I meant to mention in the letter to the woman about breast-reduction surgery that it can interfere with breast feeding later in life, so anyone considering having children should bear those consequences in mind.

Also, I'm taking a couple of weeks off from the column to finally finish my novel. The column should resume on Wednesday, May 28. Please continue to write to; I look forward to reading all your letters upon my return. And if you want to read past columns, go to the directory.

Dear Cary,

I need some perspective on exam anxiety.

I grew up being told I was very bright, and I did well without trying at the easy things. Lots of outward privilege and inflated expectations with little inner grounding. Mentally ill mum, loving but overwhelmed, professionally high-functioning but (inwardly wounded WWII vet) alcoholic dad, me taking on too much as the eldest and only daughter to keep up the appearance of normalcy throughout my adolescence and thinking that was normal.

Left home for Ivy League university, fell on face, failed first year, worked for a year, went back and failed again. I was depressed the second year. I was shattered, thought I had killed my hopes, and blamed myself. I didn't question why my parents never sat me down to talk about it once. I just felt like an unthinkably selfish and immature little rich kid who blew away opportunities others never get.

Moved out on my own, waitressed and volunteered with disabled teens, and slowly gained perspective and became passionate about issues related to disability and access and took sign language and saw the world differently. Achieved professional success in an almost fairy-tale way doing what I loved; got promoted away from the direct people contact and into managerial roles and realized I was in a success trap. I did a ton of volunteer work to fill this unmet need and was a very, very busy woman in my 20s. Had a long-term relationship with a guy who loved me only or best as a waitress, was frustrated by my changes. We were both too insecure to let go for a long time, but finally I ended it after six years.

I had gone back to university part time and almost completed a degree when I had a revelation that I wanted to go to medical school. I quit my job and went back to university full time at age 30 to finish my undergrad. I was terrified. My scary school history resurfaced and I got into therapy with a wonderful doctor who said I'd make a good doctor. I felt that catch in my heart and an almost painful joy I have never forgotten.

Flash-forward three years: I finish the degree, have a successful small consulting business, and am accepted into medical school. I leave my therapist and another not-destined-to-be-the-one and head off to school, having, I think, forgiven my family and myself, all fixed and ready for launching (the old university record having been expunged because I had been clinically depressed).

Cary, I have fallen on my face many times since then. I disgraced myself by failing my final med school exams twice (I let myself get overwhelmed, prepared in a frenzied fashion, and panicked in the exams). I have since passed my other national exams and my American pediatrics exams and have done the average score in oral exams for the past few times.

I had a few early tear-stained meetings with my advisor and a few other faculty members in whose presence I go into a kind of paralysis of insecurity and so have not distinguished myself. I have accepted their disgust at me as justified professionally and I have told myself that I don't need their acceptance as a person. I have never behaved unprofessionally and have never neglected my professional responsibilities. I am a team player and I think I am seen as such. I also have a few very good friends in the program and a long-standing small group in my hometown.

I think I am seen as a nice person who cares about her patients and who is, unfortunately, rather stupid or academically lazy. I live a kind of double life in which I'm pretty normal and accepted as such by my significant other, friends and family, but here I'm middle-aged, single and thus oddball to begin with.

In the midst of medical school, my mother, long since widowed and living 300 miles away, got Parkinson's, then deteriorated and started having bad falls in her home. By year three of residency, I negotiated a leave to get her moved, but it got more complicated medically and I had to take a six-month unpaid leave to sort it out and that set back graduation by a year.

I am a bit disorganized about studying and I have trouble surfacing my knowledge in a predictable way. It's obviously worse when I'm anxious. My retention is not very good and it takes me a long time to get it in. My approach has been to keep throwing stuff at the barn door to make sure the door is covered. There's a huge amount of shit, however, and it keeps drying up and falling off. It drives me crazy when I get flustered and can't pull it off, so to speak.

I think the culture of residency involves a kind of social Darwinism. All my years of working sensitively and respectfully with a variety of people did not prepare me for being seen as the weakest link when I was honest about my deficiencies. Although officially self-assessment is considered part of professional integrity, really it's social suicide except in a strategic way (e.g., "I can't make myself go home post-call because I can't bear to miss clinic"). So I have been stupid to not have a better handle on this. I know others who are better at dissembling. Fundamentally, I find that boring and insecure. So I guess I have my own kind of arrogance! There are some real people I've worked with and they are all better doctors, which speaks for itself.

I am now two weeks away from my final of three board certification exams to become a pediatrician. I have to pass two out of three. Nos. 1 and 2 were yesterday and the day before. I worked very hard over the past four months and quite hard over the past year to get ready. I had to write the exams with my non-dominant hand because the other was casted for a fracture. I asked for and got extra time, which helped a lot. I also took a beta blocker in consultation with my family doc for one of them, and I think it helped.

I still made stupid mistakes I recognized when I left, both days. I think I was much more wired than I recognized. My gut tells me I failed the first, but probably not the second, so now it's down to the wire. And I am very scared. I have a loving partner who also lives in my hometown and who is not here by necessity. He knows and accepts me and loves me (and I think he's the keeper).

But if I fail, I have to wait a year to do all three exams again. I have no job in that case, huge, huge debt and ... well, you get it.

I'm wondering if I am ambivalent about succeeding. I'm terrified that maybe I could decide anything to get past the uncertainty. Choking would control the outcome, even at a huge price. I am so tired and I think I'm angry at the bull and the way faculty people keep talking about how no one from this university fails the final exams.

I'm 43 and I want to be my own best ally in the next two weeks. I think I know I can deal with failure if it turns out that way. I just need to know I gave it everything I had and in a spirit of self-respect, because I do see myself as courageous, if courage means doing the thing you are afraid of. I would obviously rather be courageous and successful. Have I mentioned that I love medicine? I do, even if residency has been a very painful growth experience.

If you have any words of wisdom for me, they would be most appreciated. If you think I'm an ass, please don't hesitate to say so. If it's curable, that is.

Down to the Wire

Dear Down to the Wire,

When I first got your letter, because your exam was approaching rapidly and you seemed to be at a point of personal crisis, I sent you a one-word reply: "Pray." I knew making such a reply was a risk. It could have been taken as cheeky gallows humor; it could have been taken as a slap in the face. You never know how someone feels about being told to pray. There were many qualifications that as a secular humanist I instinctively wanted to make. But it was more important to be clear about what I was suggesting. I was not suggesting that you think about prayer, or read about it, or discuss it. I was suggesting that you do it.

I was glad to hear in your reply that you actually did it, and I was relieved to hear that you're feeling a little less anxious now. My own relationship with prayer is sort of Southern and twisted. I grew up in an agnostic family in a sort of theocratic village where Christian madrassas were run by Pentacostal mullahs. And yet, it was out of a desperation analogous to yours that many years ago I took to a nondenominational brand of prayer and it's still something I do in a pinch because smoking a joint and having a bourbon is no longer an option. I'm not a religious person, really, but prayer, if you know how to do it, can be a very useful thing.

What struck me about your letter was that it was so full of the pain of self-expectation. It caused me to ask: Will we ever be enough for ourselves? What will it take to fulfill our own impossible expectations? Why is it that the most talented and driven end up the least satisfied, the most disappointed? I sense a dynasty of shadows towering over you, a family of the great and strong whose expectations you have drunk with your mother's milk, whose values you wear like a gift of clothes that you dare not refuse.

It sounds like a family in which failure is not allowed. So I would say there is nothing more liberating than reclaiming your right to failure and openly inviting the world's most withering judgment. I'm talking about affirmative failure, proudly claiming the right to fail as one claims the right to marry or to speak one's mind. Because what is it but the right to be fully human? Celebrate failure and error! Embrace the withering judgments of mortals!

If you fail the exam, or if you pass the exam, there's still a universal exam held every day, for which you study all the time. Every time you drop your coins on the sidewalk or get turned down for a job or somebody cuts you off on the road, you're taking the universe's pop quiz on minor adversity. And every now and then there's the big exam on the subject of getting the one thing in life you really want; and again, whether you get what you want or don't get you want, what you do about it is still the test that matters.

Here's another quick thought: The important thing is not how you distinguish yourself, whatever reputation you achieve for yourself, but whether you're able to do any good in the world. It doesn't matter what people think of you and your achievements. What matters is whether you are actually useful to anyone else. It sounds as though you have equipped yourself, through your educational efforts, to make yourself supremely useful in the world, regardless of whether you pass the licensing exams.

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Want more advice from Cary? Read Friday's column.

By Cary Tennis

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