aamc.org does not support this web browser.
  • AAMCNews

    Nerves of steel, shaky stomachs


    Nikita Saxena, MD, a graduate of Boston University School of Medicine, has never flinched at the sight of blood. Needles? No big deal.

    But there is one gruesome sight that could always turn her stomach — an untreated diabetic foot wound.

    Saxena, now a pediatrics resident, still remembers it vividly from her geriatric and vascular rotations: The receding layers of skin. The exposed muscle, sometimes even bone. The acrid smell of necrotizing flesh. It took all her strength to successfully stifle every grimace and wince that bubbled to the surface.

    Saxena says she has never been squeamish. She is, however, human.

    “There are always situations in the hospital that you aren’t prepared for. Seeing someone getting a vaccine or a cut is different from some of the crazy things you see as a med student,” Saxena said. “Just being uncomfortable in certain patient care settings is really common among students.”

    And some doctors-in-training have it much worse than Saxena, getting ill at the mere thought of bodily fluids. Fainting is also not uncommon.

    In fact, a 2009 study of 630 clinical students in the United Kingdom found that 77 had at least one near or actual fainting incident while observing a surgery. Of those, 44 said they intended to pursue a surgical career. The most common factors at play were excessive heat, standing for too long, wearing a surgical mask, and the smell of cauterization.

    We asked the experts about squeamishness — what it is, why it exists, and what medical students can do to combat it.

    Why do we get grossed out?

    We all know there’s a universal “ick” response when we’re exposed to gore, but why? One theory goes back to our ancestors, according to Joseph LeDoux, PhD, professor of neuroscience at New York University. “One of the reasons we’re afraid of heights is because our ancestors lived in trees, and falling out of a tree could be dangerous,” says LeDoux. “Seeing blood obviously reflects something bad happening around you.” Those organisms that are more sensitive to blood — and therefore more likely to identify danger and move away from it — are more prone to survive, he says.

    But there can always be too much of a good thing. Some of us have evolved to possess a heightened aversion to certain signals of danger. Sometimes, the hyper-sensitivity is tied to a traumatic event from childhood, says Eric Bui, MD, PhD, acting director of the Center for Anxiety and Traumatic Stress Disorders at Massachusetts General Hospital. “This might have been a visit to a doctor or an accident, and, as a child, the person experienced intense fear. At that time, blood became associated with danger, and this association has persisted.”

    To top it off, some of us have a fainting response when we see blood, which also makes sense from an evolutionary standpoint: if we are losing blood, a drop in blood pressure and heart rate will prolong our lives. In the operating room, though, that response is less useful.

    When someone particularly sensitive to gore sees blood or related images, it is human nature to have automatic negative thoughts, according to Andrea Batton, LCPC, clinical director of the Maryland Anxiety Center. She calls these “thinking errors” or “thinking traps.” Those thoughts cause the person to run away or avoid the feared substance. “When you have a fear of blood or something gross or seeing internal organs, once you develop that fear you have an aversive response, and that can become a conditioned response,” Batton says. “The person will escape or avoid. It’s maintaining the cycle of fear and avoidance.”

    Fighting the fear

    So how can an aspiring doctor conquer a fear that’s so ingrained?

    • Food for thought: Staying fed and hydrated can help prevent a fainting episode, according to the Cleveland Clinic. Foods higher in sodium can especially help avoid fainting if they’re eaten before exposure. “Salt will also expand your blood volume by retaining fluids in the venous circulatory system and preventing a drop in your blood pressure,” according to the clinic. But it’s best to stick to smaller meals: “When you eat a large meal, more blood is routed to your abdomen, which will reduce the amount of blood circulating in the body.” If you do feel like you’re going to faint, though, make sure you are in a safe place — preferably sitting in a chair with your head between your legs.
    • Go with the flow: One method used to overcome fainting is called the applied tension technique: exposing someone to blood or needles and immediately putting them through a series of small muscle-tensing motions. This increases the blood flow to the brain and eventually changes their physiological response, says Martin Antony, PhD, professor of psychology at Ryerson University in Toronto, Ontario, and author of Overcoming Medical Phobias: How to Conquer Fear of Blood, Needles, Doctors, and Dentists. Those movements can be used at any given time to fend off feelings of faintness, he says. “Tensing all the muscles in the body can increase blood flow to the brain, and that can help people in the moment.”
    • Just breathe … but not too slowly: For people battling anxiety, slow and steady breathing might serve as a calming technique. But that may be counterproductive for people who feel faint, Antony says. “The last thing you want is to slow down your heart rate and lower your blood pressure” if you’re at risk of passing out, he says. Another self-soothing tool — distraction — might help at the time but hurt in the long-run, he says. It is best to focus on the stimulus that is causing the discomfort and slowly become more comfortable with it.
    • Face it: “Exposure, exposure, exposure,” says Batton. The process can be slow or fast, depending on what works best for the person battling his or her fear. It might start with saying the word “blood,” then writing it, then looking at an image of blood and eventually looking at an image of a wound. “When you look at the image, you get used to it, like you do to cold water in a pool,” Batton says. “Something happens that’s called inhibitory learning: every time you’re exposed you learn you’re safe, that you can tolerate that distress. The new learning trumps the old.”
    • Don’t bolt: The worst thing to do, unfortunately, is what comes most naturally — avoid the trigger.  “If I’m afraid of blood and I go and watch a surgery, and I leave, I’m maintaining that cycle,” Batton says. “The worst thing that’s going to happen is that person is going to escape and self-soothe.”

    What can medical schools do?

    Because squeamishness is so common, several medical schools offer specialized coaching to help students overcome those limitations.

    Mayo Clinic School of Medicine, for example, has a comprehensive program that includes student counseling, academic success coaching, and a focus on student wellness. “Students experiencing these types of squeamish issues (or other physical or mental issues around their learning) would have access to counselors and an academic success coach to help them develop coping mechanisms,” says Deb Anderson, a Mayo Clinic spokesperson. “Our faculty are also great front-line mentors who often help students realize that some of these types of reactions are perfectly normal as part of the training process.”

    Beyond that, “medical schools could offer some cognitive behavioral therapy,” says LeDoux — a type of treatment that aims to challenge problematic beliefs and behaviors.

    Even something as small as assuring squeamish students they’re not alone can help. “Acknowledging that the fear of blood is extremely frequent in the general population, and that this condition will improve as people are increasingly exposed to blood during their medical training, can be helpful,” says Bui.