I stood in the operating room hallway at a very early hour, thinking about everything that could go wrong with my latest emergency surgery. All the bad scenarios rushed through my head; excessive bleeding, infection, injury to another organ, anesthesia complications, and on and on.

That may sound like I was “stressing out.” Nothing could be further from the truth. Rather than stressing, I was practicing Defensive Pessimism.

The Story

The patient had been failing in the ICU for the last several hours. Unsure what else to do, the ICU doctor had called me to ask if I thought the source of the problem was in the abdomen and would a surgery help.

After seeing the patient and reviewing the studies, I believed that surgery was the only way to save this patient. But that did not mean it would be easy or low risk.

Part of my concern was the realistic assessment that the patient might not survive this “Hail Mary operation.” This was a situation where the only justification for such a risky surgery was that the patient would surely die without it. For me, the downside of operating was that if she died in surgery or after, it would now look like it was my fault.

How Not to Think

At times like this, it’s easy to let your mind spiral down an unproductive path.

“She could die. It will look like your fault. You will get sued. You’ll lose everything in the settlement and end up dying alone under a bridge.”

That is catastrophizing and it is not a productive way to think, but it does help me recognize how anxious I am about the situation.

The question is not, “Am I anxious?” The helpful question is, “What can I do?”

The Positive Value of Negative Thinking

There is a positive value to thinking about negative things. That may sound sacrilegious in the positive culture of America, where people try to cheer you up by saying, “Don’t worry, I’m sure it will be fine.” But that kind of positive thinking will not help me in this situation because there is a genuine possibility that it will not be okay. So how should I think?

At times like this, I find it most helpful to use Defensive Pessimism. It can be summed up in an old surgical maxim, “Hope for the best; plan for the worst.” So that is what I do. I stand in the hall, and I think of all the things that could do wrong. Then I realistically assess how likely each one of those adverse outcomes could be. Take bleeding as an example. We may have blood loss during the operation. How likely is that, and how much are we likely to lose? As I think this through, I decide whether I want to send a blood sample to the lab in case we need to crossmatch blood or do I want to have blood available in the operating room before we begin.

Meanwhile, back in the OR…

I work through the other problems that could occur. I assess how likely each one is and how I will respond if I encounter that difficulty. Then I make a list of items I want to have available during the operation. Those items I plan on using, I want to have available on the instrument table before the procedure begins. I am less likely to want other instruments but may need them if problems occur, so I request the nurse have those available in the room.

Now that I have thought through what could go wrong, I share my thoughts with the operating room crew, so we are all prepared. I also talk with the anesthesiologist who has concerns of his own. We work together to get as prepared as we can. And then the patient arrives.

Premortem

What I am doing with the operating room team is called a premortem. We are thinking ahead to all the things that could go wrong and lead to disaster. Then we work backward to plan how we will respond if that happens.

It may sound like we are pessimistic, but I don’t think that is accurate. We are realistic. The pessimist would say, “She’s going to die anyway. So what is the point.” The optimist would say, “Don’t worry, you’ve done this before and it turned out fine.” The defensive pessimist differs from those two in that they don’t expect to fail, but they also do not assume that prior success assures future success. Or, as one of my surgery professors liked to remind me before starting an operation, “There is a snake in every gulch.” Meaning even the routine procedure has a potential for disaster if you aren’t watchful.

What is Defensive Pessimism?

Dr. Julie Norem at Wellesley College has been studying defensive pessimism, which she defines as “…a strategy for dealing with anxiety and helping to manage anxiety so that it doesn’t negatively influence performance.” In other words, it’s using your anxiety about a situation to help you prepare and perform better. It also allows you to moderate your expectations, so events don’t surprise you when things go wrong. Making you better able to respond constructively.

Self-handicapping vs. Defensive Pessimism

Defensive pessimism is not the same as self-handicapping. Like defensive pessimism, self-handicapping also involves expecting the worst and lowering expectations. Unlike defensive pessimism, self-handicapping consists of a form of self-sabotage.

Let’s say you need to give a speech. A person who uses self-handicapping would assume they won’t do well. Expecting failure anyway, they would not see the point in preparing. Then when their self-sabotage leads to them falling flat, they would tell themselves that it was their lack of preparation that caused the failure — leaving them free to believe that they are still a capable person.

The defensive pessimist would also think about how their speech could go wrong. The opening joke might fall flat. The AV equipment could fail, or the IT person might lose the file with their slides. Rather than accept this as evidence they will fail anyway; the defensive pessimist comes up with contingency plans for each of these potential pitfalls. They prepare a comment if the joke bombs. Back up their slides on a drive they keep in their pocket. And even plan how to proceed without visual aids.

The fun part of being a defensive pessimist is that every contingency you planned for that doesn’t happen is a little win. Whereas the optimist has the opposite experience, everything that goes wrong is a significant problem for them. In the end, it is better to experience the pleasant surprise of things going well than the unpleasant surprise of waves where you expected smooth sailing.

It’s not a glass-half-empty strategy.

Defensive pessimism is not a glass-is-half-full-or-half-empty strategy. It is a realist assessment of the glass itself. The optimist looks at the liquid in the container and pronounces it half-full. In contrast, the pessimist looks at the amount of air in the glass and pronounces it half-empty. The Defensive pessimist takes in the whole. They see the glass full but full of a mixture of liquid and air, of potential good and bad. By seeing the whole picture, they can make a more realistic assessment of the situation and plan accordingly.

How to Put Defensive Pessimism to Work

The Two Strategies of Defensive Pessimism

1. Lower exceptions for how things will turn out. Imagine you are going on a family trip to Disneyland. Your family will love the rides, shows, and colorfully costumed character. But you will also have to endure waiting in lines, getting hot in the sun, and arguments over where to eat and what to do next. Accepting the reality of your trip’s ups and downs will allow you to set your expectations more realistically, so you won’t be surprised or disappointed by the actual experience. It is a matter of seeing the glass as full of a combination of air and water.

2. Vividly imagine all the things that could go wrong. On your trip to Disney, you could have car trouble. Space Mountain might be closed. It could rain, and the park food might give you indigestion. Recognizing these possibilities ahead of time allows you to plan. You can make sure the spare tire has air, pack raincoats and Tums. You can’t make them open Space Mountain, but you can find plenty of other great activities to enjoy.

Defensive Pessimism in Practice

Defensive pessimism is all about preparation. In surgery, I call this strategy “using Murphy’s law against him.” When you prepare for everything that can go wrong, little does go wrong, and what does is not a big deal.

1. Imagine what could go wrong. Think through all of the things that might trip you up. What is the worst-case scenario? How bad could it get? How likely is that to happen? The point of this is not to make you feel bad or give up. The point is to identify all the potential pitfalls and the likelihood that they will occur realistically.
2. Visualize it as happening right now. Don’t just think about it happening; imagine it as vividly as you can. How would you feel if only a few miles from Disney, the car slid to stop on the shoulder of an insanely busy freeway? How would the rest of your family react? Take the time to put yourself in that situation and feel the disappointment, frustration, and fear that situation would induce.
3. Stay calm and ask yourself, “What is the best thing I could do in that situation?” Mentally rehearse yourself staying calm. Think about what you would say. How would you comfort the kids? What steps would you take to keep your family safe and get yourselves moving again? Who would you call for help?
4. Prepare for the worst. Think like a Boy Scout and “be prepared” for the scenarios you have envisioned. That means packing the supplies you may need in an emergency. It also means making yourself mentally prepared to respond in a positive, productive way rather than melting down.
5. Repeat. Repeat steps one through four for every contingency.

The End of the Story

Standing outside the operating room, I went through each problem I identified. I thought about losing a lot of blood. I recognized that it was unlikely but had a sample of the patient’s blood sent to the blood bank to be available for crossmatching if we needed it. Then I asked the nurse to bring an instrument into the room that would help me to limit bleeding.

I worked through each potential problem in my head. I visualized myself staying calm and working through the problem. I asked myself what I needed to do to minimize the risk and made sure I had all the materials available I might require. Then I shared my concerns and plans with the other people in the room and listened to theirs.

I was able to identify and remove the source of infection that was making the woman so sick. I did not encounter any significant problems. Once again, being prepared for Mr. Murphy had kept him at bay. The patient remained wildly unstable for the next twenty-four hours. But I had known that could happen. I also knew that I had done the best I could in this challenging situation. I trusted that my preparation made it possible for me to give this woman the best surgery possible. And I slept well that night, despite the patient’s rocky course.

Over the following day, her vital signs improved, and her condition stabilized. She left the hospital ten days later. Since then, I have seen her back in my office twice, and she has made a full recovery. Another victory for defensive pessimism and the surgical maxim, “Hope for the best, prepare for the worst.”

Defensive pessimism is not assuming the worst. Instead, it is a realistic assessment of what can go wrong and preparing yourself in advance to deal with it if it does. It’s about moderating your expectations, visualizing yourself in that situation, and rehearsing staying calm and working on the problem. It is also about taking whatever preemptive action you can to minimize risk and have a backup plan if disaster strikes. In the end, it is better to be pleasantly surprised when most of the bad things you anticipated don’t materialize, then disappointed when you expected all to go perfectly and it did not.