How to Be Fearless

A philosophical cure for fear and anxiety

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“Anxiety” said the philosopher Søren Kierkegaard, “is the dizziness of freedom.” What could he have meant by that?

Anxiety can be defined as “a state consisting of psychological and physical symptoms brought about by a sense of apprehension at a perceived threat.”

Fear is similar to anxiety, except that with fear, the threat is, or is perceived to be, more concrete, present, or imminent.

Fear and anxiety can, of course, be a normal response to life experiences, protective mechanisms that have evolved to prevent us from entering into potentially dangerous situations and to help us escape from them should they befall us regardless.

For example, anxiety can prevent us from coming into close contact with disease-carrying or poisonous animals, such as rats, snakes, and spiders, from engaging with a much stronger or angrier enemy, and even from declaring our undying love to someone who is unlikely to spare our feelings.

If we do find ourselves caught in a potentially dangerous situation, the fight-or-flight response triggered by fear can help us to mount an appropriate response by priming our body for action and increasing our performance and stamina.

In short, the purpose of fear and anxiety is to protect us from harm and, above all, to preserve us from death—whether literal or figurative, biological or psychosocial.

On the other hand, severe or inappropriate anxiety can be maladaptive, preventing us from doing the sorts of things that most people take for granted, such as leaving the house or even our bedroom. I once treated a patient with an anxiety disorder who, to avoid ever having to leave his bedroom, urinated into a bottle and defaecated into a plastic bag.

Such pathological anxiety is very common and often presents in one or more distinct patterns or syndromes, such as phobia, panic disorder, or post-traumatic stress disorder (PTSD).

As with the adaptive forms, these pathological forms of anxiety can be interpreted in terms of life and death. Common phobias such as arachnophobia (spiders), ophidiophobia (snakes), acrophobia (heights), achluophobia (darkness), and brontophobia (storms) are all for the sorts of dangers that commonly threatened our ancestors. Today, man-made hazards such as motor cars and electric cables are much more likely to strike us, but most phobias remain for natural dangers, presumably because man-made hazards are too recent to have imprinted themselves onto our genome.

Panic disorder involves recurrent panic attacks during which symptoms of anxiety are so severe that the person fears that he or she is suffocating, having a heart attack, or losing control. Very soon, the person develops a fear of the panic attacks themselves, which in turn sets off further panic attacks. A vicious cycle takes hold, with the panic attacks becoming ever more frequent and severe and even occurring “out of the blue.”

As with phobias, the ulterior fear in panic disorder is of death and dying, as it is also with PTSD, which is a reaction to a traumatic life event, such as a car crash or physical or sexual assault. Common symptoms of PTSD include anxiety, of course, but also numbing, detachment, flashbacks, nightmares, and loss of memory for the traumatic event.

The symptoms of PTSD vary significantly from one culture to another, so much so that PTSD is sometimes thought of as a “culture-bound syndrome.” Culture-bound syndromes are essentially culture-specific anxiety disorders, which, again, like all anxiety disorders, can easily be understood in terms of life and death.

Dhat, for example, seen in South Asian men, involves a sudden fear about the loss of semen in the urine, whitish discoloration of the urine, and sexual dysfunction, accompanied by feelings of weakness and exhaustion. Dhat may be rooted in the old Hindu belief that it takes 40 drops of blood to create a drop of bone marrow, and 40 drops of bone marrow to create a drop of semen, and thus that semen is a concentrated essence of life.

In addition to fear and anxiety and their pathological forms (such as phobias, panic disorder, etc.), there is a more abstract or philosophical form of anxiety that has been called “existential anxiety.” While fear and anxiety and their pathological forms are grounded in threats to life, existential anxiety is rooted in the brevity and apparent meaninglessness or absurdity of life, that is, in a kind of metaphorical death.

As I argue in my new book, Heaven and Hell: The Psychology of the Emotions, existential anxiety is so disturbing that most people avoid it at all costs, constructing a false reality out of goals, aspirations, habits, customs, values, culture, and religion in a bid to deceive themselves that their lives are special and meaningful and that death is distant or delusory.

Unfortunately, such self-deception comes at a heavy price. According to the philosopher Jean-Paul Sartre, people who refuse to face up to “non-being” are acting in “bad faith” and living out a life that is inauthentic and unfulfilling.

Facing up to non-being can bring insecurity, loneliness, responsibility, and, consequently, anxiety, but it can also bring a sense of calm, freedom, and even nobility. Far from being pathological, existential anxiety is a necessary transitional phase, a sign of health, strength, and courage, and a harbinger of bigger and better things to come.

For the philosopher and theologian Paul Tillich, refusing to face up to non-being leads not only to inauthenticity, as Sartre had said, but also to pathological (or neurotic) anxiety.

In The Courage to Be, Tillich writes:

He who does not succeed in taking his anxiety courageously upon himself can succeed in avoiding the extreme situation of despair by escaping into neurosis. He still affirms himself but on a limited scale. Neurosis is the way of avoiding nonbeing by avoiding being.

According to this striking outlook, pathological anxiety, although seemingly grounded in threats to life, in fact, arises from repressed existential anxiety, which itself arises from our uniquely human capacity for self-consciousness.

Facing up to non-being enables us to put our life into perspective, see it in its entirety, and thereby lend it a sense of direction and unity. If the ultimate source of anxiety is fear of the future, the future ends in death; and if the ultimate source of anxiety is uncertainty, death is the only certainty.

It is only by facing up to death, accepting its inevitability, and integrating it into a life that we can escape from the pettiness and paralysis of anxiety, and, in so doing, free ourselves to make, and get, the most out of our lives.

This esoteric understanding is what I have come to call “the philosophical cure for fear and anxiety.”

Feelings About the Self: Embarrassment, Shame, and Guilt

shame

The psychology of the reflexive emotions, and the difference between them.

Embarrassment, shame, and guilt are all three reflexive emotions, that is, emotions about the self.

Although there is some overlap, embarrassment, shame, and guilt are distinct constructs.

Let’s look at them each in turn.

Embarrassment

Embarrassment is the feeling of discomfort when (1) some aspect of ourselves is, or threatens to be, revealed to others, and (2) we think that this revelation is likely to undermine the image that we seek to project to those others.

Potential sources of embarrassment vary according to circumstances and, in particular, to the company in which we find ourselves. They include particular thoughts, feelings, or dispositions; actions or behaviors, such as farting or swearing; conditions or states, such as a spot on the nose or smelly feet; possessions, such as our car or home; and relations, such as our oafish partner, criminal uncle, or lecherous aunt.

Sources of embarrassment need not be beneath our projected image, but merely out of keeping with it—which explains why it is possible, at times, to be embarrassed by our posh parents or rarefied education.

Shame

Whereas embarrassment is a response to something that threatens our projected image but is otherwise morally neutral, shame is a response to something that is morally reprehensible.

Shame is often accentuated if its object is exposed, but, unlike embarrassment, also attaches to a thought or action that remains undisclosed and undiscoverable to others. Embarrassment can sometimes be intense, but shame is a more substantial feeling in that it pertains to our moral character and not merely to our social character or image.

Shame arises from measuring our actions against moral standards and discovering that they fall short. If our actions fall short and we fail to notice, we can “be shamed” or made to notice—an extreme example being Cersei Lannister’s Walk of Shame in Game of Thrones. If having been made to notice, we do not much mind, we can be said to be shameless, or to “have no shame.”

In the Rhetoric, Aristotle, ever the fine psychologist, remarks that shame also arises from lacking in honorable things shared by others like us, especially if the lack is our own fault and therefore owes to our moral badness.

Finally, it is possible to feel shame vicariously, that is, to share in the shame of another person or feel shame on his or her behalf, especially if this person is closely allied or associated with us: for example, our partner, sibling, or child. Thus, even blameless people can experience shame, and so much is also true of embarrassment and other emotions. “Hell,” said Jean-Paul Sartre, “is other people.”

Try, right now, to act out the feeling of shame. The word “shame” derives from the Proto-Indo-European for “to cover,” and the feeling of shame is often expressed by a covering gesture over the brow and eyes, a downcast gaze, and a slack posture. Other manifestations of shame include a sense of warmth or heat and mental confusion or paralysis. These signs and symptoms can communicate remorse and contrition and, in so doing, inspire pity and pardon.

Even so, we may prefer to make a secret of our shame, for shame can itself be shameful—or, to be more precise, embarrassing.

People with low self-esteem, being harsher upon themselves, are more given to shame. In some cases, they may defend against shame with blame or contempt, often for the person or people who incited their shame. This is only likely to lead to deeper shame, and therefore to lower self-esteem, opening up a vicious cycle—which might be broken if, like certain politicians, they stop feeling shame at all.

While overwhelming shame can be destructive, mild to moderate shame is mostly a force for good, goading us to live more ethical lives.

In Dying for Ideas, the philosopher Costica Bradatan writes:

…the chief reason for studying philosophy is not a desire to know more about the world, but a profound sense of dissatisfaction with the state in which one finds oneself. One day you suddenly, painfully, realize that something important is missing in your life and that there is too large a gap between what you are and the sense of what you should be. And before you know it, this emptiness starts eating at you. You may not know yet what exactly it is that you want, but you know quite well what you do not want: remaining the person you currently are. You may be so ashamed that you don’t even dare to call that “existence”: you don’t exist yet properly. It must have been in this sense that Socrates used the term “midwifery” for what he was doing. By subjecting those around him to the rigors of philosophy, he was bringing them into proper existence. So closely related to self-detestation, it may be that philosophy begins not in wonder, but in shame.

Guilt

Whereas shame pertains to a person, guilt pertains to an action or actions and to blame and remorse. Shame says, “I am bad.” Guilt says, “I did something bad.”

More subtly, shame involves falling short of cultural or societal moral standards, whereas guilt involves falling short of one’s own moral standards. Thus, it is entirely possible to feel guilty about actions of which many or most of our peers approve, such as wearing designer clothes, driving a gas-guzzling car, or eating red meat.

As I discuss in my new book, Heaven and Hell: The Psychology of the Emotions, shame and guilt often go hand in hand, which is why they are so often confused. For instance, when we injure someone, we often feel bad about having done so (guilt) and, at the same time, feel bad about ourselves (shame).

Yet guilt and shame are distinct emotions. Shame is “egodystonic,” that is, in conflict with our desired self-image, and high levels of shame are correlated with poor psychological functioning. In particular, eating disorders and many sexual disorders can be understood as disorders of shame, as can narcissism, which can be construed as a defense against shame.

Guilt, on the other hand, is “egosyntonic,” that is, consistent with our self-image, and—except in extreme cases, such as that of the regicidal Lady Macbeth—is either unrelated or inversely correlated with poor psychological functioning.

Faced with the same set of circumstances, people with high self-esteem are more prone to guilt than to shame, and more likely to take corrective or redemptive action.

There is a fourth “negative” reflexive emotion, humiliation, which I will save for my next article.

Why We Garden: The Psychology and Philosophy of Gardening

Le_Jardin_de_Nébamoun.jpgIneni, architect to Pharaoh Thutmose I (d. 1492 BCE), had his garden painted into his tomb, along with a list of all the trees within it—presumably, so that they might be accounted for in the afterlife.

Ineni’s garden included:

  • 170 date palm
  • 120 doum palm
  • 73 sycamore fig
  • 31 persea
  • 16 carob
  • 12 grape vine
  • 10 tamarisk
  • 8 willow
  • 5 fig
  • 5 pomegranate
  • 5 garland thorn
  • 2 moringa
  • 2 myrtle

A grand garden of this sort symbolized control and mastery over nature, a haven of peace and plenty, of order and beauty, by which to project the status, power, and temperament of its owner. Other, more famous, examples include the Hanging Gardens of Babylon, the Gardens of the Real Alcázar in Seville, and the Gardens of Versailles.

The garden could also have a religious or philosophical message or dimension. For example, the Old Testament’s four rivers of Eden are represented by four watercourses in Islamic paradise gardens, and four paths in Christian cloister gardens. The Zen garden, by hinting at hidden principles, serves as an aid to meditation about the true meaning of existence.

The Gardens at Versailles reflect a rationalist, Cartesian vision of God-given ideas and principles for the intellect to apprehend or recognize, whereas English landscape gardens are more in the empiricist mold, presenting nature as a stream of sensory experiences skirting across the blank slate of the mind.

In either case, the garden represents a taming of nature, from dark and deadly forest, or disease-infested swamp, to an extension of our living space: open and structured to still our minds, but retaining enough mystery to sustain our interest and even, perhaps, capture our imagination.

Individual plants too can have a meaning. English churchyards often feature yew trees, which are poisonous, dark, and evergreen, and symbolize both death and immortality. A yew tree is commonly found near the lychgate, where, prior to the advent of mortuaries, cadavers guarded by vigils awaited burial.

In the ancient world, the palm tree symbolized victory, peace, and bounty, while the cedar of Lebanon symbolized pride, majesty, and dignity. Both also stood for righteousness, as in Psalm 92:12: “the righteous shall flourish like the palm tree, grow tall like the cedar of Lebanon.” Today, Cedrus libani is the national emblem of Lebanon, and a symbol of the peaceful Cedar Revolution of 2005.

Trees can also be planted to mark an important occasion, which is why British royals are often asked to brandish a shovel. In a recent annual tradition, the Friends of my local park purchase a noteworthy tree and invite a dignitary such as the Lord Mayor to plant it.

Today, gardening is more popular than ever. According to the National Gardening Survey 2018, more American households (77%) are gardening than ever before. In the U.K. 87% of homes have access to a garden, and 27 million people report a personal interest or active engagement in gardening, even if it is only on a balcony.

Sporting replacements of the BBC’s flagship Gardeners’ World achieve only a third of presenter Monty Don’s usual viewing figures of almost three million—which, in the U.K. is many more people than go to church.

Community garden projects and ‘guerrilla gardening’ are on the rise, as are garden towns and villages. Two years ago, one of my neighbours organized for thousands of daffodils to be planted on a neglected and overlooked common, transforming it into a Wordsworthian idyll for the selfie generation. I wonder, do they know that ‘daffodil’ is Narcissus in Latin?

Gardening is more and more recognized, and even prescribed, for its health benefits. These include: increased muscle strength and cardiovascular fitness; improved sleep and diet (if you grow your own produce); reduced stress, anxiety, and depression; a greater sense of community and belonging; and better self-esteem.

You don’t even have to get your hands dirty: some of these benefits accrue simply from visiting a garden, or even just looking over one—although it probably helps to notice and mentally engage with the greenery.

Researchers in Korea randomly assigned hospital patients recovering from thyroidectomy to rooms with plants and flowers, and rooms without, and found that the test group fared significantly better, asking for less pain relief and requiring less time in hospital. So yes, it makes sense to bring flowers, and, at home, to have indoor plants.

Even street trees greatly benefit our health. An American study looking at the city of Toronto found that, for cardio-metabolic conditions (heart disease, stroke, diabetes, obesity…), an increase of just 11 trees per city block compared to an increase in annual personal income of $20,000.

How might gardening help with mental health? To various degrees, we live inside the stories we tell ourselves. But gardening drags us out of our tortured heads and back into the natural world, which blunts the ideological and emotional extremes to which detached, abstract thought is prone.

In 1920, a mentally strained Ludwig Wittgenstein took up the post of assistant gardener at Klosterneuburg Abbey, explaining in a letter to a friend that he had been longing for “some kind of regularized work which, of all the things I can do in my present condition, is the most nearly bearable…”

Voltaire’s Candide (1759) is an attack on the highly abstracted, convoluted, and strained philosophy of Gottfried Wilhelm von Leibniz, and famously concludes with the phrase “we must cultivate our garden.”

In the Philosophy of Existence (1938), Karl Jaspers describes this disinterested process of looking outside oneself—or phenomenology, as it is sometimes called—as “a thinking that, in knowing, reminds me, awakens me, brings me to myself, transforms me.”

Just picture the gardener’s pure and simple delight at the first crocuses or tulips, a bird’s nest, a swarm of bees…

If gardening makes us feel better, it also makes us into better people. It is a moral education, a school of life, instilling virtues such as pragmatism, patience, perseverance, reliability, and humility, which then transfer out into other spheres.

In his treatise on agriculture (c. 160 BCE), Cato is quite clear that farmers make the bravest and strongest soldiers, and that, of all men, they are “the most highly respected, most stable, and least hated.”

In Plato’s Phaedrus (c. 370 BCE), Socrates compares the wise man to the good husbandman, who is careful to scatter the right seed in the right soil in the right season. Similarly, the good teacher is careful to sow the right words in the right soul at the right time. For Plato, the Divine Teacher, teaching is the gardening of the soul.

Building on these notions, Epicurus (d. 270 BCE) sought in his garden just outside Athens to return to an agricultural golden age of harmony, community, and self-sufficiency—to ground a flourishing life in the midst of a flourishing garden.

A garden is a microcosm of the outside world. Gardeners are acutely aware of the rhythms and cycles of nature: which flowers are in their prime, when to plant out the seedlings, when and how and how much it last rained. Just as music is time made audible, so the garden is “time made visible” [Clive James].

Winter is difficult, yes because it is dark and cold, but also because time is no longer structured by a succession of flowerings and fruitings. Time becomes amorphous, to be entertained and endured rather than savoured and celebrated like the season of magnolias, cherry blossom, rhubarb, plums, or chestnuts.

More than just keen observers of time, gardeners are real-life Time Lords, able to speed up time by working in the garden, and later to slow it right down by sitting back and surveying the fruits of their labour. Some gardeners are even able to step out of time altogether, working year round to create timeless moments of perfection.

But moments are all they will ever be. When you paint a picture or write a book, it is there for ever (and isn’t that just amazing?), but when you mow the lawn you have to do it all over again in just a few days’ time. The gardener is like Sisyphus, the mythological king made to repeat for all eternity the same meaningless task of pushing a boulder up a mountain, only to see it roll back down again.

In his essay of 1942, The Myth of Sisyphus, Albert Camus concludes: “The struggle to the top is itself enough to fill a man’s heart. One must imagine Sisyphus happy.”

Even in a state of utter hopelessness, Sisyphus can still be happy. Indeed, he is happy precisely because he is in a state of utter hopelessness, because in recognizing and accepting the hopelessness of his condition, he at the same time transcends it.

What We Can Learn From Loners

Loneliness is a complex and unpleasant emotional response to isolation or lack of companionship. The pain of loneliness is such that, throughout history, solitary confinement has been used as a form of torture and punishment. More than just painful, loneliness is also damaging. Lonely people eat and drink more, and exercise and sleep less.

Loneliness is a particular problem of modernity. One U.S. study found that between 1985 and 2004, the proportion of people reporting having no one to confide in almost tripled. According to a poll carried out in 2017 for the Jo Cox Commission on Loneliness, three-quarters of older people in the U.K. are lonely. Shockingly, two-fifths of respondents agreed with the statement, “sometimes an entire day goes by and I haven’t spoken to anybody”.

Some of the factors behind these stark statistics include: smaller household sizes, greater migration, higher media consumption, and longer life expectancy. Large conglomerations built on productivity and consumption at the expense of connection and contemplation can feel profoundly alienating. The Internet has become the great comforter and seems to offer it all: news, knowledge, music, entertainment, shopping, relationships, and even sex. But over time, it foments envy and division, confuses our needs and priorities, desensitizes us to violence and suffering, and, by creating a false sense of connectedness, entrenches superficial relationships at the cost of living ones.

Man has evolved over millennia into one of the most social and interconnected of all animals. Suddenly, he finds himself apart and alone, not on a mountaintop, in a desert, or on a raft at sea, but in a city of millions, in reach but out of touch. For the first time in human history, he has no practical need, and therefore no pretext, to interact and form attachments with his fellow men and women.

But, against nature, there are a few people who actively choose to remove themselves from the rest of society, or, at least, not to actively seek out social interaction. Such “loners” (the very term is pejorative, implying, as it does, abnormality and deviousness) may revel in their rich inner life or simply dislike or distrust the company of others, which, they feel, comes with more costs than benefits.

Timon of Athens, who lived at around the same time as Plato, began life in wealth, lavishing money upon his flattering friends, and, in accordance with his conception of friendship, never expecting anything in return. When he ran out of coin, all his friends deserted him, reducing him to the hard toil of labouring the fields. One day, as Timon tilled the earth, he uncovered a pot of gold, and, suddenly, all his old friends came piling back. But rather than welcome them with open arms, he cursed them and drove them away with sticks and clods of earth. Timon declared his hatred of humankind and withdrew into the forest, where, much to his annoyance, people began to seek him out as some sort of holy man.

Did Timon feel lonely in the forest? Probably not, because he did not believe he lacked for anything. As he no longer valued his friends or their companionship, he could not have desired or missed them—even though he may have pined for a better class of man, and, in that limited sense, felt lonely.

Loneliness is not so much an objective state of affairs as a subjective state of mind, a function of desired and achieved levels of social interaction and also of type or types of interaction. Lovers often feel lonely in the single absence of their beloved, even when completely surrounded by friends and family. Jilted lovers feel much lonelier than lovers who are merely apart from their beloved, indicating that loneliness is not merely a matter of the amount or degree of interaction, but also of the potential or possibility for interaction. Conversely, it is common to feel lonely within a marriage because the relationship is no longer validating or nurturing us, but diminishing us and holding us back.

And yet for many people marriage is, among others, an attempt to flee from their lifelong loneliness and escape from their inescapable demons. At the bottom, loneliness is not the experience of lacking but the experience of living. It is part and parcel of the human condition. Unless a person is resolved, it can only be a matter of time before the feeling of loneliness resurfaces, often with a vengeance. On this account, loneliness is the manifestation of the conflict between our desire for meaning and the absence of objective meaning from the universe, an absence that is all the more glaring in modern societies which have sacrificed traditional and religious structures of meaning on the thin altar of truth.

So much explains why people with a strong sense of purpose and meaning, or simply with a strong narrative, such as Nelson Mandela or St Anthony of the Desert, are protected from loneliness regardless of the circumstances in which they find themselves. St Anthony sought out loneliness precisely because he understood that it could bring him closer to the real questions and value of life. He spent fifteen years in a tomb and twenty years in an abandoned fort in the desert of Egypt before his devotees persuaded him to withdraw from his seclusion to instruct and organize them, whence his epithet, “Father of All Monks”. Anthony emerged from the fort not ill and emaciated, as everyone had been expecting, but healthy and radiant, and expired in his hundred and sixth year, which in the fourth century must in itself have counted as a minor miracle.

St Anthony did not lead a life of loneliness, but one of solitude. Loneliness, the pain of being alone, is damaging; solitude, the joy of being alone, is empowering, liberating. Our unconscious requires solitude to process and unravel problems, so much so that our body imposes it upon us each night in the form of sleep. By removing us from the constraints, distractions, and influences imposed upon us by others, solitude frees us to reconnect with ourselves, assimilate ideas, and generate identity and meaning.

For Nietzsche, men without the aptitude or opportunity for solitude are mere slaves because they have no alternative but to parrot culture and society. In contrast, anyone who has unmasked society naturally seeks out solitude, which becomes the source and guarantor of a more authentic set of values and ambitions:

I go into solitude so as not to drink out of everybody’s cistern. When I am among the many I live as the many do, and I do not think I really think. After a time it always seems as if they want to banish my self from myself and rob me of my soul.

Solitude removes us from the mindless humdrum of everyday life into a higher consciousness which reconnects us with our deepest humanity, and also with the natural world, which quickens into our muse and companion. By setting aside dependent emotions and constricting compromises, we free ourselves up for problem solving, creativity, and spirituality. If we can embrace it, this opportunity to adjust and refine our perspectives creates the strength and security for still greater solitude and, in time, the substance and meaning that guards against loneliness.

The life of St Anthony can leave the impression that solitude is at odds with attachment, but this need not be the case so long as the one is not pitted against the other. True lovers, says RM Rilke, should not only tolerate but “stand guard over” the solitude of the other.

In Solitude: A Return to the Self, the psychiatrist Anthony Storr convincingly argues that:

The happiest lives are probably those in which neither interpersonal relationships nor impersonal interests are idealized as the only way to salvation. The desire and pursuit of the whole must comprehend both aspects of human nature.

Be this as it may, not everyone is capable of solitude, and for many people aloneness will never amount to anything more than bitter loneliness. Younger people often find aloneness difficult, while older people are more likely, or less unlikely, to seek it out.

So much suggests that solitude, the joy of being alone, stems from, as well as promotes, a state of maturity and inner richness.

12 Tips from Neel Burton for Acing Your OSCEs

  1. Don’t panic. Be philosophical about your exams. Put them into perspective. And remember that as long as you do your bit, you are statistically very unlikely to fail. Book a holiday to a sunny Greek island starting on the day after your exams to help focus your attention.
  2. Read the instructions carefully and stick to them. Sometimes it’s just possible to have revised so much that you no longer ‘see’ the instructions and just fire out the bullet points like an automatic gun. If you forget the instructions or the actor looks at you like Caliban in the mirror, ask to read the instructions again. A related point is this: pay careful attention to the facial expression of the actor or examiner. Just as an ECG monitor provides live indirect feedback on the heart’s performance, so the actor or examiner’s facial expression provides live indirect feedback on your performance, the only difference being – I’m sure you’ll agree – that facial expressions are far easier to read than ECG monitors.
  3. Quickly survey the cubicle for the equipment and materials provided. You can be sure that items such as hand disinfectant, a tendon hammer, a sharps bin, or a box of tissues are not just random objects that the examiner later plans to take home.
  4. First impressions count. You never get a second chance to make a good first impression. As much of your future career depends on it, make sure that you get off to an early start. And who knows? You might even fool yourself.
  5. Prefer breadth to depth. Marks are normally distributed across a number of relevant domains, such that you score more marks for touching upon a large number of domains than for exploring any one domain in great depth. Do this only if you have time, if it seems particularly relevant, or if you are specifically asked. Perhaps ironically, touching upon a large number of domains makes you look more focused, and thereby safer and more competent.
  6. Don’t let the examiners put you off or hold you back. If they are being difficult, that’s their problem, not yours. Or at least, it’s everyone’s problem, not yours. And remember that all that is gold does not glitter; a difficult examiner may be a hidden gem.
  7. Be genuine. This is easier said than done, but then even actors are people. By convincing yourself that the OSCE stations are real situations, you are much more likely to score highly with the actors, if only by ‘remembering’ to treat them like real patients. This may hand you a merit over a pass and, in borderline situations, a pass over a fail. Although they never seem to think so, students usually fail OSCEs through poor communication skills and lack of empathy, not through lack of studying and poor memory.
  8. Enjoy yourself. After all, you did choose to be there, and you probably chose wisely. If you do badly in one station, try to put it behind you. It’s not for nothing that psychiatrists refer to ‘repression’ as a ‘defence mechanism’, and a selectively bad memory will do you no end of good.
  9. Keep to time but do not appear rushed. If you don’t finish by the first bell, simply tell the examiner what else needs to be said or done, or tell him or her indirectly by telling the patient, for example, “Can we make another appointment to give us more time to go through your treatment options?” Then summarise and conclude. Students often think that tight protocols impress examiners, but looking slick and natural and handing over some control to the patient is often far more impressive. And probably easier.
  10. Be nice to the patient. Have I already said this? Introduce yourself, shake hands, smile, even joke if it seems appropriate – it makes life easier for everyone, including yourself. Remember to explain everything to the patient as you go along, to ask them about pain before you touch them, and to thank them on the second bell. The patient holds the key to the station, and they may hand it to you on a silver platter if you seem deserving enough. That having been said, if you reach the end of the station and feel that something is amiss, there’s no harm in gently reminding them, for example, “Is there anything else that you feel is important but that we haven’t had time to talk about?” Nudge-nudge.
  11. Take a step back to jump further. Last minute cramming is not going to magically turn you into a good doctor, so spend the day before the exam relaxing and sharpening your mind. Go to the country, play some sports, stream a film. And make sure that you are tired enough to fall asleep by a reasonable hour.
  12. Finally, remember to practise, practise, and practise. Look at the bright side of things: at least you’re not going to be alone, and there are going to be plenty of opportunities for good conversations, good laughs, and good meals. You might even make lifelong friends in the process. And then go off to that Greek island.

Adapted from the new sixth edition of Clinical Skills for OSCEs.