I found out that one of the nurse practitioners I work with in the NICU (I’m a 2.’d year NICU fellow) is excluding me from night rounds but is not doing this to my co fellows. I usually try to go with the flow, but this makes me feel like I’m being taken advantage of and makes me feel like I might not be respected as an attending. This is making me feel anxious about working with her and becoming an attending in the future

ANSWER:

Hello!
So glad you brought this here.

So you are a NICU fellow, and you've noticed that the NP doesn't invite you on night rounds, and does invite your co-fellows. To you, this means that you're being taken advantage of and not being respected. Understandable!

I'm not here to convince you that you should or shouldn't feel some way about that.

But let's see how you are showing up when you play the story out this way.

C- you're a 2nd year NICU, NP did not invite you on evening rounds x(how many times)
T- I'm being taken advantage of
F (how do you feel when you think this?- name ONE feeling)
A- what do you do or not do when you are feeling that way? Get really juicy here...
R- ??

C- same
T2- I won't be respected as an attending
F2?
A2?
R??

Can you fill out one or both of these models?

I have a hunch that if you are feeling left out/rejected/judged, that the actions you are taking are to shrink away, look for evidence that she's the problem, judge her, judge yourself/second guess yourself etc.

If that's not serving you in your growth or in how you envision yourself as an attending, what might serve you better?

What if, instead of trying to get to a new thought, that you could allow it to just BE that the thing didn't go the way you planned. What would open up for you if you didn't have to CHANGE that thought, but instead meet that thought without resistance?
Alternatively, instead of swapping out one for the other, could they both exist at the same time?
How?
- What I was getting stuck on was that with a model of a Thought/Feeling that I didn't want, I can still process the feeling without having to progress to A/React based on that feeling alone. I can then choose to go to the intentional model and act on that instead. And they can both exist - because I can allow them to.

ANSWER:
Love this!
<3 <3

Hello BT community
I am oh so grateful for having been through this experience with you all! It has been an amazing process where each and every one of you have had an impact. As I continue my journey, I'd like to reach out and meet some friends who would be willing to walk this walk with me. So here's my info, feel free to reach out:
Maria Teresa Eyzaguirre (aka, MT)
Eyzaguirre.mt@gmail.com
I'm in the New England area, if you ever want to meet.
Loads of love

ANSWER:
Loads of Love right back to you!

Just wanted to say thank you to all of the BT participants - I have truly learned so much from your shared stories and experiences, including new thoughts I will try and seeing that I'm not the only one who feels a certain way. Truly grateful to be in the same space as your brilliant selves!

ANSWER:
I'm not crying.........(sniff). Well said, friend.

Yes, there are lots of thoughts and feelings! Just being aware of THAT can be powerful, right?
- Definitely. This has been a huge part of the learning for me - acknowledging that feelings exist, they can be identified and felt, and they are not inconveniences that I need to avoid and work around.

OK so, now you know you are a human being and it's a human being's job to have thoughts and feelings. Now what?
Why do you have to "address them all"?
What does that mean to you?
- Love the tuxedo and hat tipping! My vision was more of a disgruntled professor taking roll call and being like, "Ugh. Rage, you're here AGAIN?" But now I recognize that this is passing judgment on myself and the feelings I have, rather than validating that these feelings are normal. I like your vision better!
By addressing them, I think I mean acknowledging that they exist rather than avoiding them and remembering that multiple feelings can and do exist for the same "circumstance." And remembering the goal is not to have 100% positive feelings all the time (still working on this one).

But seriously, you have the privilege of experiencing the full spectrum of emotion.
What do you want to do with that?
- This was a bigger step for me that I'd realized, so I think my next step will be continuing to notice the thoughts and feelings. And work on developing more intentional models for the circumstances I know are going to happen (ie, C: thing happened. T: thing did not happen exactly the way I planned --> C: thing happened. T: this is me doing my best).

Thank you SO MUCH for your coaching!

ANSWER:
I LOVE this. Great work here friend, this is so wonderful to read.

I have one final thought for you. In your final reflection you gave an idea of your ideal intentional model.

"(ie, C: thing happened. T: thing did not happen exactly the way I planned --> C: thing happened. T: this is me doing my best). "

You want to get from "thing did not happen exactly the way I planned"---> "this is me doing my best".

What if, instead of trying to get to a new thought, that you could allow it to just BE that the thing didn't go the way you planned. What would open up for you if you didn't have to CHANGE that thought, but instead meet that thought without resistance?

Alternatively, instead of swapping out one for the other, could they both exist at the same time?
How?

We have a few days! bring it on back!

<3 <3 <3

Hello Friends!
Adrienne here. A few of you have asked if there is some way you could connect with other people who have been in BT this cohort.

Of course, we will not share any of your contact information with anyone else, but I am happy to facilitate if this is something you want to do.

IF YOU WANT to make some connections from BT outside of this platform, I invite you to submit an "ask-for coaching" here. You can include your email address and anything else you'd like to say or share
(do you have a message of gratitude for the other participants?,a new thought you'd like to share with the group because it helped you?, anything at all).

Whatever you submit, I'll post here and leave the connections up to you.

Hope to see you all on Wednesday night- it'll be a little party.

With so much love,

Adrienne and Tyra

Lara: rotterl.17@gmail.com

Answer:
<3 <3 <3 lara

I am really struggling with processing my grandmother's health decline/death. She is in end-stage heart failure and has been placed in hospice. She is 25 + years out from a multivessel CABG and I feel grateful for the time we've had her, but I keep avoiding the truth despite intellectually knowing it. So here goes a model
C: My grandmother is dying and in hospice
T: She's not going to be in my life anymore and she doesn't get to meet any future children I have/ they won't get to meet her
F: Heartbroken
A: distracting myself/avoiding thinking about it/processing the feelings
R: I am too distracted to do any non-clinical work (there are lots of things on my to-do list I haven't been getting to)

I also have this feeling of guilt for waiting to have children now that she's dying. I'm not sure why it's so important to me that she meet my future kids, but maybe it's because I'm really close with her. She and I have a really special relationship, where we can joke around in a way I don't have with anyone else. She's also my last grandparent.

ANSWER:
Hello Friend,

Oh, I'm so sorry to hear about your grandmother. She sounds like an incredible person. When you love someone who has been such a special part of your life, it makes sense that you grieve not only the person themselves, but experiences you would have liked to have shared with them. Grief exists because your love for her exists. F of shame)
F- Guilt? shame?
A- blame yourself, Shame yourself, "buffer" with distractions, avoidance, etc.

All of that leads you away from honoring, loving, and grieving her, is my guess.

OK, friend.

you don't need to get out of that model right now. You can set a pin in it and let it be.

You are allowed to love her, to grieve her, to imagine all of the beautiful things you wish you could have done together, and you can imagine all of the beautiful ways you will bring her memory into those experiences with you when it's time.

There is no right way.

<3

I recently had a vacation that was more exhausting than restful, and came home pretty sick (not COVID). I had a lot of thought surrounding this - will people think I'm just trying to extend my vacation? But I was genuinely unable to work so I ultimately did call out sick. Since then, my sickness has been dragging out.. I've been sleeping >12 hours a day and feeling so unenergetic, just moving around the apartment is a drag and just feel so crummy and my brain feels foggy... and my program is so lovely and supportive, never questioning anything and applying zero pressure - if anything, they've encouraged me to keep staying home until I'm better. Despite this, I've been feeling so guilty about staying home sick. I've gotten sick a few times this year and worry it's going to be in my reputation that I'm always calling out or not genuinely sick and abusing the system. I am a person who tends to get sick when stressed, and this year has been pretty stressful... I've been ruminating about how others will perceive my calling out, whether I'm genuinely sick enough to still be staying home (at what point do I just suck it up and deal with it?). Instead of enjoying this rare downtime and taking the space to get better, I feel like I've been driving myself crazy at home. And I also wonder whether I just can't handle this schedule? Like maybe everyone else is dealing with the work hours and hectic-ness but I'm the weakest link

C: I have a cold and had to call out sick, but we have a system in place so someone is covering for me
T(s): I get sick too often, they'll think I'm faking it, maybe I'm weaker than the others, maybe I wasn't meant for this job, maybe I can't handle it...
F: guilty, unworthy
A; ruminate more about being sick, less rest and recovery
R: feel crappy about myself both from being sick and also from the way I'm thinking about it

ANSWER:
Hello, friend.

I'm so sorry you got sick on your vacation. That's that absolute WORST. Ugh!

OK let's look at your model. Remember we only want ONE Thought on the T line, and one F on the F line.
Here's my best guess as to your model with some additions

Here is my guess on the cycle you are in...

T1 I get sick too often
F1 guilty
A1 worry about what other people think

--->

T2- Other people will think I'm faking it
F2- Guilty again?
A2- Judge yourself for not getting better faster

--->
T3- I'm weaker than the others-->
F3- ?? maybe shame?
A3- your self imposed beating is getting worse

-->
T4- I wasn't meant for this job
F4- ??

and so on.

OK so let's start with the first model

C- Viral syndrome
T1- I get sick too often
F1- Guilty

What is the upside of the emotion of guilt in this case?

What is the downside of guilt in this case?

If we zoom out....
What is the upside of guilt as an emotion that people feel? Why do we have this feeling? What is it trying to protect us from?

Bring it back here and we can keep teasing this one apart.

<3

Lately as residency has been coming to the end I feel this push and pull around learning experiences, especially lectures. They set off a cascade of thoughts --> emotions for me.
1) I feel interested and inspired, but then 2) insecure and of 3) sad/depressed.
FYI I have primary care training and will do a fellowship next year, then decide how much primary care vs fellowship I want to do after that training is complete.
1) In regard to feeling interested/inspired: I feel like I have seen enough that my brain can actually process these learning experiences and feel like I can and want to practically apply them ASAP. Like I have enough clinic and systems experience that I am no longer just fumbling to get through an experience but can actually do it with more intention. --> interested/inspired
2) But then I also start thinking “how did I not take advantage of this stuff earlier?” --> insecure as if its my failing that my brain wasn’t ready to hold this information before
3) I then I also think “well this is great info, BUT how will this practically work in real life, with 20 minute visits, strapped clinic resources, poor follow up, not seeing my own patients, etc” (this is a reflection on my specific clinic, may not the only reality but doesn’t seem uncommon). I am more worn out at the end of residency for sure, but there are signs all around me that burnout is affecting everyone. Several young attendings in my clinic have had some sort of burnout related issue. Nurses and MAs are leaving all the time. I end up feeling like my ideal way of practicing medicine and applying this learning is basically impossible --> depressed/sad.

Since I am going to fellowship next year, in some ways none of this should even matter. I don’t have to do this right away or possibly at all. But I can’t get past this sense of urgency around these thoughts and I still want being a GREAT primary care doctor to be a possibility. I know there are several thoughts and this is super complex. It truly feels like a cascade one 1-->2-->3 when it happens.

I tried a model for thought 3 as this one seems to bother me the most.

C: in a lecture with good learning
T: thought 3 – “how would this practically work in real life…seems impossible?”
F: sad, hopeless almost
A: Reflecting on all the failures of the healthcare system (hospital structures, 20 minute visits, physician burnout around me)
R: Feel anxious, worry about this career path that I am nowhere near even doing right now anyway

Where do I start unpacking this?

ANSWER:
Hello there! Great awareness here.

First off, it is SUPER NORMAL for the rush of all of these emotions as you enter into the final of weeks of a truly SEMINAL period of your life right? Training is a time of immense growth in knowledge, skill, relationships, in personal, professional, and every other domain. It totally makes sense that as you enter these last weeks your brain is working over time to make sense of all of it.

nothing has gone wrong here. <3

I have some ideas- let's pick a few rabbit holes to go down:
C- US healthcare system is flawed. (let's put this on the C line and see what you are making it mean about you...)

T1 - That means that I________

Whatever T1 is... Why is that a problem?
T2- T1 is a problem because it means that I______

Why is T2 a problem?
T3- T2 is a problem because it means that I ______

Follow that pattern 5 times. What comes up?

My hunch is that you're making it mean that you won't be able to be a "GREAT" doctor.

Of course, we know that that's not true because there are people who you think ARE "Great" doctors who operate under these same broken circumstances.

Are you willing to believe that you are already a great doctor?
Why/why not?

If not, are you willing to believe that have the potential to be a great doctor?
Why or why not?

Bring it back here, friend!
<3

How is this feeling for you now? When you read over your Intentional model, does it feel available to you? Have you had a chance to try it on "in the wild"?
-It is feeling more accessible now. When this particular unintentional thought comes up, which is happening fewer and fewer times, I can take a moment to think, "Wait, that's not true" and remember my intentional model. And when the situation arises, then I have now defaulted to the intentional model more times than the alternative.

Is it possible to grieve the experience you THOUGHT you were going to have in fellowship while you also embark with tenderness and acceptance into the experience before you now? How?
- The short answer is yes, I know 🙂 I've realized how many of my thoughts have led to grief - writing them down, it's like "OF COURSE you/me would feel despair/desperate/scared with these thoughts." I think it's been good to acknowledge these thoughts, rather than try to ignore them, which also helps me acknowledge the thoughts that lead to hopefulness/curiosity in the setting of uncertainty. There are lots of thoughts and feelings. How do you address them all? Working on some thought ladders.

Thanks so much for your coaching!

ANSWER:
Hello, friend. Thank you so much for bringing this back.

This wisdom right here, "OF COURSE I would feel despair/desperate/scared...", Yes, it is in offering yourself acknowledgement in that moment that can help move forward.

Incredible work here.

Yes, there are lots of thoughts and feelings!
Just being aware of THAT can be powerful, right?

OK so, now you know you are a human being and it's a human being's job to have thoughts and feelings. Now what?
Why do you have to "address them all"?
What does that mean to you?

(I'm envisioning me dressed up in a tuxedo with tails and a top-hat, and every emotion that comes up, I gently tip my hat and address it formally "Well helllllooooo JOY, lovely to see you this fine morning", "Oh, yes, wonderful weather we are having, RAGE, take care now". )

But seriously, you have the privilege of experiencing the full spectrum of emotion.
What do you want to do with that?

Hello friends,
As we have been working through matters of perfectionism and confidence, I wanted to get some input on this notion I have about "perfect timing". For me this comes up in everything from when I decide to schedule boards or steps to when it would be OK to get pregnant. I think for the purpose of this discussion I would like to use pregnancy as the example. First kuddos to all physician moms, please drop in any comments or advice you have from your own experience. In my case, I have always known I wanted to be a mom, just as much as I always knew I wanted to be a doctor. For a minute I had to sit down with myself and understand why. Since this is somewhat of a belief I grew up with, I wanted to make sure this was my own personal decision and not just me going along with what society expects of me. Once I confirmed that this is something I want to do for myself, I started planning and trying to come up with the perfect timeline. For me it is either a thing of do it now (going into my last year of residency) or only after starting as an attending (3yrs from now). My hubby is for the longer timeline, I would want the earlier choice (I can feel my biological clock ticking) . Looking at this from the "perfect timing" perspective, I am weighing in factors like the time I'll be able to spend at home, flexibility of my schedule, being able to have family help and obviously finances. And so, objectively speaking, it sounds like my husband has more going for his argument than I do and honestly I am coming around to the idea of doing it his way, but still the question in my head remains: Why do we always have to wait for the right time to do things? I feel like this results in us not taking advantage or appreciating our current opportunities because we're always waiting for something better to come and in the meantime we are just letting life pass us by, being a passive expectator rather than an active player in our own story. Anyways, not quite a model, but any input on this "perfect timing" longing and how I can stop waiting for that perfection?
I know being aware is step1 and I've been thinking maybe just working on my own self confidence might help, but what are your thoughts and tips?
Thanks 🙂

ANSWER:
Hello! What a wonderful thing to be exploring with yourself. 🙂

OK, let's start by having you answer some of your questions to yourself...

-Why do you think you want to wait for the "right time" to do things?

-Is it true that this means you "are letting life pass you by as a passive spectator rather than an active player"? Why or why not?

You have proposed two timelines, yours and his.
What are options 3,4, and 5?

Bring it on back here!

<3

Why are you trying to take responsibility for someone else's feelings?
- I am trying to take responsibility for someone else’s feelings because, with the model, I know I can handle them and make sense of the situation and I worry that he will… wallow? I don’t really know what I’m so worried about. Or maybe that if I let him have responsibility for his own feelings about the situation then that’s a burden for him and I feel bad about that? I am exceedingly conditioned to want to prevent people from having negative emotions and/or more work, because of me or something I did.

"It doesn't feel safe to NOT take responsibility for his feelings?"- This is saying “it feels safer to take responsibility for his feelings”—Which leads me back to the way that you asked it- has it ever happened that not taking that responsibility left me feeling unsafe? Yes. Asking men to be responsible for their behavior is unsafe, because when you expect men to be responsible they abuse their power and you (i.e. me) end up sexually assaulted. Holy moly. Holy actual fucking shit.

C- Your brain made sense of this experience based on past programming.
T- Wow brain, way to go protecting me, you did an A+ job
F- Thankful
A- ?
R- Stop worrying about how my decision “makes” someone else’s life harder?, this seems like the wrong result with this model…

ANSWER:
RIGHT, so if you have not learned that it is safe to let people (especially men) experience their feelings, then the way you were thinking about this initially makes total sense. and YES, this was your brain taking care of you.

Let's take a look at your model.

I think the result here is that you are engaging positively and compassionately with the part of you that is a protector. you're not second guessing them, or being frustrated because they're not with the program of the new evolved you that isn't an approval addict anymore. It means you engage with yourself with love and gratitude and trust.

When you engage with thankfulness/gratitude with the protector part of you, what changes?

So much love, sister.

<3

Last week I signed a letter of intent to accept a job that I am excited about. In the end, the decision came down to two offers and though at times this decision making was a bit challenging, overall it was clear that the job I selected is the “better” job for what I want to do. The first job (the one that I turned down) was smaller, with a more intimate practice setting, and I got along well with the person that primarily interviewed me and would have been my boss/partner. I accepted the other offer last Wednesday and called the other person on Friday to let him know that I had chosen the other offer. Before the call I practiced with my friend, and though I was a little anxious about it I expected to feel better after I called but I immediately felt worse. Yes, this was the right decision for me and I took a job that I am excited about, but I immediately made this other person’s life harder, “let him down,” and now has to start back at the drawing board of reviewing applications and finding other people to interview. I am a relatively classic approval addict, but I also caught myself thinking how if this person had been a woman I would have trusted her/been confident that she would navigate this disappointment and I would have moved on. For reasons I can’t fully explain, I feel bad (and to blame) about the fact that this particular man has to restart the hiring process. We got along well, he was inappropriately affectionate at moments, and I think he expected me to say yes. Somehow these things seem to make the situation feel slightly more complicated.

ANSWER:
Hello! Great awareness here.

In your most logical brain, I know and you know that you aren't responsible for how this person feels (that's driven by their thoughts about you declining the position), but you're grappling with the fact that part of you still thinks you are. This is normal.

Let's start by answering the question you posed-
Why are you trying to take responsibility for someone else's feelings?

If that's hard to answer, lets's try this one:

Why does it make sense based on old programming, that in this case, with this man (who you experienced as "inappropriately affectionate at moments"), that it doesn't feel safe (at least immediately) to NOT take responsibility for his feelings?

Does it make sense that if the idea of "letting down" a man who has been "inappropriately affectionate" to you may seem not safe and is something that you should avoid? If this makes sense, then let's see how you want to engage in the model below:

C- Your brain made sense of this experience based on past programming.
T- (what do you, or how to you want to think about that?)
F-
A-
R-

Bring it back here as much as you need to.

<3

Thank you so much, Dr. Mann, for taking the time to coach me! Here is a follow up. From many thought downloads, I chose the models that had the most A/impact for me.

Unintentional Model
C: I have a medical condition.
T: I must not be strong and resilient.
F: despair
A: accumulate evidence for why my other previously-believed good qualities are also not real, compare myself to others, get angry at myself for the things I am unable to do, minimize my accomplishments, avoid any and all new opportunities because these appear as opportunities to fail rather than succeed, descend more deeply into imposter phenomenon (this was painful to write down! Still cannot believe I was doing this to myself, all day every day, and not noticing. I would not do this to an enemy, let alone the people I care about).
R: I don't trust myself.

Intentional Model - trying this on is a work in progress, but so much better.
C: I have a medical condition.
T: I am strong and resilient irrespective of the circumstances or things that happen to me
F: relief
A: take pride in the things that I do accomplish, forgive myself for the things that I am not able to do, trust myself in choosing what I can and want to do, (cautiously) set new goals, be more open with the people I care about
R: approach myself and the world with kindness

Expectations for when I start fellowship
1. To say when I am feeling the symptoms of my medical condition out loud to someone.
2. To forgive myself when I am not able to physically do things and/or take a day off, and then let it go.
3. To remember that a hospital functioning is not solely dependent upon me.
4. To continue to do my best and remember that the definition of 'my best' will change.

I would truly appreciate hearing the coaches' thoughts. Thank you all!

ANSWER:

Hello! wow, what great work you've done here. I'm so glad that you've brought this back.

You have done a really beautiful job creating your intentional model, and I'm loving reading your expectations of yourself (I may even borrow some of them for myself).

How is this feeling for you now? When you read over your Intentional model, does it feel available to you? Have you had a chance to try it on "in the wild"?

Is it possible to grieve the experience you THOUGHT you were going to have in fellowship while you also embark with tenderness and acceptance into the experience before you now? How?

So much love <3

How do I explain concepts to the team and encourage learning (like using socratic method) and balance my fear of sounding like the condescending attendings who have made me feel crappy in the past?

ANSWER:
Hi Friend! Glad you brought this here. I love that you're thinking about the way you want to show up in your new role as an attending! One reason I know you are going to be great it because you care enough to think about how you want to do it and how you DON'T.

OK now, we know that there have been times where you have had attending say words or ask questions, and something about the way they did that made you think "That was condescending" and then you felt crappy (or inadequate, or ???).

A few prompts to get you thinking about what you want to do and what you want to not do:

1. What do you think makes someone a "condescending attending"?
2. Have you had attendings that were able to use socratic questioning that you didn't perceive as condescending? What things did they do or not do that resulted in you feeling safe (psychologically) in that interaction?
3. Let's try to bring attending-you into more focus. "I want to be the kind of attending that ___(fill in as much as you can here about your ideas and inspirations, and expectations of yourself)__________"

What comes up in these prompts? Bring it on back here and we can keep coaching on this. <3

I just started the course (apologies but it's been hectic), and I started it because I'm feeling so overwhelmed.
- I just had a newborn. I wasn't ready to have kids (honestly, I wasn't sure I wanted them at all, but b/c my husband's parents are older in their 70s, he wanted them sooner so they could know their grandparents). A new born in and of itself is exhausting but with my ambivalent feelings, it seems even harder
- Nursing is exhausting but pumping won't be any better as it still takes time and it requires extra steps to clean pump parts and bottles.
- I will have to be on wards soon, though, and I'm looking forward to "nursing breaks" to get away from incessant rounding. (I know they aren't truly breaks)
- I will be a chief resident next year and duties are already being passed on to me that I don't have time to think about.
- I need to study for boards.
- I need to decide if I want to apply for fellowship or not. If I don't apply for fellowship, I need to think about jobs and not just that but also where to live. There's lots of pressure from family to move to 3 different cities to be close to parents/siblings.
- I am still on mat leave and by default most of the household tasks have fallen to me.

I just feel so overwhelmed with everything. And I'm so tired.

c: I am a new mother, a wife, a 3rd year resident balancing onboarding and fellowship, a sister/daughter/daughter-in-law
t: I am failing at everything. I don't have enough time to do it all.
f: overwhelmed, stress, sad
a: losing connection with my husband, being short-tempered with him, having little patience with a newborn, indecisive about fellowship, feeling immobilized about decision making
r: disconnect from the world, crying often, not sharing feelings, lack of action (fellowship applications or not)

From another question, I saw this prompt re: fellowship.

1. Pursuit of advanced fellowship is aligned with my values because......
- I am interested in pulmonary medicine and think clinic +/- consults will potentially lead to less burnout down the road
- Pulmonary medicine is more interesting than hospital medicine to me
- Less risk of midlevel encroachment -> more job security
- Higher pay -> faster retirement

2. Not pursuing advanced fellowship is aligned with my values because...
- I get an attending salary -> possible faster retirement
- I don't care for critical care medicine. I'm unsure if I would be less miserable with crit care fellowship vs hospitalist
- I don't have a fellow's schedule but a hospitalist one (but then I lose every other weekend)
- I could be less miserable if I balance out hospitalist work with something else (i.e. education/teaching with working one week on a month instead of 2)

I know this is a loaded question with many aspects. I'm just so tired. I can't process anything. I just want to sleep for 8 hours straight but it still won't be enough and I'll still be in the same predicament.

ANSWER:
Hello my friend,
We are so glad to have you here, and thank you brought this for coaching.

What you are feeling right now, the overwhelm, stress, sadness, disconnection, indecision, EXHAUSTION, all of that is real. Your reasons for feeling those things are also real. Your hunt for certainty and something to ground yourself with (fellowship decision) makes sense when so many other things feel overwhelming, and out of control.

It is normal to struggle to make a big decision when you are physically, emotionally, and cognitively exhausted.

You're not crazy, you're not alone, and you are absolutely enough.

For a moment, I want to invite you to acknowledge (without judgement or blame or qualification) the exhaustion you are feeling in your body and in your mind.

I invite you to acknowledge that your body has grown and fed a human baby and kept you both alive while doing so. This is a heroic feat. Look at how your brain has been working overtime at a break-neck pace to point out and then solve all the problems. This is hard, invisible work.

In this moment, when it's heavy and all around you, what do you need most?

There are no right answer here. Options might be something like:
"I need to know that ________", or
"I need to believe that it's possible to__________" or
"I need to meet x/y/z of my physiologic needs like to bathe/sleep/scream into the void", or
"I need to give myself permission to ____________"

When you are ready, I invite you to bring anything that comes up for you for more coaching.

sending so much love, <3

For context - I help take care of patients in a nursing home. One of my patients is this adorable 95yo patient who was super dehydrated (Na 159). In the nursing home, it is hard to get a PIV so we always start with diclysis. Patient is Black. Her daughter is a very concerned pediatriac cardiologist who wants daily updates from the team (seems unreasonable for a SNF). She doesn't understand geriatrics principles of care seemingly, and wants to dump fluid in her mom's veins.

Unintentional model:
C: I go update a patient's daughter at the end of a long clinic day
T: I already know this is going to be a frustrating conversation
F: annoyance
A: Get really worked up and have a fight response when patient's daughter acts exactly like I thought she would
R: Have a sick feeling in my stomach and not feel good about all the rest of the good work I accomplished today and be completely colored by the last conversation I had with this patient's daughter.

I was really mad at myself for getting annoyed because I knew it was going to happen, and couldn't wrap my head around how the conversation could have gotten better. Unless I said, okay we will put in the PIV even before labs come back from the 2L of fluid we had given her mom over the last two days, it didn't feel like she was listening to me. I also felt belittled as a fellow because she asked to speak to my supervisor, who turned out to share my POV. I didn't want to go back to talk with her about the final plan but I did it anyway. I felt bad that I was annoyed because I knew that she was just trying to advocate for her mom, in a system that isn't built to treat Black patients with good medical care all the time. I felt like my unconscious bias against Black patients was taking over even though I feel like an informed person and an advocate for BLM and that made everything feel worse.

Intentional model:
C: I go update a patient's daughter at the end of a long clinic day
T: I am being helpful to the overnight call person and the nurses who have to deal with this high maintenance daughter who is just trying to advocate for what is best for her mom.
F: Empathy
A: Try to listen to daughter's point of view without raising my voice and getting frustrated, approach from empathy.
R: Leave conversation feeling like we at least compromise on her mom's care so that both of us are happy.

To top it off, I had another phone call with sisters of a Black patient today and they also came off to me as "hard headed" about not wanting to learn how to get foley trained for when they travel with their brother. When I tried to explore why, the just said "I've been saying this the whole time, I don't feel comfortable with the foley training. I don't know what more there is to talk about." I felt bad because the same feelings from my conversation from yesterday came up again.

Appreciate any advice. Thanks!

ANSWER:
Great thought work to bring here!
I want to make your Circumstance line even more factual. Right now, you put one of your actions in the C line (which is ok - since it is something you did in the past, but I bet the T was prior to this action?). When I read your thought download I see a beautiful mix of complex and perhaps seemingly competing values (valuing the patient and family experience, and also valuing your own boundaries on time for example).

I also read your valuing how you show up for black patients, knowing that racism and your own bias exist, and feeling some shame/guilt (? is this true?) when you perceive that you aren't showing up as your best self.

Here are your circumstances:
C1: Patient is Black, elderly, living in a SNF and dehydrated.
C2: Daughter is a pediatric cardiologist who requests daily updates from the medical team.
C3: Systemic racism exists in ways that we can and also can not understand.
C4: Your unconscious bias towards people of color exists in ways you understand and see and also in ways you don't
C5: Your patient's daughter asked to speak to your supervisor out of concern for her mother.
C6: Your other patient's siblings are not comfortable with foley care

Can you pull out your knee jerk T/F/A/Rs for each of these? Some questions as you think about your thinking:
-How is this "for" you?
-Can you be annoyed at black patients sometimes and also be an advocate for BLM? How come? IF not, how come?
-What is the daughter teaching you about the world? What is she teaching you about yourself? What is she teaching you about doctoring?
-Adults are always going to feel differing levels of comfort with medical therapy and home care. How do you want to show up for those that don't do what you want them to? How do you want to show up for yourself in these situations?

I invite you to pick one or two models from those Cs to bring back here, this is very important work that so many of us are benefiting from.

Finally - I do want to end on an important point which is that you showed up here, in this space with vulnerability and accountability for your T/F/A and Rs. Can you help me find the T that led to you leaning in instead of away from this culture-shifting work? I guarantee it's one that you'll want to hang on to and perhaps practice later:

C: You noticed your own bias, and that you showed up in a way that you'd like to change
T: ????
F: ???? (motivated? uncomfortable? Curious? Ready? vulnerable? courageous? frustrated? ---> get specific since this feeling, even if uncomfortable, is leading to important change)
A: Call yourself out, post it anonymously on a public forum for others to benefit from, think about your own thinking, consider how you want to show up, and ask for help.
R: you are evolving into a better version of yourself RIGHT NOW.

<3 <3

Following up on my initial question. I really loved your response, thank you! I've talked to some mentors and have found ways to make fellowship better and in ways that bring me back to my values.
To answer your questions:

What things brought me to a career in geriatrics?
(You hit the nail on the head with connection). I think I've always looked up to older adults, their wisdom, and wanting to care for a vulnerable population.

What ways can you lean toward those values even if the service is slow?
I think getting back to just getting to know the patients as people will be helpful. And also learning and reading on my own.

What do you want to make of the last (now 3!) months of fellowship?
I want to continue to learn how to treat older adults as full people, continue tickling my medicine brain while also using the new social determinants of medicine skills that I have picked up. Keep being curious, and exploring in places I don't feel comfortable in.

ANSWER:
Thanks for bringing this back! I'm so glad my response resonated with you.

OK! Now you're onto something with your responses. You have listed a lot of actions... let's put them in the A line and run the model backwards:

R- in your last 3 months of fellowship, you show yourself all the ways that you can be in connection with your patients and your work

A- Get to know your patients as people, engage in self directed learning/brain tickling, explore places you don't feel compfortable in (yet), practice skills you are learning (what else goes into achieving that R line? Have grace for yourself? For others? for your program? what else?)

F- ? What feeling would drive those actions? (Curious? Committed?)

T- What T that is available to you RIGHT NOW helps you reach that feeling?

C- 3 months left!

OK now, you practice thinking that T on purpose. Many times per day.

If you try it on "in the wild" and it doesn't feel believable...
Why?
What DOES feel believable?

<3

One of the toughest things throughout residency for me has been transitioning to living alone, where a lot of the external cues/regulation I had to do certain things are no longer there. A big way this comes up is mindless eating as a means of soothing myself, and naturally I have seen the result of some weight gain. I have worked through this a lot and fortunately been able to get back intro my pre-residency gym routine which has made me much happier and has been much more fulfilling! Still I am noticing I have hardwired the habit of eating to self-soothe/numb when I come home, and so today I decided I'd do a thought model surrounding this and curious to get some feedback on it. A lot of this comes up when I have these thoughts of needing to be in control of my time and "recharge" for the next day, but inevitably eating past the point of comfort drains me and sets me up for an even less pleasant following day.

Unintentional model:
C: I come home from work
T: I don't have much time left to myself before I have to run right back to work tomorrow
F: Agentless/powerless/out-of-control --> anger/frustration
A: Seek something that I tell myself will bring me pleasure/relaxation, most often eating in front of the TV, and eating way more than I would like
R: I end up not really focusing on the food nor TV/being mindful of either as much as I would like, and then I overeat and feel even more out of control in anticipation for the coming day

Had some trouble figuring out the exact feeling the thought caused, so I came up with a few but they don't quite capture it, and the feeling of not being able to choose how I HAVE to spend my time, or control the long hours leads to anger

Intentional model:
C: I come home from work
T: I wonder what would bring me the most pleasure/relaxation/fulfillment this evening
F: Curious
A: Start brainstorming/trying different activities
R: Potentially find something I enjoy way more that actually adds value to my life, and may ultimately break the cycle of the overeating habit that has been tied to the thought I have every time I come home

One other question I had was which part of the intentional model should we be trying to choose? Most often the thought or is it really any line other than the circumstance that we can play around with?

Thanks so much in advance!

ANSWER:
Hello Friend,

I am so glad you brought this here. You have such wonderful awareness in your thought download and in both your UM and IM. Really nice work!

You are describing the action of eating food as a way to diffuse the uncomfortable emotions of feeling powerless/out-of-control/without agency.

We call this "BUFFERING" and buffering can be any number of actions---- eating when you aren't hungry or the food isn't nourishing (overeating), over-drinking, scrolling on social media, buying things you don't need, numbing out with Netflix. On their own, these actions are neutral, actually. But what makes them "buffering" is when you use them to avoid/diffuse an uncomfortable/unpleasant emotion AND they lead to a NET NEGATIVE result for you.

The interesting thing in this case (as you point out) is that you (and me, and many other people), might eat (or shop, or drink, or scroll) to avoid feeling out of control, but then after the eating/drinking/scrolling/spending is done and that dopamine we get fades....... we feel....... out of control and powerless... right?

I love how you are working towards an emotion of curious in your intentional model right now, and that it absolutely the way forward.

Here are the circumstances:
You are a human with a human brain and a human body
You go to work and you come home from work
You have practiced, over many years, using the action of eating food to diffuse/buffer uncomfortable/unpleasant emotions.
Sometimes you eat food in excess of what your body needs

Before you start practicing a new model, I think it wold be really helpful to get curious and non-judgmental after the over-eating happens.

I call these questions "write it down and move on", and these are a great place to start once you've realized that you were operating in your UM. And remember, we don't use these questions to beat ourselves up, only to understand ourselves and love ourselves more. OK?

What did you eat or drink that was not in service to your mind/body?
Why did you eat it?
What did you notice?
What did you learn?
How can you let this go now?
How do you want to feel moving forward?
Would you like to do something differently next time? What?

You can ask yourself these questions any time you do something that you want to get curious about.

I invite you to bring this back for more (and more...)

<3

Feeling a bit overwhelmed while trying to people please in the hospital. I'm an intern and rotating on a high-turnover service. One of my patients has a lot of consultants on board and many moving parts because we're not totally sure what's going on. The patient and family are pretty nervous about not knowing what's going on, and have their mychart open refreshing throughout the day, and ask us for the reasoning why med doses are changing, why a subspecialist note doesn't comment on said medication change, why we ordered a lab that a consultant asked for if it didn't say it in the note, etc. While I would love to update them, I don't have enough time to update them this frequently while also taking care of my other to-dos for all my patients.

C: Patient/family are checking mychart and asked for 4-5 updates today based on what has changed in mychart
T: It's not possible to update them, and they're going to be mad and think they're getting bad patient care
F: guilty
A: Ruminate about not checking in more often, complain about it to my team, spend extra time with this patient/family to update them and end up spending less energy on my other patients
R: spend more time on one patient than others, giving worse patient care to my other patients? and patient/family are still expressing unhappiness with the level of updates.

I know in theory that I can't control what this patient/family think, and I know that I can't sustain checking in with the family so many times per day. I feel frustrated and burnt out with this amount of work. I also feel like if this were my family member in the hospital, I would also want frequent updates. I wish our system was built differently so that we did have the bandwidth to give clear and helpful updates as much or as little as patients and their families would like. But I also feel like it's not fair to give special consideration to this patient/family and not others. Today I stayed late trying to finish up all my tasks and spent less time updating other patients/families than I wanted to. I'm struggling to be OK with having this patient/family be upset with me. Yet, I think it's important that I don't burnt myself out trying to please this one patient/family and thus end up providing worse care to my other patients.

ANSWER:
Hi Friend,
I'm SO glad you brought this here.

This is the perfect example and PROOF of how we are never in charge of what other people think/feel/do.

I see how you have accessed empathy for them in your download above. You can imagine what they must be going through and I commend you for that.

As you point out, There is likely no amount of updating/checking in that would allow this family to feel informed and at ease about the care their loved one was getting. You could call them every hour on the hour and they may STILL have thoughts that lead to them feeling distrustful or anxious about their loved one's care. The only result of you bending over backwards to try and make them satisfied is you having a sore back.

Expectation vs. reality mismatch is fertile ground for frustration. Both for you and for them.

The good news for you here is that YOU are in control over your expectations for yourself as it pertains to how you engage with your patients' families. Let's get really clear on what you want to be able to do for all of your patients. Make a list here of what is reasonable and possible (i.e. not perfectionistic or impossible) to expect of yourself when it comes to communicating with your patients and their families:

Example: " I can expect myself to call my patients' families "x" times per day (or week?), and will do my best to honor their request for ______. On days when I can't call everyone, I will _________. I can expect myself to provide "x" minutes for each call. If families have more questions than I can answer in that time, I will say say__________. If I need help, I will ___________. "

What else would you add to this?

The reason to do this exercise is to define for yourself what "good enough" is, and to free yourself from defining your success or worth as a doctor by what a stressed/anxious/worried/scared loved one is thinking/saying/doing.

What you are doing matters.

<3

I think the answer is -- "yes, I was doing the best I could with what I had." That answer saddens me a bit because what I had felt like so much less than everyone else. I'm a bit mad/ embarrassed because I think my poor mental health set me back. I keep on thinking about how much more I could have learned and achieved if I had more grit and resilience. I know that wallowing in these feelings and dwelling in the past will not help moving forward, though.

ANSWER:
I'm so glad you brought this back. Consider these questions and if one resonates with you, I invite you to bring it back here.

Is it OK to be sad about the idea that you did the best you could with what you had? Why or why not?

Why should one be embarrassed that they struggled to do an 80+hr/week job when dealing with grief and/or depression following the unexpected loss of a parent?

What would it have looked like to have "enough" grit or resilience during that time? Does that seem like a reasonable expectation that you would have of someone else?

Keep it coming, friend.

<3

Thank you so much for your dedication to coaching us in this program! I really wish I had access to this program earlier on in residency.

I wanted to ask for coaching on some of my thoughts surrounding my skill and progress during residency. I am graduating this year (eek!) and feel like I have not learned enough. I'm afraid I will be expected to be a totally independent practitioner without the requisite skills and competence. As some background, I had a parent pass away very unexpectedly about 1 year before starting residency. I started my program feeling depressed and raw and without much emotional reserve. Being back in the hospital was really hard. I had a lot of questions about what might have been done differently for my dad to prevent his death, and I think it fueled a lot of anxiety for me in my clinical practice. I was constantly afraid of making a mistake and causing harm. And this led me to avoid pushing myself to act independently, avoid pushing myself to accept new learning opportunities. I did not want to mess up and hurt someone. And that of course led to a vicious cycle of me feeling like I was falling behind. To make a perfect storm, my program is one that does not tend to offer much direct feedback, though there's a lot of hero worship among peers (i.e. people talk about each other as being "really good" or "really strong" in a way that I find detrimental). I am not one of the people that others talk about as being particularly good or strong. Now I feel like it's too late in residency to turn things around, and I may just graduate as a subpar doctor.

ANSWER:
Hello! Oh, Thank you for those kind words, and we are SO GLAD you are here now <3

Friend, oh goodness, I can imagine how hard it would have been to start residency shortly after losing a parent, to question what could have been done differently, and to be afraid of making mistakes. I can imagine you as an intern, doing the best you could, feeling depressed, and like you didn't have the emotional reserve. I can also imagine that your brain was doing its' best to incorporate new medical knowledge and clinical reasoning during that time. Finally, I can understand why your brain is convinced that you don't know enough. It's trying to protect you, AND it is misguided in its' approach.

It's OK. Let's walk through it together. It might take a few back-and-forths, if you're up for it.

I suspect these thoughts feels VERY TRUE to you:

"I have not learned enough"
"It's too late to turn things around"
"I may graduate as a subpar doctor"

Notice these thoughts assume as FACTS that
a) there is a time when you will reach "enough" knowledge and skills to stop worrying
b) you are headed the wrong way
c) that there is a time after which one can't change their heading

Those are not facts.

Here are facts:
You are a human being.
You are a resident.
You lost a parent the year before residency.
You have advanced in your training year after year and are on track to graduate this year

OK sister, I think you brought this for coaching because you can tell that your beliefs about yourself are keeping you stuck and aren't serving you. That if you keep them, you are signing yourself up for more self-flagellation and less actual learning and growth, right?

If that is true, then let's explore the following:

Do you believe that during that first year of residency that you were doing the best you could with the cognitive and emotional reserve you had available to you?

If the answer to that is "no, I wasn't doing the best I could with what I had", who/what is it serving to judge yourself in that way?

if the answer is "yes, I was doing the best I could with what I had", what else could be true?

Bring it on back here.

<3

Sorry for the slow response! The transitions have now become a reality, where I have a beautiful son who is the cutest in my humble, totally unbiased opinion, and my family is in the process of moving. It's hard to think much about internal transitions while we're learning to understand our son and his needs, not to mention becoming new homeowners, but here are a couple of thoughts...

Academia: I have felt that many of the faculty I have worked with in academia don't have the best boundaries. That being said though, many of those are people I did not personally look up to, whereas those who had stronger boundaries were those that I did.

Leadership: I can't say that I'm certain, but I know deep down the emotion/thoughts are that I wouldn't be able to be successful at being able to be present with my family and pursue a traditional leadership position. That said though, before getting married and starting our family, I used to define my worth by achievement and I believed that becoming a leader was the ultimate goal. I can't say the same now, and lately (before maternity leave) I see myself wanting to be more present with the people I care about.

Flexible Academia Job: I think I'm having a hard time defining a flexible academic job because it seems like a lot of those who are in academia are constantly busy, publishing, having meetings (this is probably perceptions, but not the actual reality). I think it doesn't help that I live in a competitive region, where there is an external perception that this place is a rat race.

Community Practice: The "settling" perception comes from feeling like the community is less involved with the hubbub of an academic center where there's more resources and specialists to speak to one on one. Interestingly enough, my residency training was in a semi-academic, but really more of a community practice setting - and working with community partners felt more rewarding to me than publishing/doing research.

Dream Job: This is a good question, because lately I've been wondering if I made the mistake of going into medicine. I enjoy working with patients and families, but do find myself drained at the end of the day (but this may be the burnout speaking). What I have been able to piece together is that I do like the bread and butter medicine of my field. I like working with ancillary staff/consultants. I like teaching medical students and mentoring residents - and I want to make the art of medicine fun. With that all said, I am also an introvert, so I also want to have a healthy balance of residing in my little alcove and read pediatric articles and think about how best to translate for my learners/patients. Most importantly, I want to do all those things above, and be able to go home and spend time with my family (which these days include being driven crazy by colic and frequent feedings, but also adoring my baby and hoping he's gaining enough weight for the next weight check...)

ANSWER:

Welcome back! You're right on time 😉

I love reading those reflections and I especially love reading about your dream job! Here's what I'm hearing that a "dream job" means to you.

- working with patients and families
- working in a multidisciplinary team
- Teaching and mentoring learners
- making the art of medicine fun
- taking time to read/learn and translate that knowledge for your learners and patients.
- time to connect with your family

Im noticing in some of the other sections some "all or nothing" beliefs popping up. Here are some I'm picking up:
- In academics, "successful" people don't have good boundaries
- Can't be a leader AND be present with your family
- Academics has to be a rat race

Let's see if we can choose ONE of those beliefs to explore a bit more.
Which of those feels the most true to you?

Can you make a list of 5 examples of how that might NOT be true?

Bring it on back!

This past weekend I finished a one month off-service rotation that I had been dreading since this year's academic schedule was released last spring. Every time I looked at the schedule I squinted my eyes when they gazed over this block because I was dreading it so much. It was a rotation I hated in residency and it was absolutely the last rotation in the world I wanted to do as a fellow; it was going to be awful, I was going to do horrible, I had never independently managed sick liver transplant patients before, and everyone at my fellowship institution was going to find out really for sure that I wasn't meant to be here. To pile additional dread on top of months of pre-meditated anxiety, our nanny quit the Sunday night before the rotation started and I was concurrently studying for my oral board exam (which I took yesterday).

I can tell you now that it was one of the best rotations that I've had as a fellow. On my first day presenting 25 patients on Zoom to 20+ team members with ICU-style presentations for every patient I joked- "THIS, I PROMISE, is going to be the WORST patient presentations you'll see from me all month. I can't remember which faces match with with patients and I'm going to get some of these plans wrong but I'm promising you that I'm gonna get better each day." I normally fall into myself when I'm not sure if I'm getting the details of the plan correct etc etc and instead of getting so worried and self-conscious about it all I just made it so lighthearted and almost funny. They loved it. I came across confident, even if I didn't get all the details right I didn't worry about it because I had disclosed that I was going to make a few mistakes, and the "confidence" was totally a redirected nervous front but it carried me through the difficult parts of starting a new rotation until I really did learn each patient and was able to make plans on the fly. Because I had set a lighthearted "improvement-oriented" tone I wasn't as hard on myself and unexpectedly and ultimately ended up having more confidence than I have even on my home services. I got a lot of good feedback at the end of the month with more than one attending telling me did I really great job and that when I start my job as an attending someone will be lucky to have me as a partner.

If this had been written by someone else I would have said "that's you, that won't happen for me" and I staunchly maintain that I don't have imposter syndrome, I AM AM IMPOSTER-- if you could just let me tell you ALL the ways that I REALLY shouldn't be allowed to be here I could MAKE you see that for me, it's not a syndrome, it's the #truth. But this rotation... it was good. It was great. The quiet suffering and worry and all the other stuff-- it wasn't there. Now I need to take this back to my remaining home-rotations and figure out how to bring the authenticity of "I'm still figuring this out" when I always feel like I should already know the answers within my primary specialty. But... I feel like I'm getting closer to figuring this out. R?

You blow me away!
<3