hello
This happens a lot but including one example below
C: husband asked "where is the bread"
T: i've already told you that this morning
F: irritated
A: my responses thereafter reflect the irritation, sometimes I answer in sass, sometimes I'm silent, other times I verbally highlight how this is something we talked about already earlier
R: he expresses that I am not being understanding, that I'm quick to point out when he forgets things and in turn become more irritated and recycle the above ----> tension and disconnection in relationship
I wish I could catch myself before expressing annoyance with someone forgetting such a trivial thing
ANSWER
Hi there!
Thank you for sharing this incredibly relatable model!
One small but important note: your result is *never* about someone else's actions. Your result is only for you. Your husband said words about your not being understanding because of HIS thought and feelings, not because of anything you did or didn't do. Your ultimate result of tension/disconnection is spot on though, mainly because you are busy in your head proving he is wrong and shouldn't be rather than just being in the actual relationship
C: husband asked "where is the bread"
T: i've already told you that this morning
F: irritated
A: Sometimes answer in sass, sometimes I'm silent, other times I verbally highlight how this is something we talked about already earlier. I'm quick to point out when he forgets things and in turn become more irritated and recycle the above.
R: Tension and disconnection in relationship
Your actions in this model are all coming from REACTING to the feeling. Remember back in month two when we learned that there are four options for us with any given feeling? React, Resist, Avoid or Allow. The piece of golden insight that you brought is that you "wish you could catch yourself before you act" - which is the perfect place to start. In order to do this, you need to notice the feeling without reacting to it. The tricky part is to also not avoid (with distractions) or resist (with willpower) the emotion, but rather allow it. This means feel it with acceptance.
What if it's completely normal to feel irritated in any given relationship a lot of the time?
What if irritation wasn't a problem?
What if irritation itself was actually a portal to presence in any moment? How can this be true for you?
Can you "play" with irritation?
Can you not wish it away, but instead use it to get to know yourself better?

So I'm still pretty new/unfamiliar with the CTFAR model. So I'm going to start with a thought download, and give it a stab. I have had a number of life circumstances occur this year, including a big move, transition from mostly clinical to now entirely research, had my first child, and am essentially a single parent due to my husband's unforgiving job requirements. Prior to this year, I achieved a lot of clinical, academic and leadership success, and I was really on track to continue that success in this research portion of my training. I am not used to falling behind the expectations of myself or others. But the life changes of this past year have been like a tornado through my life, and I haven't recovered. I can't quite explain it, and I actually think there is a significant element of mental health which has contributed (post-pandemic burnout/post-partum anxiety and depression) for which I am seeing a therapist. But the ways in which it has impacted my work has been devastating. My "work ethic" when it comes to work is not the same as it used to be, yet I'm always busy. The flexibility that research allows means that the rest of my life (my daughter, daycare drop off, doctor's appointments, meal planning, food shopping, homeowner headaches, etc) fills the time and my research essentially occurs when/if I get to it. It has now been a full year of "research" for me and I have presented one abstract at one conference. At my stage in training, after a year of research, I am far behind where I should be, and far behind where my mentors expect me to be. This has gently been communicated to me, but I feel it like a ton of bricks because I know what I am capable of, and cannot reconcile this with my complete lack of productivity this year.
This came to a head recently, as I am required to fill out a self-assessment for my training program. When given the choice of "Strong", "Acceptable" or "Needs Improvement", I cannot identify a single area in which I can honestly indicate strength, given that I have not achieved the skills/attributes of the self-assessment this past year. I struggle even to find the areas in which I can write "acceptable". This self-assessment will be discussed amongst our training leadership as well as our mentors, and I am utterly embarrassed by my own self-assessment, but moreso by what it is demonstrating: that I am behind, that I know I am behind, and that my usual confidence is shattered.

C: I am filling out a self-assessment for my training program
T: I think I "need improvement" in almost every asset on the self-assessment
F: guilt, shame, embarrassment, disappointment (both in that I am not meeting expectations and that I will need to submit such a pathetic self-assessment)
A: beat myself up for my lack of productivity, making my confidence suffer to an even greater extent
R: lack of confidence and embarrassment about perceived lack of productivity reduces my work ethic even more, creating self-defeating cycle

ANSWER
First of all- way to go with the model! This is exactly how it feels to learn a new thing (clunky, awkward and new) and you ROCKED it.
Second, thank you so much for sharing this- it surely will resonate with the rest of your colleagues here. I'm just going to use this succinct model for our sake:
C: I filled out self-assessment for my training program
T: I think I "need improvement" in almost every asset, I am behind
F: shame (let's look at this one first)
A: beat myself up for my lack of productivity (call it "complete lack"), making my confidence suffer to an even greater extent, struggle to see areas where I am acceptable or strong, feel gentle communication as a ton of bricks instead of soft words, come up with some vague metric about where I should be right now that doesn't match where I am
R: Reduce my work ethic even more, creating self-defeating cycle

Ok friend, this is a perfect example of your inner critic on overdrive. A few questions to consider:

-Given your stage of LIFE (not just training), where "should" you be right now?

-Looking at your total LIFE (not just training), where are you strong? List all the ways.

-Do you think that successful doctors ever have rough patches? Are they allowed to hit stages where they are less productive? How do you imagine they navigate through these?

-If a friend shared that she was going through some mental health struggles (like post-partum anxiety/depression, burnout), what would you tell her about setting expectations for her research year?

-If you looked at your whole LIFE this year (including you as a mom, wife, friend, doctor and HUMAN ) what is one expectation of success that you can choose from a place of self love? How will you know you have succeeded?

Hello. I just had a hard day with a child who is whining (1.5 yo) and wants to be held all the time. Naturally, I want to be able to get some things done but it’s hard with a child on your hip at all times! So I put him down, and he whines. The sound of him whining brings up such anxiety/bad mom feelings it’s so so hard to deal with. What I end up doing is trying to finish what I started (ie get myself glad of water without holding him) and he whines. In the middle of my task I try to explain what I’m doing (which of course is wasted effort- he can’t comprehend waiting another 2 min! He’s 1,5!!! What am I doing?!?!)

C: child wants to be held, whines when put down
T: please make that noise stop so I can finish (whatever 1-2 minute task is easier with both arms)
F: anxiety
A: I explain to my 1.5 year old what I’m doing; naturally it doesn’t work and the whining and anxiety continued
R: I just get more and more flustered and frustrated and by the end of the day I’m exhausted and I say things in an annoyed tone to a child who just has separation anxiety, a normal developmental phase.

How can I do this better? Just accept there will be no 2 handed tasks done for a few months?

ANSWER:
Ohhhh- I love this one. I have been YOU. The issue here is not that you have a whining toddler. The issue is the thought: "the sound of him whining brings up such anxiety/bad mom feelings it’s so so hard to deal with" that you believe is a fact. This is not a fact, it is a thought. I will say, as a mother, that the sound of a child crying absolutely triggers an automatic cascade of neurotransmitters and hormones in us that are out of our control and create an instinctual urge to act to quiet them, (this is a fact), but this cascade of events does not necessitate you calling yourself a bad mom. That, my friend is hard to deal with.

What if you could choose how to respond to that hormone release from the crying a different way? How could that actually mean that you are a perfectly normal (even amazing?) mom? If that is a reach, can you at least get to a place of neutrality about this C?

What about this:
C: my kid cries and my body releases hormones creating an urge to help
T: ??
F: ??
A: ??
R: I show up as the mom and self that I want to be

C-i take home call
t-i can't do this anymore
f-resentful, depressed, exhausted, underappreciated
a-cry a lot, complain about home call
r-completely ostracized at work, make more mistakes at work, lose sleep and time trying to give myself the confidence to quit

it's more complicated than this, because i wan't to quit but i feel incredibly guilty. i have been told "it gets better as an attending" but all of my attendings are miserable. its affecting my relationship. its ruined my mental and physical health. i just don't know how much longer i should do this to myself before i try to exit residency.

ANSWER:
Wow, great job on your model! A few notes - in general it's helpful to pick ONE emotion that this thought brings up for you. Try to see what is the predominant emotion. Usually, when you have lots of feelings coming up, it means there are lots of nuanced thoughts in there (for instance, I bet "resentful" is coming from the spin, "I shouldn't have to do this anymore" or "this is too much, they shouldn't ask people to do this" or something, yes?). I'm actually going to take your second layer that you gave us and put that into a model to see if we can create any space there for you while you are making this decision.

C: training includes home call
T: I want to quit, but (???)
F: guilty
A: look with a negative view at your attending's career to confirm your T, close yourself off at work ("ostracize"), vent, complain about the call (I'm guessing to your partner? and others) in a way that affects your relationships in and out of work, lose sleep over rumination about whether to quit or stay, turn the issue over and over in your mind without actually moving forward either way.
R: You create extra misery for yourself and don't change your circumstance

I want you to look closer at this T. Why do you feel incredibly guilty for wanting to quit? Get really clear on this question first, what are the thoughts behind the guilt?
Do you think you shouldn't want to quit?
Do you think wanting to quit means something about you as a person? As a doctor? What?

Bring your answers back here, sister and we will help you work through this deeper level- you are definitely NOT the only one feeling this way!

C-i received feedback that "people would like me more if i came to more social events after work"
T-i don't want to give these people ANY MORE OF MY TIME, >80 hours a week is enough!
F-pissed off
A-still skip events. worry about how other people feel about me skipping events.
R-treated like an outsider at work

For context, I am in a surgical residency that does 36 hour shifts once a week and works from Friday at 6 am nonstop until Monday at 5 pm once a month. I have struggled with this and have expressed this to my program. I asked for a leave of absence last year because I was depressed, suicidal, and needed time off to rethink my choice of being a surgical resident. It resulted in a huge blow up in my program, a change in the call schedule, and everyone hating me. They have told me I don't work hard enough, that they wish I would just quit, that I should feel grateful for the opportunity to take care of people, that I signed up for this, and that my priorities are wrong.

Ever since, I have no friends in residency. I am treated differently. They then tell me I need to come to social events. This has resulted in my peers telling me that if I make a mistake with patient care, it is attributed to me being lazy and not willing to wake up to come in to the hospital and see a patient. When my peers make mistakes, they get told things like "it's ok i bet you are tired since you have kids" or "he normally does a good job, this is an exception."

I feel resentful that they want MORE OF MY TIME when I have already expressed to them that I am struggling with exhaustion. This exhaustion has ruined my relationships, my health, my life. They don't deserve more of my free time. Why would I put in time with people who have already told me openly they don't respect my boundaries and disagree with my values? Why does the fact that I won't go out drinking with people make me a worse resident? How do I survive a malignant program?

ANSWER:
Hello! I'm so glad you brought this here, friend.

I can tell how painful this is for you. I'm not going to try and take you from feeling bad about this to feeling good about this- that's not how this works. What I want to do is ask some questions so you can find where your power is in this scenario. OK?

I want to start with the model you submitted and offer a few suggestions. You did a great job identifying a neutral circumstance on the C- line, and identifying your thought, and the one feeling that thought creates. I want you to get REALLY juicy on your A line. This should be as much as you can think of. What else do you see yourself doing or not doing when you are pissed off? Lastly, the result is always FOR YOU (not for anyone else. Their results go in THEIR R line of their model).

C-i received feedback that "people would like me more if i came to more social events after work"
T-i don't want to give these people ANY MORE OF MY TIME, >80 hours a week is enough!
F-pissed off
A-still skip events. worry about how other people feel about me skipping events.
- you look for confirmation and proof that folks are mad at you
- you imagine terrible things people might be thinking or feeling about you
- you engage in arguments in your head to defend yourself from those things you imagine they are thinking
- you keep your guard up
- you probably don't look for proof that people are on your side (maybe they aren't but if they were do you think you would see it?)
- you spend your beautiful and sacred time away from the hospital being mad about what happens in the hospital
R-You give away EVEN MORE of your time

I want to explore a few things. I invite you to choose ONE of these to chew on and bring it back here for more coaching.
1. You said your feeling was "pissed off"- often anger is a surrogate for another emotion that is harder to name or feel. If you had to guess, what do you think is one layer below "Pissed off" (often for me its rejection, embarrassment, shame, exposure, fear)?

2. The emotion of "pissed off" in and of itself is not a problem unless the result FOR YOU is not one you want. Sometimes, being pissed off helps us defend ourselves, advocate for ourselves/others, and resist the status quo to make positive change. In this case, the result is that you spending even more of your time on this program being angry about it. It is totally fine to stay pissed off if you want. I'm curious, what is an up-side of being "pissed off" in this scenario?

Let's keep chipping away at this. <3

I do this thing where I try to control the future to make it less painful. For example, I look at the ER tracking board and predict which patients will come to me. Sometimes (often, actually), I'm right, and I can prepare and look things up and all that. But obviously, often I am wrong and the downside is spending a lot of the night in dread of what might happen. I'm afraid of giving up this habit (or even stopping as a trial for a night) since being unprepared feels worse than the current dread situation, but I wonder if there's something better out there than these two options.....
Other places I find myself doing it are - preparing for clinic way in advance, packing for trips really far ahead of time, being overly scared about getting sick so trying to stock up on all the things, and generally thinking of ways things could go bad and then try to prevent them from going bad. I think I may be good at preventing badness though, so is it worth it?

ANSWER:
Thanks for bringing this here. I have a few questions for you, and I invite you to choose one and bring it back here for more coaching.

1. Let's get specific about your example of preparing for clinic. Why is it a problem for you to prepare for clinic way in advance"?

2. You said "being underprepared feels worse than the current dread situation". What is it that is causing you to feel dread? Can you sum it up in one sentence?

I'll be here when you're ready.

C: Just moved to a new city for fellowship coming from a community hospital residency to a HUGE academic institution. I'm currently on the consult service.

T: They're going to find out I'm not worthy and I have no clue what I'm doing. They're going to think I'm an idiot

F: Inadequate, dread, shame, doubt, unworthy, guilty because this is what I've wanted for so long

A: Avoid situations, not asking questions that I should be asking

R: Fellowship won't be as fun as I wanted and I'll be hoping the next step after is better.

For context: I just fast tracked from residency into a fellowship where we work with children and adolescents mostly. It's so ironic because I work in a field where we help people with their own thoughts, emotions, and working through their own cognitive distortions, however I still find myself thinking negatively first and foremost about myself, my worth, and my abilities to do things well. I've wanted this position for so long, and am finally able to live with my fiance in the same city. However, the adjustment has been extremely hard for me being away from what I know. New EMR system, brand new hospital, all new people, and knowing absolutely no one. I feel like I have to please people in order to be liked and to succeed. I feel like sometimes I can't be myself or be stern for fear that people will not like me. I feel self conscious for how I write notes, how I collaborate with others, and how I come off. I feel like people are judging me because I'm an IMG and not as "smart" as them because I didn't go to an American med school. I definitely feel imposter syndrome and a heavy weight on my chest because I feel like they really will find me out to be less than what I portrayed in my interviews as if it's a facade.

My previous program director was an absolute prick and really made me think I was inadequate, Narcissistic and machismo, he enjoyed a sense of control and intimidation, but also kept me going with validation that I was doing well with patients. He would mention how I seem very anxious and that made me feel even more self conscious. I do feel a sense of inadequacy. Circumstances surrounding that include that /I come from a small community residency and now am at a big institution with people who look way more official, come from more prestigious backgrounds, and I feel lost. I don't know anyone's names well, I feel like I dread when there's a new consult because I'm not going to know anything, how to deal. The attending also makes me feel intimidated because he comes from a prestigious background and I feel like an idiot when presenting to him because sometimes I get things wrong. There was an incident where he wanted ammonia levels and I saw it but didn't really act upon it- not really sure why. He then mentioned it to me, I felt like an idiot, apologized and he said "well this is why you're here to learn. From a learning aspect ..this is something good to know about encephalopathy."

I dread criticism because I try my best to be a perfectionist although it has its pros and cons. I feel like I've come really far in life, but still have this automatic thought that I'm not good enough or less than.

ANSWER:
Hello friend, and WELCOME!
Thank you so much for your post- I know many people here have experienced similar things to you are describing.

First of all, CONGRATULATIONS! You are doing it! You are living in the same city as your partner and doing the job you've been dreaming of for many years. You are helping children and adolescents learn how to interact with their thoughts and feelings. you are doing what you are meant to do! That's incredible! I want you to linger here in this paragraph for as long as you can. How many seconds can you let this feeling wash over you? hold on to it for one....more....second.

Notice how quickly your brain wants to point out that despite literally accomplishing a dream of yours, you aren't doing it right and people are going to find out. I was just watching a clip of Dr. Brene Brown and Oprah asked her something about what is the most challenging emotion for human beings. Brene said "JOY" and described that for most people, joy immediately becomes forboding and we immediately go to fear of losing everything (or being found out). She offers that the key to softening into joy is willingness to be vulnerable.

Posting this here is vulnerable, and I honor this step you've made <3 Your brain is doing a normal human thing by offering you some thoughts that we can pick through together.

In your model above, I'd like us to get a little more specific- we do this by choosing just ONE thought at a time. (of course we always have more than 1 model running in our heads at a time, but for the sake of this work, we will look at one at a time).

C- Fellowship in new city, on consult service.
T- They're going to think I'm an idiot
F- (what ONE primary emotion do you feel when that sentence runs through your mind)?
A- (Get as specific as you can here, can you list 5 or more things you DO or DON'T do when you feel that F)

R- You don't show yourself or them your best.

In invite you to fill out the F and the A line on that model and bring it back here. What comes up for you as you do that?

C: I constantly see horrible diagnoses
T: One of these awful diseases is going to happen to ME too
F: Fear (of death, severe disease)
A: I avoid activities and spend a huge proportion of time thinking about my own death or the death of friends and family members
R: I don't enjoy life freely anymore even when I feel okay

More context: I am a neurology resident and was found to have a cerebral aneurysm a couple days ago. It feels like all my illness anxiety (that has been going on long before I had a real scary diagnosis) has been confirmed. Every time I see a patient with a disease that just strikes them out of the blue I can't help but feel like it could kill me or someone I love just the same. While this makes me more empathetic to my patients, it is making it impossible to live a normal life. Sometimes I wish I could go back to how my life was before I knew about medicine in this way that has filled me with constant fear. Sometimes I think I am not strong enough or tough enough to work in medicine; everything is too personal, too relatable, too scary for me.

ANSWER:
Thank you for bringing this here- I am certain that this core fear is shared by every single one of us since fear of death is part of what makes us HUMAN. Our brains are literally programmed to imagine the causes of death for us since this was an adaptive behavior thousands of years ago. Now.... not so much.
I'm going to bring your (excellent!) model into your more specific example since you gave a recent C that is touching you:
C: Found out I have a cerebral aneurysm
T: I could die from this
F: Fear
A: Illness anxiety is fueled: Think of it constantly, imagine yourself or a loved one getting all of the diseases your patients get, avoid activities, spend a huge proportion of time thinking about death as a scary outcome
R: Don't enjoy life even when you feel physically fine

Ok. Deep breath. Here is the truth: your thought is true. About ANY C. We could all die at basically any moment. There is no certainty at all, ever in life. Take another deep breath. This is the reality that we are always living in - it's what connects every person. I want to pose to you that this truth, ANY your thinking about it may not actually be a problem for you. In fact, there are many mindfulness based techniques that call our own or loved ones deaths to the forefront to remind us of life's preciousness. Being uber-aware of death may not have to be your achilles heel, my friend, it could be your superpower. The difference is if it's fueled by fear (which creates the problem) or by acceptance, love, or gratitude. Same thought, different flavor.

Now - it's a leap to go from "I could die at any moment and I'm terrified by this" to "I could die at any moment which makes me so grateful for this experience" right? This may be a lifetime's work. But we can take a baby step right now.
Today - let's just start with NOTICING.
Can you notice when your brain goes to your own mortality and create one moment of space around it before your lower-brain autopilots to fear?

C: you remember your aneurysm and consider your own death
T: "Oh! There my brain goes again, thinking about death. I am noticing this."
F: ??
A: ?? Is there any difference, even a small one, between your actions here and the ones above?
R: ???

I know your brain will still go to fear immediately after this. That's ok. That's what it's practiced at, it's familiar. We are just gently nudging it to create even one moment of non-judgemental observation just before or after this moment. Can you try this for a week and let us know how it goes? From one fellow anxious doctor to another - sending love <3.

C: We are struggling with male-factor infertility and just underwent a stimulation and egg retrieval which was c/b me being quite sick with OHSS requiring multiple surgeries (culdocentesis, 1.5 L fluid removed) and an ER visit for stitches after passing out. We had 7 embryos but just found out that only one of them is genetically normal and they now want us to go through another cycle of stimulation and egg retrieval
T: It is a sign that I shouldn't be a mom; I can't go through another cycle with residency. \
F: Trapped
A: Wanting to give up on both having a family and residency,
R: ??? I don't know, I just feel completely frozen and heartbroken. And judging myself for all the feelings and the ways it could be worse.

For context: My husband and I have been struggling with infertility for >2.5 years. We initially thought it was because of my past medical history (eating disorder, PTSD) c/b rough residency schedule. We ended up finding out that it was d/t male factor infertility. I am in a combination program so there is very limited elective time and it feels hard to schedule a pregnancy around required rotations and licensing exams. Let alone 1-2 months to be so sick if I get OHSS again. I already had so many thoughts about not being worthy of being mother because of my own pmh and fears about going through a pregnancy. I don't know if this is related to residency enough to be included here but I feel like being a doctor is just making it all more impossible.

ANSWER
First- just sending you love and care through this. I hope you feel our collective love to you (I'm sure so many women reading this are sending it your way).
Second, great job with the model! I'm going to distill your C a little and bulk up your A line to highlight how you are creating (one of) your result (s):
C: Partner has male-factor infertility and you have been advised to undergo a second stim/egg retrieval cycle after yielding one viable embryo w/ the first.
T: It's a sign that I shouldn't be a mom; I can't go through another cycle with residency.
F: Trapped
A: Consider giving up on both having a family and residency, judge yourself for having feelings that you think could be worse. Guilt trip yourself about your past and look at your prior self in a negative lens. Make your diagnosis mean you shouldn't be a mom (instead of confirming your own strength and making it mean that you of all people should), catastrophize about the future pregnancy and symptoms, lock yourself into only one view of how residency should look that doesn't include navigating health issues or parenthood.
R: You trap yourself by making the decision feel impossible and break your own heart

Here - your thought is creating a result for you. Can you see that?
I want to stay here with this thought and find out how true it feels for you. I also want to see if you are able to "play" with this thought in a way that feels less heavy to you. I wonder - can you write a paragraph about how the opposite is true? Try this: How is your current situation and your past proof that you SHOULD be a mom? List every way you can think of. Write out how your past experiences have equipped you to deal with what might be in the pipeline for you as a mom and doctor.

If you are up for it, you can play with the second part of the thought as well in the same way (what are some ways that you could go through another round in residency? Even if you do need to take time off - have you ever heard of other doctors needing to take time during residency? How might this look for you?).

This challenge is NOT to tug you to change your mind. It may be right for you to decide not to do another cycle right now, or it may be right to decide to. I don't know the right answer for you, but I do know that your current thought is narrowing your options unnecessarily, so all this challenge does is create some extra space and breathing room in your mind so that you can look at all angles. Bring whatever comes up back here!

I was supposed to be out of town for this long weekend but had to cancel plans because my dog was sick (she’s fine now). I was on inpatient last month, so I was excited to get out of town and be in a different place. I was expecting to relax, eat out, just hang out… and maybe fit in a few work/side project things in my free/down time. Now that I am in town for the weekend I feel like I have just been wallowing every day. Its sort of a yo yo between feeling like I’m doing nothing or have nothing to do (and I guess innately feeling like that is a bad thing), and also feeling like I should take this time to tackle more of my to do list (work and not work) than I would have if I had not been in town. I don’t feel like I’ve really enjoyed my down time, but I also don’t feel like I’ve been very successful at making the most of my time. I think if I had been excited to leave town to also help me get into the relaxation head space. Ever since med school I’ve felt this pressure to “make the most of my time.” I remember trying to make a single day off the most jam packed agenda plus fitting in studying. But as residency has gone on I am more inclined to do less on my days off, but I still judge myself for that sometimes. It’s like staying in town and not having a ton of plans is a waste of my time. I think I would like to be grateful to have a weekend off (regardless of what I do), but I am not sure what thoughts would be best to get there and feel authentic

C: it’s the weekend
T: “I must maximize my time!”
F: disappointed
A: lots or pressure, hard to achieve what I want, wallow
R: don’t appreciate my weekend

C: its the weekend
T:
F: grateful
A:
R: appreciate having the weekend, return to work feeling rested and content

ANSWER:
Hi There! This is such a great thing to bring for coaching, friend. Great job on your awareness of your models. I'm noticing you want to move from your first model (which feels bad), to a new model (that feels good). This is totally normal... OF COURSE once you are aware of how one way of thinking is not having a good result for you, you want to get right out of it and feel better. But as you've noticed, your brain isn't moving as fast as you want it to and before you can work on changing your thoughts we want to take a closer look at some things.

You have some rules about what is or is not a good use of your time, and what it means to be productive.

I'm curious about 2 things, I invite you to chose one and bring it back here for more coaching.
- How do you know what's a waste of your time, and what's a good use of your time? Make a list of things that are NOT a waste of time and why, and things that ARE a waste of time and why. make it as juicy as you can 😉

- What would you be allowed to feel if you utilized all of your time with maximal efficiency? Why?

<3

I have a lot of residency experiences that are kind of just sitting a box that I don't know what to do with. I had my intern year of residency in the pre-COVID setting but everything after that was in the COVID times, which gave me some really heavy experiences. I think everything in the box is all wrapped up, with sadness, grief, anger towards residency admin, feeling like no one knows what happened, feeling justified in my feelings, and feeling like I didn't have it that bad and shouldn't feel that way. I also know that all those experiences changed me and how I look at the world, how I care for and protect myself, and how I engage with work/patients. Its not something I'm dwelling on each day, but keeping with the box analogy, its in the corner, I look in it every now and then and still don't really know how to put it away or organize it, so I just leave it in the box. I just started fellowship and have a much different work/life balance, so I don't feel like I will have more situations like I did in residency. I could just tell myself that all of the bad experiences made me stronger and feel grateful for them, but then I feel like its me accepting how unsupportive our leadership was at times, how they didnt protect us,, and also accepting that so many of my patients who died from COVID "made me stronger", which feels disrespectful to them.

I can try to boil it down into a CTFAR as best as I can, even though I know there's a lot of different things wrapped up in each other.
C- Residency experiences were intense and heavy, more so because COVID
T -I feel like the experience weighs on me, and I don't know where to go with that. I feel like I need to do something with it but cant.
F- sadness, anger, injured
A - thought loops about past experiences, anger towards residency admin, thinking about patients I've had. wishing I didn't have to go through all of that. Commiserating with co-residents about the past.
R - perpetuating cycle of the same negative thoughts, distracts me from the present, makes me feel down momentarily. feel like I'm stuck in the same loop so I don't try to process it and just leave it as it is.

What is a good first step forward?
Thank you

ANSWER:

Hi Friend,
Thank you for bringing this here. This is so important.

I think everyone would agree that the pandemic brought innumerable reasons for us to experience grief, sadness, anger, fear in ways we wouldn't have if COVID never happened. It brought reasons for connection, service, compassion, and love too. Each of us may have felt those things for different reasons- all of which are valid, and we sometimes hold conflicting feelings at the same time (sadness and gratitude, or grief and love, for example).

You will experience anger, grief, sadness (and many other uncomfortable or "negative" feelings) because they are required in the human experience. None of us make it out without feeling them. We call these emotions "clean pain".

RESISTANCE (to what did/didn't happen, what admin did/didn't do, what you do/don't feel) is what is causing pain for you now. We call that "dirty pain", because we add it ourselves by wishing or believing it could or should be different than it is.

I have a few ideas for you to explore and bring back for more coaching if they resonate with you:

1. We usually think that ACCEPTANCE of what and how things happen requires our APPROVAL that they happened that way (or at all).
I'll offer that you do not have to approve of something to accept that it is.
Can you think of examples of how this true?

2. I can tell that you have some resistance to feeling sadness/grief/anger because you said "I didn't have it that bad and I shouldn't feel that way"
How might it be true that you SHOULD feel those things?

We will be here as you unpack that box, friend. <3

I was recently diagnosed with a rotator cuff injury and am supposed to start PT. I went to my first appointment, but most of it is about doing the work at home. I struggle with trying to create new healthy habits, and integrating PT exercises into my day seems like just another task that I don't have time for. And one that I see myself committing to, but not being able to achieve in the end (like exercising, this stretching program I wanted to do, meditation, etc. etc.). Here goes my model:

C - I have a rotator cuff injury and was assigned PT
T - I don't have time to do PT
F - Overwhelmed, stressed, fear of failure
A - Make more lists/schedules, try to prioritize things, set unrealistic goals, beat myself up for not being able to make a simple change, resent my career choice for giving me chronic stress injuries and not enough time to manage them
R - I become less motivated, continue to have daily shoulder pain

My mind knows that in the end it will be better for me to be in less pain, but it's hard to find the motivation and I have so many other competing priorities. Thanks for the thoughts!

ANSWER
Fantastic model, friend! Love that juicy A-line, which clearly summarizes your result.
Here you are holding two models: the one you wrote, and also this one:

C - I have a rotator cuff injury and was assigned PT
T - in the end it will be better for me to be in less pain
F: ???
A: ??
R: ??

Can you fill in the rest? What feeling does thinking about caring for yourself create?

This is normal for habit change - the cognitive dissonance between wanting to do something and also NOT wanting to do it in the moment is what behavior change is all about, and why most people end up feeling even more guilty without any actual change. A good

The trick is to not battle the first model, but to simply allow it to be there, and decide ahead of time what your "winning" thought will be. If you decide (ahead of time) what you would like to do and commit to doing it no matter what, then your work is to simply allow the overwhelm and fear to be there without listening to it. All of your thoughts are simply data, not directives. The first model is trying to keep you safe in some way (see if you can understand what staying there is doing for you, even if misguided), so we can let it float by without being mad, but also without listening to it.

The first question to gaining some perspective around this first model is:
-How is it (also) true that you definitely have time to do your PT exercises? List all the ways, even if you don't like some of them. Get creative here.

I matched for a one year fellowship following multiple years of training at a different institution. My fellowship program indicated they would likely be hiring for more faculty positions in the coming years. They have a track record of hiring former fellows and it would be a dream come true to work here long term. I am starting fellowship next week and just found out they posted an ad recruiting for new faculty. Now that it's *actually true* that they are hiring, all of a sudden all of my imposter syndrome feelings are coming up. To add to that, I had to start late because of parental leave at my prior program so I haven't even started working yet and somehow I'm supposed to apply for a job there?!
If I had to put it in the model:
C- [new program] is recruiting for attending positions this year
T- there's no way I'm qualified for this, I haven't achieved enough yet to be an attending, they probably are already annoyed I had to start late, I'm going to do something dumb clinically when I start at this completely new institution and they'll think I'm an idiot
F-inadequacy, fear, avoidance
A-avoid working on an application, act anxiously/awkwardly at work instead of confidently
R-apply late, not even apply, not get the job, reinforce all of my inadequacies

How do I convince myself that the thoughts I'm thinking are invalid or at the very least unhelpful? Is there a way to 'fill myself up' with different thoughts to drive different feelings and actions?

ANSWER:
Hello! What a PERFECT thing to bring here.
I want you to pretend you and I are sitting on the couch and we are watching this like it is a movie:

It's the last big scene.... our heroine has made it THIS FAR! She is ALMOST THERE and there is nothing between herself and the thing she's been dreaming of forever except this sneaky little voice (we will call it the "Inner Critic") inside her head that says "You're not qualified for this, all of that work you've done over the past 10 years is not enough, you're going to mess it up, they'll think you're an idiot".

If we are the audience and we are watching this movie, it's not a surprise to us that this is the moment when our character's inner critic gets LOUD, right? It's been in the background waiting it's turn and now it's coming in hot. the Inner Critic says, "It's my time to shine! let me tell you ALLLLLLL the ways you can't do it, despite literally YEARS of evidence to the contrary, take a seat".

Right?

Here's the thing:
What if the Inner Critic is just trying to protect you. What if she, albeit misguidedly and loudly, wants to do everything she can so you don't have to feel exposed, vulnerable, disappointed, rejected, embarrassed, or ashamed. She thinks she's helping you by making sure you feel inadequate now so you don't have to feel disappointed (or worse) later. This is her MO.

The first step, after becoming aware that your Inner Critic exists and before you can convince her that her thoughts aren't helpful is to enter into a dialogue with her with much interest and curiosity as you can.

Ideas for you to consider and bring back for more coaching:
1. What do you think your Inner Critic wants? What is she trying to protect you from?

2. What would you like to say to her?

I'd love to continue coaching on this friend, and I invite you to bring back whatever comes up for you here.

<3

Thank you for the fast reply!

1. What do you think your Inner Critic wants? What is she trying to protect you from?
-exactly as you said - she's trying to protect me from all the things you mentioned - applying for the job and not getting it exposes me to SHAME, embarrassment, disappointment, letting down my family and having to move AGAIN, proof that everything I feared about myself is true

2. What would you like to say to her?
-my first inclination is to tell her to STFU
-but I think you're going to tell me to approach her with love and compassion
-maybe I could tell her that maybe it won't be that bad if I do apply and don't get hired and try to convince her
-or maybe I could tell her maybe it will be bad - it will hurt a lot - but if I'm already feeling all those bad feelings [dread/shame related to avoidance] she's inducing in me - then what is she really protecting me from?

what do you think?

ANSWER!
Yay! Thanks for bringing this back!

I'm curious... let's see what happens when we put a few options into a few models...

C- Your inner critic says "you're going to do something dumb"
T1- "STFU"
F1- ?(how do you feel when you tell her that?- ONE emotion)
A- what actions do you take from that F?

T2- "It won't be that bad if I apply and I don't get hired"
F2?
A2s?

T3- "It might hurt a lot, but this hurts too"
F3?
A3s?

What happens when you look at these separately?

Response to the coaching from my first post, struggling to go on. (Thank you for answering!)

"I want you to look closer at this T. Why do you feel incredibly guilty for wanting to quit? Get really clear on this question first, what are the thoughts behind the guilt?"
I feel guilty that my family and partner sacrificed a lot to get me to where I am now, and I'm not happy with my job.
I think that quitting would make me a habitual "quitter" and that people would see me as lazy, unwilling to do hard things, quit when it gets tough.
But then I feel even more guilty that my partner and family has to put up with me STAYING in residency if I stay. I am miserable, I cry all the time, I never have time for them, I sleep a lot, etc.
I've had to make a lot of personal changes to stay in this job. I'm now on antidepressants. I worked through the embarrassment I felt of needing those a long time ago. But it has since caused me to gain a lot of weight and now I feel guilty I'm not as attractive as a partner as I used to be because I do not feel attractive or pretty. I feel like I'm letting myself go. (Will make a separate post likely on trying to lose weight/taking care of myself)

This is probably way too much to bring here, but that's my deep dive / thought download on the question.

ANSWER:
Thank you for the authenticity here! This is deep work worth doing, and I promise you are not the only one wrestling with this. Let's look at one of these thoughts in a model:
C: Decision to stay or go about medical training
T: I'm no happy with the job, but quitting would make me a habitual "quitter" and people would see me as lazy, unwilling to do hard things, quit when it gets tough.
F: Guilty
A: View both decisions through a strong negativity lens (focus on how residency pulls you away from people, "makes" you miserable, blame it for your C of depression and weight gain, and beat yourself up by saying you have let yourself go) and (spin a story of how if you quit you would quit other things, beat yourself up for being lazy, make yourself a villain for controlling where your family is and what they do, and catastrophize about what you think others will think of you if you quit).
R: You create a lose-lose situation.

Ok. Your brain is really trying to protect you here - it's playing out all of the worst case scenarios because it thinks by doing so it can prevent them from happening. But actually, you can not ever control other people, or the future - so not only can you not prevent things, but you are living both worst case scenarios for yourself NOW.
You are spending a lot of time worrying about what other people are thinking and feeling of and because of you - but in actuality, not only can you never create thoughts and feelings in other people, but you never even get to know what they really think.

Let's instead focus just on YOU. Let's start to unpack some of your core beliefs here:

Are you sure quitting once makes you a quitter forever? Have you ever stooped doing something before?

So what if you are unwilling to do hard things? Why do you think you must do hard things? What are your thoughts about people who decide to not do a hard thing? Could you be wrong?

I invite you to bring this to live coaching - (in multiple stages of your work!)- it's the best way I've moved the needle when I've found myself stuck, and you would be also benefitting so many of your peers.
If it doesn't feel right, keep coming back here! Sending so much love to you in this journey.

So often I find myself just feeling stressed and anxious and not being able to pinpoint what it is that's bothering me. I find myself snapping at my husband, avoiding doing work, and just having a general feeling of not having anything left to give to the people around me. When I try to work through the CTFAR model, I often can't think of what the circumstance is.

C - ?
T - "I feel stressed."
F - tremulous, nervous, tightness in chest,
A - going to sleep early to avoid talking, snapping at my husband, watching TV instead of being productive so I can just zone out
R - I end up not getting done any of the work I need to get done and act grouchy towards my husband leaving me feeling even more guilty and stressed the next day.

But I have trouble pinpointing what exactly the circumstance is that's making me stressed and figuring out what I can do to change it.

ANSWER:
Great awareness here. It can take a bit of practice to tease things out. If it feels like a challenge, that's OK and it doesn't mean you're doing it wrong.

I picked out a few Cs that I think we'd all agree on, and I want you to move "Stressed" to the F line.

C-you are a human, in residency or fellowship training, have a husband.
T- ?
F- Stressed (feels like tremulous, nervous, tightness in chest)
As- avoid talking, go to sleep early, snap at husband, "zone out" on TV

It's not the Cs that are making you feel stressed, it's the way your brain is making meaning out of those Cs and narrating it to you.

I bet there are 10+ reasons you could feel stressed right now in your life. What might they be? I invite you to list as many as you can. Be as petty and mean and whiny as you want. We have no judgement here. Let it all out, sister <3

C- Your inner critic says "you're going to do something dumb"
T1- "STFU"
F1- ?(how do you feel when you tell her that?- ONE emotion): it feels kind of ... powerful? (I can't tell if this is the 'wrong' answer or if you're trying to guide me towards something different). Like I can just say, hey, knock it off Inner Critic Self, you should know better than this.
A- what actions do you take from that F? Can sort of reorient myself to a more normal way of thinking about clinical work. Knowing that no one enters a training program knowing everything, because why else would they be there. Working on being inquisitive and curious rather than stiffly trying to save face all the time. Knowing that even if I make a mistake it's more about how I work through it than about whether I made it in the first place. And knowing that I've been working in this field for long enough to know how to do all of that.

T2- "It won't be that bad if I apply and I don't get hired"
F2? Is lying a feeling? Or at least insincerity? Maybe the feeling is 'incredulous' because it strains credulity to think that this wouldn't be painful.
A2s? Still having the bad feelings and then being annoyed at myself that I can't overcome them just by lying to myself.

T3- "It might hurt a lot, but this hurts too"
F3? This thought makes me feel somewhat serene. Almost zen-like. Like if I were the kind of person who could make this their primary thought, I could then imagine I'm the kind of person who could experience rejection and let the feelings wash over me, experience them, and then move on with some sort of acceptance or peace.
A3s? seems like this could help me neutralize the feelings of inadequacy, shame, avoidance, dread, etc etc that my Inner Critic is imposing on me. If I can have some confidence that even if the worst outcome comes to pass I will survive it, maybe my I.C. wouldn't have to fight me so hard right now.

Answer:
Well done! Our questions are always meant to help you explore your thinking so you can choose the thinking habit that serves you best. I promise I am not trying to lead you anywhere, and there is no "right" or "wrong" answer. 🙂

It looks like each of these paths takes you down a slightly different road. Here is what I see as the Rs

Model1
T1- "hey knock it off, IC!"
F1- Powerful
A1- (as you listed)
R1- You engage in a gentle but critical dialogue with your inner critic (ha!) and you have your own back.

Model2- this one does not take you where you want to go...
T2- "This won't be that bad"
F2- Incredulous
A2- (as you listed)
R2- You kind of gaslight yourself and then use it as a reason to be annoyed and beat yourself up further.

Good to know!

Model 3
T3- "It might hurt a lot, but this hurts too"
F3- serene
As- experience feeling like rejection without fear or resistance,
move forward with acceptance or peace
build confidence in your ability to handle these emotions while having your own back
you demote the inner critic to a less prominent position at the table in your head.
R- You accept the human experience as one that has pain but also all of the other things you want in life too, supporting yourself as you move through it with less resistance.

All of these models (and many more more) are available to you. I can tell that model 1 may be available to you right now, and model 3 feels like a stretch.

What comes up for you as you look at these result lines?

<3

I am stuck. After so many years of hearing "it gets better after ___" i am tired of waiting for it to get better. I finally finished my first year of fellowship and I am heading into the research years but now I just have so much time where I just wonder if what I am doing is right for me and so I procrastinate doing anything at all, then feel guilty for underperforming/not meeting expectations, etc. I feel so burnt out but the thoughts around leaving or changing what I am doing challenge everything have worked towards since high school. When I decided to go into medicine I already knew i wanted this particular specialty, so I have had a singular goal for 15 years and now I am realizing that it may. not be what I want.

Cue the existential crisis.

I think I love the medicine aspect of my specialty, interesting patients, i connect with them which I love. And my division is overall wonderful. However, I don't feel like many of them are thriving and work life balance is few and far between. I WANT A LIFE! one that exists outside work and is robust and full of things that give me an identity again! I worry i cant have that if I stay here or even in this specialty. (For context - it is a small pediatric subspecialty and leaving my current institution despite loving the city and wanting to stay, would mean moving multiple states away. In addition, most if not all positions are in academia and i just do NOT want to do research but the full time clinical load at my current location seems unbearable. Also, if i leave for a smaller location it means more call (Big division = 8-10 providers, small =1-3). I feel trapped but I enjoy the medicine and the patients so I do not quite want to leave. How do I craft a life that fits me? Especially when i still operate on a mindset where asking for or making time for what I want/need is so difficult and if i do muster up the courage to ask for it I feel selfish.

Taking a stab at the CTFAR --
C - small specialty with limited job flexibility
T - I will never have the life I want
F - hopeless
A - spiraling constantly - should I leave my specialty? medicine? should i stick it out for 2 years then decide?
R - Unhappy, dreading work, grumpy

================================
ANSWER
Hello soul sister! Your brain is trapping itself, just like all of ours does. You believe you are trapped between two impossible choices, but what I want to show you is that it's just your black-and-white thinking that is trapping you. Here are a few examples of where you've given zero wiggle room:
-I love the specialty, patients and division, BUT I can't have a life outside of work if I stay here.
-I don't want to do research or full time clinical work, but I have to pick one of those.
-If I switch to a smaller program, life will get worse with more call

BUT there is brilliance in your post. You wrote: "How do I craft a life that fits me? Especially when i still operate on a mindset where asking for or making time for what I want/need is so difficult and I feel selfish doing it." That's just it, my friend! Dig in here. Answer that question and pretend there are no limits: how DO you craft a life that fits you? First step is to write out exactly what that looks like. All the parts.

Then the second part is working through your unnecessary mindst that it's 1) difficult and 2) selfish. Neither of these are a Circumstance, which is great news.
Let's pretend for the next week (or month?) that is IS possible to stay in your specialty, your location or wherever you choose and craft the life you want. Even if you don't have any examples of people that have done it before you - can you start exploring what it would take? Who might you go to for help? Who would you want to connect with (hint: maybe you don't know them yet). By focusing on this empowering question, you will put your brain to work figuring out how it CAN happen, rather than it's default which it telling you all the ways that it CAN'T. This exercise will be important to practice no matter what you decide, a strong black/white negativity bias towards our future is rarely helpful. Getting out of the victim/disempowered space, you are teaching your brain to take control of your life in the way that it wants.

C - my specialty
T - I wonder what it would look like to have exactly the life I want
F - ????
A - ???
R - Start creating that life now

C- Someone mentions something in a clinical context that I don’t fully understand/ know enough about
T- Omg I have no clue what we are talking about / I don’t know what this piece of information means/implies, and I should definitely already know this since I’m the fellow
F- Overwhelming anxiety/ feelings of being flustered/ wishes that I could disappear into the wall even though this is a Zoom call and no one yet knows/ has figured out that I’m an idiot/ I have no clue what we are talking about
A- Tell myself that I have to read more/know everything (all while knowing that’s not possible) and not doing anything to actually make progress on learning things (because who has time for that when on my best days I’m rushing home to hopefully have a chance to see my kids
R- Nothing really changes; I continue to grow in my clinical knowledge on the “moving sidewalk of medical training” but there are still so so so so so so so many things I have to learn/know more about and I remain nearly terrified of becoming an attending soon; am frequently terrified knowing that I will soon/ultimately be found-out to be a fraud.

ANSWER:
Hello Friend,

Alright, great work bringing your model! Before we dig in I want to give you a few notes. We always want to look at just ONE thought at a time. Of course we are thinking hundreds of thoughts all the time, but for the sake of this meta-cognitive practice, in each Model, I want you to pull ONE thought and ONE feeling that the thought evokes. The other important thing that we want to do is make sure the C line is objective. Your C line presumes that it's possible to "fully understand" and "know enough". These terms are very subjective, I know that because a) as human beings it's impossible for us to "fully understand" or EVER "know enough" right? We will always, always, always be exploring and learning,

So... Let's look at it a little more granularly

C- You are a fellow on a clinical service having conversations about medical concepts (I think everyone would agree that these are facts, right?)
T-I have no clue what I'm talking about
F- Flustered (how does this feel in your body? can you describe it?)
A- hide/withdraw, berate yourself, set unrealistic/impossible expectations for yourself,
(what else do you do from a place of "fluster"? What do you NOT do?)
R- You don't create a safe space for yourself to learn and grow

Now, we NEVER want to use the model as a tool to beat ourselves up further, OK? It's just to show you your thinking.

Here's what I want to offer you:

Just because you have this pattern of thinking does NOT mean something is wrong with you, and does not mean you are doing it wrong. In fact, it comes from a value of deep CARE about learning, growing, and developing your skills so you can best serve your patients, Your brain is just going about it in a not-so-helpful way.

Your brain is doing EXACTLY what it has been conditioned to do by your socialization and experiences. It is going overboard trying to protect you from exposure, rejection, embarassment, and all of those uncomfortable things. It's really trying to help.

But now, you're onto it, and you see that even if this way of thinking was helpful in the past, now it's not only unhelpful, but potentially keeping you from fulfillment at work and at home. Good to know.

The first step is to just notice that this thought pattern is there and to step into a "watcher" space, being curious and nonjudgemental.

Here are a few things to chew on and bring back for more coaching:
1. I invite you to look for the upside to the voice in your head- are there pieces of what she is telling you that might be helpful. If so, what/why?

2. what would it take for you to believe that you "Knew enough"?

<3 Bring it on back here, sister.

I’m a late person, I always have been. I know that my thought patterns contribute and I need help working through them.

I hate the way being late makes me feel and how it makes me look to other people (rude, irresponsible, untrustworthy).

I notice that I can put together a full plan on how to get to work on time, including a timed checklist of tasks, but when it comes time to execute, I talk myself out of it.

Here’s what my model looks like:
C- it’s time to get in the shower so I can be on time for work, according to my post-it
T- I don’t want to. Getting ready is boring. [Depending on the circumstance, I’ll think:]
1- Let me spend a little more time on my phone zoning out on Instagram or playing a game. I hardly ever get time for myself anyway. I’ll just get ready really fast, it’ll be fine!
2- I JUST got started on this [research task, reading/laundry/other chore], I’m in the zone and I should really keep going. I’ll just get ready really fast, it’ll be fine!
3- [Lose track of time completely, realize with a jolt it’s time to leave, still spend the same amount of time getting ready because:] “I’ll just get ready really fast, it’ll be fine!”
F- swing between irrational optimism, anxiety, and despair
A- leave for work late, arrive very obviously late or at best only right on time or one minute late but stressed and sweaty.
R- continue to feel disappointed in myself, presume others hate me.

Help- how do I break the cycle?

ANSWER:
Hello friend!
I'm so glad you brought this here. If I had a dollar for every time I justified my procrastination through "irrational optimism" and "It'll be fine!" thinking, I'd have about a billion dollars right now. You are not alone! My brain likes to offer me the thought that I should only get out of bed when the minutes are in a multiple of 5, and it's VERY CONVINCING that this is a totally fine reason to stay in bed (and subsequently be late for work). Our brains are so tricky! 😉

So here is what is happening- you have a toddler living inside of your head and she just doesn't. wanna. do. it. You and your rational adult brain are pleading to her like "Pleaaaaase, please, it's important to me that we get to work on time" and the toddler is like "Nope, I have all the reasons not to get ready right now, and I'm in charge here!" Then, you engage in a tug-of-war with her, and surprise! no one wins! (if you've ever argued with a toddler, you know this is true, no one wins)

OK- Nothing has gone wrong here, your inner toddler is used to getting her way, and now you're trying to change the rules on her and she is going to throw a fit. That's fine, we will figure it out together.

First I want to offer some feedback on this model so we can look at one thought at a time. So a few pointers:
1. the C line needs to be very objective and factual
Ex: It is ___am, signout/1st patient is at ____am. I have not showered yet.
2. for your T line choose ONE thought.
3. on your F line, choose the main emotion that thought creates for you.

I invite you to explore one of these prompts and bring it back here for more coaching:

1. You said "I hate the way being late makes me feel". what is the feeling you have when you walk into work late?

2. What is the main justification that your inner toddler uses to convince you not to hop in the shower at the time you said you would? Why does she think that's a good reason?

Bring it on back here, friend. This is worth your time <3

C: My husband's love language is food, in particular he feels loved when someone cooks for him (and expresses love by cooking)
T: I am not good enough at cooking to cook for my husband in the way that he needs/wants (was considering putting this in the C line because it's a #fact)
F: Annoyed that cooking is his love language, annoyed that he needs more from me
A: Several times that I have tried to cook for him it has gone very poorly (he gets mad at what I've chosen to make for example), or will come up with several reasons why I shouldn't even try, which disincentives me from doing anything to achieve this goal
R: I make minimal to no efforts on this front even though I know how important it is to him and to our relationship

ANSWER
Nice insight! I'm going to distill your model to make it extra precise and concise here:
C: My husband SAYS he feels loved when someone cooks for him
T: I am not good enough at cooking to cook for my husband in the way that he needs/wants (lol I'm so happy you left it in the T line b/c it's def a #thought!)
F: Annoyed
A: Negativity bias towards prior attempts, make your success contingent on his reaction, come up with reasons to not even try, disincentive myself from cooking at all
R: Prove cooking isn't even worth trying at, and don't show up with love

Ok. I know your T feels like a C here, but please believe me that it's not. What if, in fact, what your husband really *needs* is not someone to cook delicious food, but just someone that makes an effort to love him? Perhaps a hilarious Pinterest fail ends up bringing you closer together. The truth is that actually we never get to know what another person needs. Even if they tell us outright, we can't be certain that that is a #fact, since we are all just doing our best to manage our minds, which isn't always perfect. This is great news, since then you can LET GO of his model. Just gently hand it back to him, and stay in your own model since you can't control him anyway.

Let's put him aside for a moment. Let's pretend that there are love languages for SHOWING love, not just receiving. Since you can only control your own mind and feelings, let's see if you can get in to a love feeling:

How do YOU want to love your husband? When you are feeling love for him, what actions do you do (or want to do)? Extra credit if you can find a thought that you believe today behind that action and feeling.

C: Husband
T: ???
F: Love
A: ???
R: Show up with love

Bring a new model back here, and/or questions that come up with trying to do this work!

Hi coaches! As a fellow that takes home call, I have to practice judgment on whether I think a patient call necessitates notifying my attending. Over the weekend, I triaged a pretty straightforward call, so I thought. But come Monday morning, my attending let me know that I had misjudged and her personal preference in clinical management was more conservative. She said it is really "fine and not a big deal" but just wanted to talk about it. The patient ultimately should not be harmed and still received the appropriate care, albeit delayed. The clinical question from the call is a relatively straightforward issue, one that we learn in residency.

C: received a patient call over the weekend that I triaged incorrectly which lead to my attending addressing the clinical scenario with me
T: how could I have judged this incorrectly? I hope the patient is not harmed. It's a straightforward clinical issue that I should be familiar with from residency. This attending probably thinks I'm an idiot and won't trust me anymore as a physician.
F: guilt and inadequacy with embarrassment
A: label myself as a dumb physician, and continue to ruminate on the issue all day which leads to decreased productiveness
R: ... I'm having a hard part with the R... The immediate result is that I've wasted time and energy on this issue that my own attending said was not a big deal.

Logically, I know this was not a big clinical issue, no harm was caused and I can learn from the situation. But help! Irrationally, I still can't help but blow this out of proportion, feeling inadequate and guilty, which is typical of my reaction in most work scenarios where I have erred.

ANSWER:
Hello!

What a good thing to bring here! This is a PERFECT example of how subjective this practice of medicine can be.

Here are the Cs:
You are a fellow who takes home call.
You got a consult.
You triaged it based on your experience and did NOT alert your attending
You are not a mind reader.
Your attending has thoughts and said words to you including "It's fine and not a big deal"

Looking at your C line, "I managed this incorrectly" is actually not a circumstance, it's a thought. Here is proof:

YOUR MODEL:
C- Patient details go here (this complaint, the labs, the exam, etc- OBJECTIVE THINGS)
T - "This is pretty straightforward"
F- ? (Certain? Secure? Responsible? what was the feeling in the moment of the care)
A - review the chart, make/enact your plan, communicate what you think is needed to the team, whatever else you did in the moment
R- You took care of the problem based on your assessment of risk

ATTG's MODEL
C- Same exact pt details go here
T- "I would have liked to know about this sooner"
F? (we can only guess about their model..... but perhaps this is responsible? nervous?)
A- she talked to you about it, shared about her communication preferences/set expectations for the future
R- (For Her) is that she communicates what she would like in the future based on HER assessment of the risk.

OK so you had ONE thought about the patient and your attending had ANOTHER thought about the patient. I bet if we asked another attending, they would have ANOTHER thought about it. Who is to say what is correct or incorrect?

Your thought "I triaged that incorrectly" puts you into this model

C- Patient X while on call
T-"I triaged that incorrectly"
F- How do you feel when you think that? choose ONE feeling (guilt? inadequacy? embarrassment?)
A- beat yourself up, ruminate, etc, look for where you are wrong, find proof.
R- You block yourself from learning AND block yourself from showing yourself what you DO know.

Your brain is doing something it has been trained to do for MANY years--Find the single best answer. It's right or wrong. Correct or incorrect. Right? Look, we made it where we are because our brains can find the "single best answer" on a multiple choice test. Literally, we were selected FOR this skill. Then we arrive in the clinical milieu and see that there are a billion different answers. Some may be better than others, but most of the time "correct" and "incorrect" are VERY SUBJECTIVE. That is what makes the "art" of medicine!

Here's what I'd like to offer you: The whole point of medical training, and the reason you aren't an attending yet is because you are learning to CALIBRATE your thinking by coming up with a plan and then getting feedback on that plan from people who have been doing this a little bit (celestially speaking) longer than you have. You could have been on service with a different attending that night and they might have thought you did this exactly right and given you no feedback at all. would that have been the "correct" way to handle it? Who can say?

Training exists to help you calibrate your clinical reasoning so that when you are out on your own, you will have informed your practice based on the practices of many other smart and experienced people who do that job and thus be within the standard of care. That's it. That's the goal.

A few things to chew on and bring back here if it resonates with you:
1. What do you think your attending was worried about that led her to offer you this feedback?

2. What is this patient and this experience teaching you that you didn't know before?

3. If you were back in the scenario with the same information you had then, would you handle it differently knowing what you know now? why or why not?

Hello. I just started my residency in July and had to move to a different city. Since moving here, my boyfriend has tried to come every other week to stay with me. He has to drive a couple of hours to visit me, which has really strained our relationship. There have been several things from the beginning that I noticed, for example, he is very "serious" and "dry" and I feel like I am always the one who needs to approach him to get a hug or any physical affection. Also, whenever I am sad or stressed out or even crying I don't feel like he really gives me any words of encouragement or that he tries to console me. He is a man of a few words and I really like talking which has been really a problem for us. He also worries about finances a lot and even though I am very organized with money he stresses out about it because he feels we're not compatible in that regard. He has complained a lot about how much money he is spending to come to visit and how hard the driving is on him. We have talked about marriage in the future but I am having doubts as I don't feel I am completely happy but then I don't feel brave enough to end our relationship as he is a nice person and I don't want to hurt any of us. He also has real anger issues and I think I have a very stable mood, so that is something that really makes me uncomfortable whenever he gets mad (he just started going to counseling for this). He didn't have a good childhood and his family is not a very close one, so when I talk about how I want to help my family in the future (morally and financially) he doesn't understand it and only agrees to a certain extent. He wants me to give him a guarantee that things are going to work out with me as he "doesn't want to waste four years of his life if I break up with him at the end of residency".

Residency has been a tough learning curve for me as I am from another country and I have no family or friends here, sometimes I feel that that's why I am hesitant to end up things with him because I really have no one else and I get overwhelmed. I keep telling myself, "I would be happy with him if we get married someday, but I don't think I'd be as happy as I strive for". On the other hand, he has been supporting me since the beginning when I was applying for residency and I feel guilty for even thinking about ending things up. I try to justify that the way he is is not his fault but just a consequence of his circumstances and the things he experienced growing up. We are very different personality wise but I feel like he has been trying to adapt and I have tried too as well.

All this has been a lot to deal with as I feel very alone in this new country and residency has been very overwhelming for me. Me and my boyfriend decided to take a "break" to not talk to each other and see how we feel, and we are going to meet soon to talk about it and decide if we continue or not. I just don't know what to do because I do care about him but I just don't know if we are meant to be together or not.

C-Residency has been overwhelming and I had to start a long-distance relationship. My boyfriend and I are very different personality-wise (introverted vs extroverted, one is very affectionate, the other not so much, he worries a little too much about finances whereas I try to plan and balance things more). He is also already asking me to commit to only going to these 2 states in the country for fellowship so he can keep his job "as he doesn't want to give up his career for me" but I have explained that is not that easy).
T- I don't feel like my boyfriend is really in love with me because he doesn't seem to want to support me in my career choices or how I want to help my family in the future. I feel like he sees me as an investment and wants to have a guarantee he's not going to lose me ( in fact he has mentioned it as an analogy). But I also think I am being selfish and a bad person for thinking about ending our relationship as he hasn't been "bad" with me and has been there since the beginning of this process. I don't want to be unfair but I don't feel completely happy.
F- Confused, overwhelmed, sad, undervalued, stressed.
A- We decided to take a break to see if we miss each other. I do miss him a lot but I also have been relieved to not be having disagreements all the time.
R- I either break up with him or not, but I am concerned that by doing that I am going to feel even more alone and it's going to make a big impact on my performance at the hospital. I am working so hard to be a good resident and I want to be in a good state of mind for it.

Thank you for your help, I really appreciate it.

ANSWER
Thank you very much for your time, energy and mental work to write this all out. I wonder how you feel now even after just getting it out of your head and into the world? Any different?

I'm going to distill your model (you have many thoughts and feelings up there in your C line 😉 and it's really important to keep the C line factual as deciding on purpose how to think and feel is where your true power lies):

C-I am a resident in a long-distance relationship with a person that thinks and feels differently than me often, and has asked for commitment.
T- I don't feel completely happy with him and am thinking about ending the relationship, but this is selfish and I am a bad person since he has been there since the beginning of this process.
F- Guilty
A- justify that the way he is is not his fault but just a consequence of his circumstances and the things he experienced growing up. Try to adapt to him and his needs/personality (i.e. "people please" by being not your authentic self). Ultimately, decided to take a break, which leads to relief, but spin in overwhelm, indecision, and confusion about what this means about you. Try your best to prevent negative emotions in the future by figuring out the "right decision"
R- You don't feel happy with him OR YOU.

Ok, sister, this is a heavy one and I want to offer you simply the beauty of what you have ALREADY given yourself: A moment to breathe. You have decided to take a break, so I want you to REALLY do that. Instead of a break, you have done the opposite in your mind, you have decided to give your brain a real workout by telling yourself that you must make the right decision and solve this unsolvable problem asap. Your lower brain is working overtime, and the result is not moving you forward.

What if you give yourself space to feel what life is like without him - WITHOUT ALSO JUDGING YOUR REACTION for just a week or two? I'm going to give you an assignment option (this is rare! but I thought I'd take advantage of our delve into feelings this week): Look at this week as an experiment - notice what feelings come up. See if you can process a few (get out a pen and paper and write down what they feel like. Where is "missing" in your body? Where is "relief"? "Guilt?" How long do each last? Can you watch them come and go without any judgement *just for this week*?

If you have the bandwidth, try a thought download every night this week. See if you can pull a model out (limit to just one sentence and one feeling - don't worry about picking the "right" ones, just any that come up) and see where your thoughts are getting you that day, with curiosity, like a scientist. I want to give you permission to be "light" and curious with this for one week.

If you struggle to do a thought download each night, here are a few prompts:
-Do you believe the only two options are settling for "less that happy" or being lonely? Why or why not?
-What do you want today?
-If the worst thing you could possibly experience in any decision you make is an emotion (and it is), what do you WANT to do, for you?
-I give you permission to give up trying to control him. Trying to please him. Trying to do the right thing (there is no right thing). Now what do you want?

Hi there! I thought I would bring an issue heavily weighing on my mind to this forum to get some coaching. I have been talking about this with my therapist as well, but given that we have this opportunity for coaching too, I would love to get some fresh perspective.

The Circumstance: I just turned 36, and therefore am at medicine’s definition of “advanced maternal age.”
The Thoughts: I am running out of time to decide if I want my own biological children. I am worried that if I don’t decide soon (to either have a child or freeze my eggs), then I may regret the decision later when I no longer have the option. I am also worried it may affect my new partner (of 8 months)’s desire to be with me, since he strongly desires having kids of his own.
I don’t know if I want kids – while I have been becoming more comfortable with young children in recent years (a new niece, some friends’ children), I don’t feel that I have maternal instincts. Selfishly, I am also just about to finish medical training (finishing fellowship next summer), and I feel that training has taken up so much of my 20s and 30s that I want time to have more work-life balance, to travel and to be active outside (I am an avid climber, runner, hiker, and even mountaineer) and do not want that to be taken away from me with having to be responsible for a young infant. I feel resentful towards medicine for rushing me in this decision and potentially taking away that independent time. I also feel that climate change and overpopulation are serious issues that I would likely be negatively contributing to by having my own biological child(ren).
On the flip side, there is a part of me that sees the joy of having a family, especially with this new partner that I am very excited about. I look into the future when I am an adult, and wonder whether I will regret not having my own kids, especially when they are adults and I can relate to them.

Feelings: Many! Indecisive, selfish, anger, anxiety, worried, fearful, resentful

Actions: I have only talked about this once with my partner… so I am avoiding the issue with him. Due to my anger about feeling rushed to make this decision, I am resistant to do anything about it (eg pay a lot of money to freeze my eggs) so instead am doing nothing.

Results: Time marches on and I’m still getting older without making a decision! I may be forced into a decision that is not my own (no children? Non-biological children/adoption), due to my indecision.

While I know that a piece of this is that more detailed conversations with my partner are warranted(!), I would love some coaching on some of my thoughts that I’ve presented. Thank you!

ANSWER:
Thanks for bringing this here, I know this is really tender. Let's acknowledge that the decision of if and when to become a parent is shaped by MANY messages we have received and integrated from society/medical community/our religious or spiritual upbringings, etc. It is very normal to engage with yourself in debate where you are trying to weigh all of these things.

It seems like the predominant emotion you're struggling with here is the emotion of indecision. When we pull ONE thought and ONE feeling out and put it in a model, I wonder if it looks like this:

C- You are 36 years old and have a partner of 8mo (I left "AMA" out because even if it is a neutral term that describes something of meaning to the medical community, I suspect it is not actually a neutral term to you --- it's not to me either, for what it's worth).
T (one)- I don't know if I want to become a mother
F (one)- Indecision (how does that feel in your body)
As- You talk yourself in circles arguing for and against, you blame the fact that you're arguing with yourself at all on residency training, you avoid exploring your own desires and learning more about your partner's,
R- you block yourself from learning about your true desires and double down on the pain of carrying this weight.

I have a few questions for you that I invite you to bring back for more coaching.
1. Often indecision/confusion is a surrogate emotion for one we are even more unwilling to feel (regret, rejection, self-judgement, shame, many others...). Our brain offers confusion/indecision because we are PRACTICED in being in those emotions. What do you think your indecision is a surrogate for?
2. I wonder if you think there is a "right" answer to the question of whether or not you want to have a child. If this resonates with you, how would you know if you made the "right" decision?

A side note: I noticed you mentioned that you don't think you have "maternal instinct" and that reminded me of an article I recently read in the NYT (It's a collection of the authors T lines), but there were things that resonated with me. particularly this segment:
"The notion that the selflessness and tenderness babies require is uniquely ingrained in the biology of women, ready to go at the flip of a switch, is a relatively modern — and pernicious — one. It was constructed over decades by men selling an image of what a mother should be, diverting our attention from what she actually is and calling it science...New research on the parental brain makes clear that the idea of maternal instinct as something innate, automatic and distinctly female is a myth..."
https://www.nytimes.com/2022/08/26/opinion/sunday/maternal-instinct-myth.html

If "maternal instinct" wasn't a thing, Would that change anything about your thoughts about your potential as a mother?

How do you overcome feeling inadequate as a chief resident when you don’t know how to do something and your junior residents and attendings expect you to know what to do in certain situations, particularly new situations?

Background: I am an OBGYN resident and had a postpartum patient code this weekend. My attending had not ever ran a code and looked to me, who had also never run a code. Everyone was suddenly looking at me for what to do and I also did not know what to do in a new situation.

ANSWER:
Hi Friend. Wow, I'm so sorry this happened. I'm sure that was terrifying for everyone involved.

Let's see what this looks like in a Model
C (everyone would agree on these)- You are an OBGYN Chief Resident, There was a postpartum patient who had a code. You had never run a code before. Your attending had never run a code before.
T- My attending and junior residents expected me to know what to do
F- Inadequate
A- assume the expectations (thoughts) of other people,
What else do you see yourself doing from "inadequacy"?
(Sometimes this is like rehearsing the event in your head, looking for all the ways you messed it up, imagine the ways people you look up to or compare yourself to would have done it "better")
R- You perpectuate unrealistic expectations for yourself.

I know this scenario was awful and I won't try and convince you that it wasn't. A patient was dying before your eyes and probably all of you HOPED (how is that different from EXPECTED?) someone else knew what to do.

You just experienced an FFT, A "F*cking First Time". And FFTs are not supposed to be easy. They are usually rocky, painful, awkward, and hard. Dr. Brene Brown has a great podcast about FFTs where she offers an approach to moving through them .

1. Name it- "I had my FFT running a postpartum code"
2. Normalize it- "Running a code for the first time is not supposed to be easy- It's uncomfortable because I haven't done it before"
3. Put it in Perspective- "This was even a first time for my attending. just because I felt inadequate this time doesn't mean I always will"
4. Reality Check Expectations- "I am in a field where thankfully codes are pretty uncommon, I will probably always freeze up at first because that's a normal response. But with more experience I will become more capable, comfortable, and confident"

A few questions for you to consider:
1. Why is it a problem to feel inadequate sometimes?

2. Unless your attending explicitly said "I expect you to know what to do in a postpartum code", then we are just guessing about expectation. That guess brings the above Model along with it, and that model is painful for you.

How might this feel different if you think "They HOPED I knew what to do" instead of "They EXPECTED me to know what to do"?

Please bring this back for more, coaching, sister. You are not alone in this one!

- Here's Dr. Brene Brown's episode on FFTs We have a whole module on them coming up!
https://brenebrown.com/podcast/brene-on-ffts/