T1- I'm being looked down on for my choices

C- you are a parent, and people say words about that ("that's crazy, I could never have kids AND do residency")
T- yet another person thinks I should have waited and prioritized my education. I cannot be a good mom and a good resident at the same time.
F- How do you feel when you think that? (Guilty.)
A- What do you do when you feel that way?
Feel sad, try not to talk about my home life, try to gain approval as a resident more

What do you not do?
Make anyone else feel that way. Maybe overly congratulate others and be extra excited for other people's outside family life.
I also try not to talk about my kids with people who don't ask about them. I also tend to not spend time with coresidents outside of work because I am the only one in my class with kids and at times I feel our ideas of fun are very different. I distract myself with food, trying to exercise more, and more time with my family.

Your brain is already offering you that it's possible that this could be a compliment. Why do you think your brain is also suggesting that it's an insult?

Because people's body language and tone when they say this don't feel positive. Because it feels like a way other point out that I'm different and alone. It feels like people insinuate that I cannot do both and do both well.

Get really curious here. What is the upside to believing it's an insult?

I guess this could be an upside because it confirms my beliefs that I am different and alone and thus gives me permission in a way to spend all my free time with my family and working on my health which I genuinely enjoy.

ANSWER:
I love that you brought this back for more. I'm going to clean up this model with you

C- You have kids and people say words about it
T- "I cannot be a good mom and a good resident at the same time"
F- GUILT
A- seek professional approval, don't discuss your home life or talk about your kids (hide/conceal this?), don't engage in social time with co-residents, distract yourself with food/exercise (we call this "Buffering"), You also look for ALL THE EVIDENCE that people could possibly be judging you.
R- The result for you here is that you judge yourself for the way you are showing up as a resident and as a mom.

One of the things we want to share with you in Better Together is that YOU, and ONLY you, get to decide what "good enough" means in any of the roles you inhabit; resident/parent/daughter/sister/partner etc.

Your brain is probably offering you nearly impossibly high definitions of what "good enough" means in each of these roles, right? Don't edit yourself at all here, or try to respond with the "right answer". What does the voice inside your head tell you would be "enough" ? Get as juicy as you can with these.

How would you know if you were a good enough mom?

How would you know if you were a good enough resident?

<3

I am doing long distance with my partner who is also an intern and it is going about how you expect it to. We are both incredibly busy and make time to call/text when we can with the understanding that sometimes it might be a few days before we can have a meaningful conversation. I am typically fine with this, but cannot break this pattern of every 3-4 weeks of not seeing each other becoming frustrated at the situation and placing the blame on my partner. I then feel guilty after bringing up these feelings because we're both so tired to begin with that it feels silly to use our precious phone call time to blame the other person for needs not being met. In truth, I don't really mind the fact we can't talk everyday and I don't see myself with anyone else, I just wonder if there's a way to reframe the situation to where I am A: no longer frustrated about it and can move on to acceptance or B: I can break the habit of putting stress on our relationship when maybe its just the demands of residency that are bothering me.

C: My partner and I are long-distance and busy
T: I should have lower expectations or put less strain on "us"
F: Anxious, overwhelmed, stuck, no good solution
A: I ruminate on the issue by myself, broken communication between the two of us, distress around my future // family // dating
R: Less present in the relationships around me, isolation around uniqueness of my relationship situation

ANSWER:
This is the perfect situation to bring here! Nice job on your model. I'm going to clean it up just a little bit (note, we can't say "busy" in the C line, since "busy" is a T. I also want you to pick one F here - you mentioned guilt in your thought download, so I'm going to use it).
C: My partner and I are long-distance and residents
T: I should have lower expectations and put less strain on "us"
F: Guilty
A: I ruminate on the issue by myself, broken communication between the two of us, distress around my future // family // dating, guilt trip self, blame partner
R: You put more strain and higher expectations on YOURSELF

You asked how to get to a new place. Let's try a "result model" here where we put the RESULT you want in the R line and then work our way backwards to see if you can find a believable T that supports it.

RESULT: Acceptance of the C, no additional strain/stress
-->
ACTIONS: (fill in the blanks here - what do you have to do and NOT do? List it ALL)
-->
FEELING: (fill in the blank: what's the ONE feeling that would fuel these actions?)
-->
THOUGHT: (pick a BELIEVABLE thought, that you truly think is true today that cultivates this feeling for you).
-->
CIRCUMSTANCE: My partner and I are long-distance and residents

Having trouble with the T? (***it's tricky!)
How do any of these feel?

"It's totally normal to feel unpleasant about this relationship at this life stage every 3-4 weeks, and doesn't' have to mean anything about the future."

"I am totally allowed to miss my partner even to a point of frustration, and it can be no one's fault."

"This is hard, and I love myself and my partner."

What else is true for you here? Bring your model back! <3

I'm a third year resident and have an intern who is very strong in terms of his medical knowledge and clinical reasoning skills, but he mansplains. I am soft spoken and sometimes he will interrupt me while I'm speaking; or if I ask him to do something or place a specific order or consult a service, he will never do so immediately. He will always question if it is necessary, sometimes he will begrudgingly do it if he ends up agreeing or if the attending ends up agreeing, and sometimes he minimizes what I say or offer to the conversation about the patient. He will sometimes doubt me/doubt what I say or want to do for the patient, which makes me doubt myself. He is a good doctor, but the mansplaining really gets to me and sometimes angers and frustrates me.

ANSWER:
Hi Friend! So glad you brought this here! I can say with near complete confidence that most, if not all, of the women in the group have experienced this. It is OK to be angry and frustrated by mansplainers!

I want to be really clear to you and to everyone else here, that we NEVER use the Model to gaslight ourselves/each other. So while it may not be "provable in a court of law" that he was mansplaining to you (I wonder if he would agree?), our work in coaching is NEVER to make you ask yourself second guess an experience like this. I'll NEVER tell you that you shouldn't be angry or frustrated when you perceive you or your role on your team to be undermined or minimized, - ESPECIALLY when it relates to your identity as a woman, or any other group that is not cis-white-hetero-male. You are 100% entitled to those feelings, and you may want to keep them.

What I am interested in though, is what happens between the events, and your feeling of self-doubt. Let's play with it in a model

C- R1 presents as a man. You ask him to do things and he doesn't act immediately. He questions if what you are asking him to do is necessary. He interrupts you when you are speaking. Sometimes people express their doubt in your plan. Mysogyny, racism, ableism, and more exist in our workspaces.

When these things happen your brain has a THOUGHT about them, and that thought generates the feeling of self-doubt.

What do you think that sentence is in your brain? that makes you doubt yourself?

T?
F- Self Doubt
A- second guess yourself, you judge him for having these behaviors, (what else do you do when you doubt yourself? what are you NOT doing when you doubt yourself?- make this section super juicy)
R- You don't establish or practice trust with yourself

Alright friend,
After you've filled out that model, I invite you to bring it back here for more coaching.

One final question I have for you is this: Mansplaining/misogyny/institutional racism/sexism/ableism/etc will exist in our worlds. Sometimes we will be on the receiving end of things that aren't polite/just/fair/kind.
What would it look like if when you received this, it didn't rattle your foundation of trust with yourself? Paint a picture for me of what it would look like to have your own back in circumstances like this one, no matter what.

So much love sister!

I recently received some vague feedback through my program director that I could improve my "communication with nurses" its difficult to take action on because I'm not sure what it means or what type of problems were being described. I had some feedback similar early in training and it seemed it was not so much about me as just being a young female physician. Some thoughts I have include that my direct feedback has been positive, none of my attendings have identified any problems, and I feel like I have a good relationship with a lot of our nursing staff. Other thoughts include that it's not the first time I've heard this type of feedback and I'd like to be an expert communicator so I don't think it's beneficial to just assume it's not true. I feel frustrated because I work hard on this skill. I feel sad because I want to be liked. And I feel motivated to implement change now before I graduate. Actions I've take so far have been to ask for feedback ahead of a shift from attendings which has not resulted in any identifying areas to improve as well as asking for feedback from nurses after running a case together. Current results have not yielded anything actionable at this point. So I'm not sure if I just brush it off or continue to elicit feedback in this area in particular. I care a lot about team communication as its so important in emergency medicine but I also don't want to beat myself up about something I can't improve if it's not really about me.

ANSWER:
Ok this is fantastic insight into the MANY different models that you have going on in your head at any given time. This is true for all of us, and you have laid out four predominant ones about the same circumstance here. I’m going to separate them out so we can untangle them a bit.

C: PD says I can “improve communication w/ nurses”
T: my direct feedback has been positive, none of my attendings have identified any problems, and I feel like I have a good relationship with a lot of our nursing staff, so they are wrong
F: (??) skeptical?
A: reject the feedback and move on
R: you don’t create a problem (but also potentially miss a growth opportunity)

C: PD says I can “improve communication w/ nurses”
T: it's not the first time I've heard this type of feedback and I work hard on this, shoot!
F: Frustrated
A: ask for fb (fruitlessly so far), also engage in some comparison and blame (look for how they are wrong).
R: you move toward growth by taking the step of asking for critical fb, regardless of the productivity of this.

C: PD says I can “improve communication w/ nurses”
T: I want to be liked! (and this seems like they don’t like me?...?)
F: Sad
A: What do you do here? Not do? Is this where you “beat yourself up”?
R: You don’t like yourself

C: PD says I can “improve communication w/ nurses”
T: I want to be an expert communicator
F: Motivated
A: ask for feedback from many sources, what else might you DO and NOT DO if you stay in this motivated space?
R: Improve your communication skills (just by asking for fb, you are actually growing your communication skills! FB is a super challenging conversation that you are learning to master here).

Now you get to decide which model you want to spend the most time in. And notice that they ALLLL require work. The work of the first one is that “brushing it off” is actually a bit of a cognitive load if your brain keeps reminding you or getting into a defensive space around the issue. It can be done with commitment to the thought, but I don't want it to seem like the "easy" choice. Looking at these four models, which one seems right for you (note: "right" can be "right now" and another one may be right for later).

Notice how you ask the question about “brushing it off” or “eliciting fb” and then you mention “beating yourself up” as if that's just PART of the latter action. Why would this be true? Does it feel like eliciting fb is beating yourself up? Is that something you do afterwards?

New to the program, loved the last call, I think this experience is actually going to be amazing for where I am in terms of growth, so thank you, thank you, thank you!
Alright, here is a big topic running in the background for me, that I clearly need to address sooner rather than later.
Medical training is full of landmines, but the hardest one for me is standardized testing. I fully believe (and this might well be the hurtful thought in my whole process) that I have gotten worse at test-taking with time. I took 2wks off to study for one such exam last summer and still managed to fail it, which only reinforced my current (flawed) belief system. The problem is that I have to at least have registered for that exam by the end of this academic year or it'll affect my ability to progress in my current training program. I know I only failed by 5% and it would have been ideal to just retake it right away, but I let myself spiral in thoughts and emotions while taking on extra responsibilities as excuses to avoid studying. For almost a year now, I have made my work life probably more stressful than it needed to be by focusing so much on chief responsibilities, admin work and social gatherings that should definitely not have taken this much energy. I have avoided asking for help and taken things much more personally which even made my interpersonal interactions harder. All in all not a good picture. Enough background, here is my current working (but clearly flawed) model:
C: Need to retake a standardized test by then end of this year.
T: I'm not good at this, I will fail again, I have currently too much on my plate, I'm not in the right head space to study. I need to deal with myself so I can confidently and calmly sit down and dedicated all my attention to study so I won't run into trouble again. Also, this is an expensive test, I don't know if I'll be able to pay that on my own, not feeling confident financially neither. Residency is just hard, but so is life, just keep dealing.
F: mainly fear of failure, but also tons of stress and anxiety as well as very little confidence in myself.
A: Completely avoid subject of exam in any way shape or form, hyperfocus on every other little detail, keep the anxiety/procrastination cycle, prolong the pain it creates for me.
R: I'm so very close to ending up having to take this exam against the clock, which will again reinforce my flawed belief system re: exams and end up in a likely failure once more.
This is probably a common topic, I have read through similar threads in the forum, but I need help taking the steps necessary to dump this cycle.
I've read some answers suggest sitting with the feeling for a while, I think I have done this enough.
You might ask what are instance where I have succeeded and why I should trust myself to pass this exam and honestly, this is not the first time I fail tests after medschool, so I have no recent positive experiences with exams. I know in terms of practical knowledge and daily work, I am a good doctor, I just cannot seem to translate that to paper in a quiet, timed, rigid environment.
Please help. 🙂

ANSWER:
Hello, and welcome! So glad to have you!

Alright, you're onto yourself here. You have noticed a thinking pattern that isn't serving you- wonderful awareness.

A few points of feedback on your Model. First, YAY! Nice job separating into the C/T/F/A/R sections. One thing that we want you to do is make sure you only have ONE Thought (one sentence), and ONE Feeling (or emotion) in each model. Of course your brain has like 100 models running simultaneously, but we like to just look at one at a time.

Here's what I would pick out from your model above-

C- Exam. Last time, was 5% short of passing score.
T- I will fail again
F- I wonder if the emotion is defeated? Dejected? Incompetent? Shame? (if you think "I will fail again" what emotion comes up for you)
A- Don't schedule the exam, avoid studying, hyperfocus/fixate on other details, Shame and blame yourself for what you could have/should have done differently last time, You are not speaking very kindly to yourself, you're not thinking very highly of yourself, you're not encouraging yourself. (We call this "beating yourself up")
R- You fail yourself

Here's what I see. I see a woman who has a pretty well established Inner Critic. That's the voice in your head that tells you "do better! jump higher! You should have done THIS! You should have done THAT!" I can practically HEAR the whip you have at your back as I read your words.

Now listen, many of us have gotten where we are because we have kept a whip at our backs with our own thinking. At some point, it served us because it helped us get something we wanted. Here you are, a doctor! Right? But now you're noticing that handling yourself this way isn't really getting you what you want anymore, in fact it has you avoiding doing what you know you need to do to progress. It's become counter productive.

I want you to imagine that a good friend of yours, a wonderful, compassionate, and capable doctor, came to you with this problem. Would you say these things to her?
"Wow, you've gotten worse at test taking over time!"
" It would have been ideal if you took again right away?"
"You're letting yourself spiral in thoughts and emotions while taking on extra responsibilities as excuses to avoid studying"

OK- would you say these things to your good friend? Why or why not?
If not, what might you say instead?

Why might it be helpful to try a different way of speaking to yourself about this test?

You have a few options here. You can keep the same whip at your back and see what happens, or you could try a different way of preparing this time. What might that look like?

I’m currently a first year fellow and am considering an advanced fellowship. When I decided To start expressing interest my female mentors were all ears and ready to support and listen. But when I told a male mentor who I truly Believe usually has our best interest at hand he goes “well it’s a lot of work how are you going to balance it with a family” in that moment I just began to fume and just have running thoughts of how this would never happen if I was a man. But what got me more and what I’m still struggling with is the self doubt it creates for me. It is something that I am Constantly thinking about now and wondering but can I do It all or no and that is what sucks the most. That on the outside I’m like oh yeah I’ll prove him wrong but inside I just keep thinking about how he could be write.

Unsure how to fit this into the model but I’ll give it a try:
C you can’t do an advanced fellowship because your a female and will want a family
T could he be right ? I’m gonna prove him wrong ! But he could be right ?
F anger but then self doubt and anxiety
R starting to back off from what I like and saying I need More time to decide

ANSWER:
Hi Friend, I'm so glad you brought this here, and I'm sorry this happened.

Let's start with your model.
We always want to have our C- line be a neutral fact. Here are the facts.
C- You are currently a fellow, You are considering advanced fellowship. A male mentor said "that's a lot of work how are you going to balance a family".

T- He might be right, I can't do it all.

F- self-doubt

A- you question whether and how you could do either task or both, you look for evidence that you aren't doing enough, that you're not doing it all, (what else do you when you are feeling self doubt?)

R- You don't show yourself what you CAN do.

It's easy to think that the reason you feel self doubt, is because of the thing he said. But in between what he said is a sentence in your own head. A sentence that agrees with him. "Maybe you CAN'T do it all".

What if that isn't true?
What does doing "it all" mean to you?

Bring it back here, friend.

I am currently on protected research time following a busy fellowship (pulm/CC at the height of COVID). I had a lot of anxiety/PTSD following my clinical service, and going into research was a blessing. I love working in the lab, but I get stuck in spirals of anxiety that lead to procrastination when writing papers/grants. I have been using therapy to work through anxiety (which is much better), but I still struggle with procrastination. Sometimes I think I might be confusing self-compassion (allowing myself to take time to comfort myself) with a procrastination strategy. Of course lots of other things are going on in the background (aging parents/elder care, ensuring I have a job at the end of the year, busy April and May with travel). All of my thought download sentences start with "I need to..."
This is the biggest thing I want to work on during our coaching time!

In my UM:
C: I have a grant due in June
T: The deadline is coming up quickly, I don't know whether I will write it in time in a way that is worthwhile
F: Anxious
A: Don't work on it because it feels too big, scroll the internet, do other tasks/chores
R: Stress at the last minute to get things together, causing myself and my mentor increased work

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

Procrastination always goes in the A line of your model, as you have it here. Nice job.

One of the ways your brain has learned handle feelings of anxiety around a given task is to procrastinate. Perhaps once upon a time, you were anxious about a task, you procrastinated and got it done at the last minute, and the result was GOOD! Maybe you got what you wanted, and your brain learned, "hey! This is what works to get things done around here". Now you see that sometimes the results of this pathway aren't always what you want, it adds stress, and work to the process. You are asking your brain to try something new (not procrastinate), and it's having a hard time, it wants to do it's usual thing. You're learning how to negotiate with it. Good deal. You're already onto yourself and that's the first step!

In order to get to the next layer of the onion, I want to invite you to think about a few questions and bring them back here for more.

1. How might you be able to tell if something is self-compassion or procrastination? Pretend you are defining these two words to an alien who doesn't know anything about how the human brain works. How would you define them, how might the alien learn to differentiate between them? Are they mutually exclusive?

2. Let's do an experiment where we put the fact that you experience the human emotion of "anxiety" on the C line.

C- Anxiety is a feeling you feel sometimes (maybe it's also a diagnosis you carry, either can go here)
T- (what do you think about the fact that you feel anxiety sometimes?)

Bring it back when you're ready.

I am having a very hard time making a decision about my future. I am currently in a fellowship and am thinking of applying to an advanced fellowship afterward (additional 1 year). That being said, I honestly feel extremely tired and am sick of being underpaid. I am exhausted from training but at the same time, I know I would really enjoy this fellowship. I also am at a point in. my life where I want to start living my life including moving in with my long-distance husband and providing for my parents. The advance fellowship would mean more work....for the same pay as a generalist. I honestly cannot decide if I want to do it. I love it but is it worth it?

C-advance fellowship decision
T-need to make a decision ASAP
F-high levels of anxiety
A-going into a downward spiral because I feel I would disappoint myself professionally if I did not apply but would disappoint personally if I did
R-worry that I will make a rash decision that I will later regret

ANSWER:

Hi Friend,

You are worried that you are going to regret a decision you make, and fear of regret is going to keep you stuck in this cycle. As you see, there is potential for regret either decision you make!

Instead of thinking about all of the things you could regret, let's check in on your values and look at this decision in a way that honors your values regardless of which choice you make.

I can pick out a few values from what you've shared above.
- You value being compensated adequately for your work
- You value interest/enjoyment in your work
- You value your relationship with your husband and family

What other values do you hold?

In what ways could EITHER choice you make be aligned with your values? Consider this in both the immediate term (now and the additional year(s) of training, and in the long term... like 5 or 10 years out)

1. Pursuit of advanced fellowship is aligned with my values because......

2. Not pursuing advanced fellowship is aligned with my values because...

Bring it on back here with whatever comes up!

Thank you for the quick response! I was surprised by the model revisions because 1) I have been getting feedback from attendings recently that I might be putting too much pressure on ME and 2) My brain seriously did not consider the fact that I can feel a certain way without it having to have any impact on my decisions or future. Updated result model:

R: Acceptance that my partner and I are long-distance during residency and move towards cultivating a stronger relationship
A: Improve communication between the two of us, addressing thoughts/feelings before they build up, more present moment, less distress around my future, stop trying to put my future into the box I expect it to go into
F: Struggling a bit here... secure? confident?
T: I am allowed to miss my partner even to a point of frustration, and it can be no one's fault and doesn't have to mean anything about the future.
C: My partner and I are long-distance in residency

Thank you.

ANSWER:
Oh friend, thank you for posting this lovely reframe.
You mentioned "acceptance" in your R line, I wonder if that's the F that you are looking for here.
Acceptance doesn't always feel pleasant, but rather it's a simple willingness to show up for what is in front of us.

I wonder where else in your life you can apply this strategy??

My partner and I are about to hit some major milestones in the next few months. We are expecting our first baby, will be moving into our first home, and I will be finishing my fellowship shortly in a couple of months. We're really excited, but it has been leading to some overwhelming questions for me going forward.

Before my partner, I defined myself by my career. I did multiple extracurriculars as a medical student and was often the resident that stayed after sign out to tie up loose ends and mentored my more junior trainees. I pursued a competitive fellowship with hopes of coming to a competitive region to pursue academic medicine in the long term. After meeting him though, I've noticed my priorities have changed in that I've been setting more boundaries around our time as a couple and my own wellness (for which I am grateful in the whole scheme of things). Now that we're having a baby, I am finding myself questioning what I want. I'm not saying academic medicine is out of the question now, but I can also see myself satisfied with a less clinically burdensome career like medical editing that allows for more flexibility for me to be with our growing family.

I'm struggling with these feelings because it does feel like a large paradigm shift from what my thoughts were a couple of years ago. Additionally, I feel that my local mentors and peers are more on the traditional path of pursuing a leadership position in academic medicine - so a part of me feels like I'm settling, even though ultimately I know the decision is mine alone to make. In case you're wondering, my partner is wholeheartedly supportive of me cutting back clinically (as long as we can manage it financially of course), and unsurprisingly our relationship does better when I'm not on service or coming back late from busy community hospital shifts.

So to summarize in CTFAR (hopefully I'm doing it right):
C: new baby, new home, finishing training yay!
T: But what do I want from my career?
F: Uncertain
A: Less engaged and disingenuous with my peers and mentors as well as work
R: Mixed feelings about my career and family

ANSWER:
Thanks for bringing this incredibly relatable post while you are in an internal transition. Often, transitions highlight the thoughts we carry about ourselves and the beliefs we have about life. Humans naturally try to make sense out of the world by finding patterns (especially doctors who are literally taught to do this on purpose).

Sometimes though, those patterns we think are true, actually are illusions.

Yes, you can find examples of them if you go looking, but often we turn a blind eye to things that contradict the stories that make our lives feel understandable and clean.

In this coaching program - there is space for you to start questioning these beliefs. I want you to think about each of these questions. Write down the thoughts that come up in response, and push yourself to see if you can also write why the *opposite* might be true.

-Why do you believe that staying in academia means you can't also have healthy boundaries?
-Are you sure that pursuing a traditional leadership path will pull you away from your family?
-Why can't you define a job in academia that is flexible?

On the flip side....

-Why are you labeling community practice with fewer hours as "settling"? In what ways is this not settling (but actually thriving, growing, and also reaching)?
-If it were possible to maintain healthy boundaries and get the job that is most fulfilling, what would you do?

Bring it back!

Listening to the 11/2/22 call with Dr. Fainstad, I paraphrased the following: Imposter syndrome holds you back; healthy uncertainty pushes you forward.

Then, I had an idea! (that I want your feedback on). What if, in my brain, I re-label my imposter feelings as feelings of healthy uncertainty (i.e. I might not know enough etc).

For me, here is what seems to happen. I have feelings of inadequacy. Yes, despite graduating medical school, making it through residency, being hired as a fellow and getting feedback that I’m a good physician (i.e. evidence that I might be adequate), I still feel a deficit in my knowledge base that I know deserves time and effort. BUT, when thoughts come up that my knowledge base is not at the level that it needs to be, I call these thoughts imposter thoughts, I push away the imposter feelings, and “sush” them away by presenting myself with ‘evidence’ that that I made it this far and I’m at least doing an adequate job. The result is that I don’t actually make time to study or read and then, as expected, the thoughts and feelings return meanwhile I’ve made no progress in this domain.

What do you think about the idea of re-labeling my imposter thoughts as thoughts of healthy uncertainty and then using that to try to push myself forward, i.e., Oh yeah girl, YOU BETTER MAKE TIME TO READ!, instead of “oh, those are imposter thoughts” followed by reminding myself that I’m good and worthy (which results in keeping myself stuck, stagnant, and not making progress towards achieving my goals of improving in a certain domain).

It seems like I’m trying to tease out how specific thoughts/feelings of inadequacy might, for me, actually contain components of healthy uncertainty. And that I can hold two thoughts at the same time: that my knowledge base is weak AND that I’m not an imposter.

Ok, a model:
C: I am presented with a scenario where I wish I had a deeper knowledge base
T: I wish I had a deeper knowledge base
F: First feeling is of inadequacy which quickly pivots to an internal monologue of my worthiness
A: No action
R: No change, no motivation to push myself or take the time needed to expand my knowledge base

ANSWER:
Hello and welcome back!

You are ONTO YOURSELF here, sister, and I love to see it.

I'm seeing you struggle to reconcile these thoughts:
"My knowledge base is weak AND I'm not an imposter". You tried to slide that one in there like I wouldn't notice 😉

I think the reason this isn't shifting easily is that you really believe that your "knowledge base is WEAK".
See how you presented it as a fact/Circumstance?

That is not a circumstance. It is your thought about your knowledge base, and it also comes with a healthy dose of criticism- "weak" isn't a neutral descriptor of a knowledge base for you, I'm guessing. I know it's not a circumstance, because I think your knowledge base is VAST compared to mine (as it pertains to your field) 😉

Right now, you are used to expanding your your knowledge by berating yourself and showing yourself only your deficit, or your lack. This is your practiced technique. This isn't bad or good, or right or wrong, it's just the way you've done it before.

Now I want you to think about a child seeing bubbles, or feeling their toes in wet sand for the first time. Think of the WONDER they experience as they explore that limit of their knowledge/experience. How does a child explore and expand their knowledge base? what thoughts and feelings drive the action of touching the bubbles and watching them pop, of sticking the wand in their mouth? of bending over and feeling the sand, throwing it, playing in it?

These are my BT 2.0 questions for you
- Can one's knowledge base be VAST and can they still want to expand it?
- Can one identify the limits of their knowledge without being "weak" or "inadequate"? How?
- What feeing would FUEL active learning in a way that is not a punishment for a deficit?

How do these land?
"I have a knowledge base that I want to expand"
"My knowledge base is always growing, AND I'm not an impostor"

or, buckle up for this one...

"My knowledge base is not related to my worth"

Bring it on back, sister!

I have been trying to understand what is underlying the part of me that feels miserable in pursuing medicine. I think that at the core of it is feeling shame over choosing this career path for myself even though it frequently negatively impacts my family. My inflexible schedule puts a lot of childcare responsibility on my husband, I am often exhausted and easily irritated with him and my kids when I am on a particularly difficult rotation. This leads to a spiral of trying to overcompensate by doing more around the house when I can, making sure he gets a break as soon as I get home, not getting a break for myself because that also feels selfish and there is no time, which then leads to me feeling burned out. The underlying feeling is definitely shame because the message of putting other people first has been ingrained in me (and I am guessing a lot of people socialized as women) and the pursuit of a medical career is something that makes me feel accomplished and like I am doing something worthwhile with my time. I also worry that my husband blames me for how difficult the past several years have been. We have talked about it and he has said he does not blame me, he blames the inhumane medical training system and that the choices we have made to get to this point we have made together. My first thought when he said that was “he is just saying that to make me feel better.” So much to unpack here 😉

I’m having trouble getting out of this thought cycle that is not serving me

C: I am a mother of young kids, a wife and a doctor
T: Choosing this career is selfish and takes away from my time with my family
F: Shame
A: Overcompensate by trying to do more when I am exhausted, don’t allow myself to take a break, fall into the “I’m doing everything around here” thought cycle, snap at my husband and kids
R: Doubting myself, growing resentment

Taking a stab at an intentional model
C: I am a mother of young kids, a wife and a doctor
T: I can choose something for myself and still be a good mother and wife
F: Acceptance
A: ???
R: Honor all three of my identities that bring meaning to my life

The thought in the intentional model feels like a reach maybe because I’m clinging on to the thought that “selfish” and “good” cannot both be true

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

I'm so proud of you, for many things, but especially for showing yourself where you want to be moving towards in your thinking about your life and your work. Look at all of the wisdom you already have! You are noticing that you sometimes are operating out of shame. You are noticing that there are parts of your thinking that have been programmed by your socialization as a woman in our culture. You are noticing where your brain is sneaking in thoughts about all of that that aren't moving you towards where you want to be.

You are looking for how to move into this intentional model, and it's not easy. And that's OK. It takes a lot of practice to start believing a new thing.

You want to start believing that you can choose something for yourself AND be a good mother and a good wife. Let's put your brain to work on finding evidence for this.

What evidence do you have that PEOPLE (not necessarily you), can take better care of other people when they take care of themselves first?

What evidence can you find that PEOPLE (not necessarily you), can be a good parent AND a good doctor?

In what ways are you already like those people you were thinking about above?

Bring it on back here, and we can keep going. this is really important work!

I find myself frequently “giving in” to nursing requests. I remember first feeling this as a medical student, but explained it away to myself as not having enough clinical knowledge base to reason an argument for or against the request. However, I don’t feel like I have gotten much better at this after 3 years of residency. One recent example comes to mind, a nurse asked me if she should put in a larger gauge IV in case the patient is going to need contrast for an imaging study. We were waiting on a subspecialty team to let us know exactly what kind of imaging they would need. I told her that we should get the larger gauge IV “just in case.” She asked the same question to my attending and my attending said that we will not need contrast because of the type of malformation the patient had and whenever she has seen this in the past it is visualized without contrast. When the nurse asked me the question, my knee-jerk reaction was just to say “yes” without really thinking about it. I could have looked at the type of imaging the patient had in the past to figure out if contrast was used, I could have asked the attending myself. I know this is a small example and if the patient would have gotten a larger gauge IV it would not have been the end of the world. However, even small instances like this reinforce my self-doubt. I think there a multiple underlying thoughts that lead me to this result including “the nurse knows better than me” and “I want the nurse to think I am competent/like me.” In juxtaposition, when a nurse makes a comment that I feel is biased or judgmental and might negatively impact the care we are providing for a patient, I feel more secure in myself and my assessment of the situation to say something.

I'd love some help replacing this thought model

C: nurse asks me to order something
T: they know so much more than me, I should just order it
F: self-doubt
A: don’t take time to critically think, fixate on all the times I made the wrong choice or the nurse was right and I was wrong
R: don’t allow myself to build confidence

ANSWER:
Hello!

Great job noticing how the action of deferring to or agreeing with a nurse comes from the feeling of self-doubt. I think it's interesting that in some cases, when you think that you are in a position of advocacy for a patient that you feel more security and trust in yourself and your decisions. Why do you think that is?

What I am noticing here is it might be the idea of revealing the limits of your knowledge or skills that feels uncomfortable or unsafe to you. This can be amplified when we feel like we are on-the-spot for making decisions. That makes sense, right? Sometimes we are even shown that it is PSYCHOLOGICALLY UNSAFE safe to say "I don't know, let me think about that". If that's the case for you, does it make sense to you why you may have learned to doubt yourself instead of trust yourself?

OK I have a few questions for you..

What does it mean to you to have "confidence" in your decisions?
- does this mean you always know the "answer"?
- Does this mean that your "answer" is always "right"?

How would a person who has "confidence" in there clinical decisions handle questions that are at the limits of their knowledge or skills?

Bring it on back!

I really do see how your thoughts create your feelings, etc. etc... BUT I also wonder if certain brains just do better (feel better) in certain circumstances. This comes up for me most in my specialty decision. I chose to do a noncompetitive primary care specialty because I believe this is where I am most needed and I do feel passionate about it. However, I REALLY struggle with the lack of respect and prestige from the rest of the medical community and sometimes I wonder if it just would have been better to choose a different specialty if prestige and respect are things my brain values? Honestly I wish I didn't value it, but I do. I am jealous of specialists and wonder why I worked so hard in undergrad and med school just to feel like I am looked down on.

Circumstance: I am a resident in a noncompetitive primary care specialty.
Thought(s): My field does not have much respect from the rest of the medical world (and sometimes an outright lack of respect from lay people too). I can't help but think that if I had just chosen a more prestigious specialty I would be happier.
Feeling(s): Envy for specialists. I feel less-than. Insecure. Shame and regret mixed with anger?
Action: I start to spiral in my head, thinking about ways to fill that void of external validation within my chosen specialty. I waste so much time trying to get out of these painful emotions - trying to figure out how to solve the problem - how to make sure I will be happy in my career. But ultimately I worry that I will never get the respect I am looking for or deserve. Because I am caught up in these emotions and never-ending problem solving, I tend to disengage and be less present in my day to day work or with my relationships - which just adds to the insecurity.

I know that if I change my thoughts I will feel better. And I know that I have days when I feel good about my decision because I am thinking better thoughts. But right now I am on a specialty service and just feel triggered.

However, it's also soooo tempting to think that changing my situation would make it easier to have pleasant thoughts. Partly because I can think of examples in which my circumstances did seem to make it easier to have pleasant thoughts. Ex- if I did poorly on a test in college it felt awful so I studied harder for the next one, aced it, and felt really proud. Or when I work out regularly I feel strong and capable, but it's harder to feel this way when I haven't been working out. Or a slightly different example - when I'm on a beautiful hike it's easy to feel inspired and amazed, but when I'm in a run-down town or neighborhood I feel depressed and sad.

So when do we choose to change our thoughts vs our circumstances? I know that trying to change circumstances for external validation is not sustainable, but damn it seems to have worked well in the past and sometimes feels like the easier way...

ANSWER:

Hello! I love that you brought this here!

OK friend, lets talk about prestige and respect. You introduce them here as somethings that you talk about them as if they are FACTS that either exist or don't exist and are given to you by the "medical community". I invite you to go back and read your thought download, especially that first paragraph.

How does one know if their specialty has enough prestige? enough respect? where is the line?
Is it about how competitive the fellowship is? why?
Is it about how much money they make? why?
Is it about how the depth of the knowledge? the Breadth of the knowledge? Why?
Is it about something else?

Could you make a comprehensive list of all specialties, and put them in columns of "respected" and "not respected", "prestigious" and "not prestigious"?
- How would you decide what went on each list?
- Would everyone in every specialty agree that you put them on the right list?

If you couldn't get consensus on your list, then "prestige" and "respect" are not circumstances.

Who is one person that if they said "Oh wow, People who do X specialty are freaking incredible. I have so much respect for the job they do!", would change your mind about what the "medical community" believes about you and your specialty?

The person who needs to respect your specialty is YOU. Do you?

We can talk about changing your "C" when you like your reasons for your answers above 😉

Please bring this back here, friend. This is important work.

Ok so last Fall, I had a situation with my friend where I felt I wasn't a "good enough" friend. As suggested, I went through and wrote a list of:
-what a good friend AWALYS does
-what a good friend SOMETIMES does
-what a good friend NEVER does

And if I'm being honest, even though I was trying really hard not to, I turned my words against myself. Used them as "evidence" that I wasn't a good enough friend. Enter a bit of a shame spiral.
BUT then I added another thing to my list of things a good friend ALWAYS does and that's take care of herself first. Put on your own oxygen mask before helping others. Which was a powerful revelation. And so for me, that meant stepping back from the friendship for awhile. The thing is though, I still feel guilty. And maybe that's still me desperately trying to hold on to the old ideas. A few weeks ago, she wrote me a letter saying, that she felt we were emotionally distant and that she wasn't sure what changed. Which added to my guilt

I've also realized that I was struggling with the friendship because I feel/felt very defensive and/or would avoid certain topics etc to avoid feeling defensive. Yikes.
And I guess I could use some good probing questions to figure out why I would always get so defensive during our conversations. And suggestions on how to try to turn off "defense mode" in general because it's exhausting.

Hmmm, one possible model

C: I have not been in close contact with my friend
T: I am taking time to learn how to take care of myself
F: guilty (ah, I wish I didn't feel guilty about this, because its so important to take care of yourself!)
A: keep thinking about it over and over again, not allowing myself the room to figure out me
R: an exhausted brain that already has a lot of other things to think about

C: my friend says something
T: gosh, she really doesn't understand me and is implying that my thoughts/experiences about XX are less than
F: defensive, unworthy
A: become less likely to trust her, filter what we can talk about
R: not have the supportive friendship we once had

Looking forward to a little guidance 🙂

ANSWER:
Hi there, wonderful to have you back!

First off I'm going to share something from a coach I really respect, Kara Loewentheil. She is going to host a coaching call with us in Month 3, get ready! She is a feminist coach and recently she shared the following on her instagram which really resonated with me. She said:

"Society doesn't want us to like ourselves, because the thought is that if we do, it might distract us from taking care of (or even thinking about) anyone else. But I just don't think it's accurate. I don't believe that if you like yourself you become self-obsessed. In fact, it's the exact opposite. People who loathe themselves and think critically about themselves are far more self-obsessed than those who like themselves. For example, when you hate yourself, you obsess over how you look, what you ate, and what you said the other day etc. You're so busy thinking about yourself that you're less likely to think about other people. You may think about others in the sort of people-pleasing, manipulative way to get validation or make sure they aren't mad at you (because that would confirm that you should hate yourself)- which means you're not thinking about them for their own sake. But when you like yourself, you have more energy to care about other people because they're not just a means of validation to help you feel safe or OK When you like yourself you no longer need that external source of security or validation because you are already secure with who you are"

So my Better Together 2.0 questions for you are this:
1. Do you REALLY think you deserve to feel guilty about the way you are taking care of yourself? Why or why not?

2. What are you looking for from her in terms of validation or approval, that you could start by offering yourself?

<3

C: We have a male junior that always praises men and ignores women's achievements and knowledge! always ready to hug women though!
T: He is extremely sexist!
F: angry, annoyed, inpatient
A: avoid talking with him and being around him as much as possible.
R: whenever he is around (which is a lot! because he is junior of the same program where I am the senior resident) I feel ramped up and don't enjoy anything as I usually do. I have stopped teaching him a long time ago unless because of patient care I have to speak up and even then, I usually tell him I don't care if you agree and are going to listen to me or not. I just feel responsible to tell you this... I feel drained when I have to supervise him even though I look calm and ok!

I talked too much about my emotions! 🙂

ANSWER:
Hi There!

OK-Let's dig into how this shows up as a problem for you. Is it the fact that sexism/misogyny exists? Is it that when you are faced with sexism/misogyny you don't like the way you are showing up?

C- You are a senior resident. You have a junior resident. you think he is sexist and you like your reasons (I'll let you leave this here on the C line), sexism and misogyny (and other -isms) exist in our relationships and workspaces.

I suspect the problem is that you aren't acting in alignment with your values when you are upset about the fact that all of this is happening. You aren't teaching, you aren't doing other things you normally do, and your experience of your work is not enjoyable.

Now, I'm not saying we just roll over and accept being treated poorly, just throw our hands up in the air and give up. What I am saying is that sometimes you might experience things like this that are outside of your control.

What result do you want FOR YOU when that happens? How do you get there?

I felt angry again today, and tried to notice what it felt like in my body. My cheeks got hot and my chest was tight and warm. I could feel my muscles and my jaw clenching. I'm going to try and work through a model of what made me angry today.

C: Last week I got 3 new consults on a Friday right as I was getting ready to leave for dinner and a concert, so by the time I finished my consults I didn't have time to email my signout for the weekend before the show. I messaged the weekend covering person and told her I would do it later that evening. She called jeopardy before I sent sign-out. The person who took over messaged me about sign-out at 10:30pm and I replied at 11:30pm when I was home and writing sign out, then sent it to him shortly thereafter. Today, my associate PD asked me, "Was there an issue with signout last weekend, I was told you didn't send it."
T: Why can't I spend one Friday night going out to a dinner and concert without getting punished for it? Why would the fellow report me when he got signout that night and I was responsive to this message? I would never report anybody for something like that, even if I thought they deserved it.
F: Anger
A: Tell the PD I sent it and there was just confusion with the jeopardy situation, thatI wasn't aware it had caused enough of an issue that it had needed to get reported. Replay the situation over in my head and find all of the ways in which the other person could have communicated better.
R: Feel resentful, feel pressure to never let life outside the hospital interfere with perfectly meeting all my obligations. Snap at my husband about something unrelated because I'm feeling anger.

Intentional Model
T: Wow, it sounds like this other fellow must have experienced a lot more stress than I would have over sign-out, given that it was significant enough that he felt the need to report it.
F: Empathy
A: ??? I don't think I can make a "real" apology about this because I still feel I didn't do anything wrong, even if my behavior had a negative impact on his experience. I would want my co-fellows to be able to send a late sign-out to me so they could attend events, complete consults thoughtfully, etc. I I also feel like letting him know that if he's frustrated with my work he can talk to me about it, ideally before going to leadership, may come off as either passive-aggressive or confrontational.
R: ???

I'm realizing maybe I'm trying to jump to the intentional model/apology stage first—maybe I need to just sit with my anger again? Hmm.....

ANSWER:
Ok, wow friend- you are already processing emotions like a BOSS. This is incredible work!
Let's clean up this unintentional model to make it a little simpler: Note the neutral C, the bulky A and the new R. Yes?

C: 3 new consults on a Friday afternoon. You chose to email sign out later in the evening not realizing that the weekend person would be different than the one you warned. Today, associate PD said: "Was there an issue with sign out last weekend, I was told you didn't send it."
T: Why can't I spend one Friday night going out to a dinner and concert without getting punished for it? Why would the fellow report me when he got signout that night and I was responsive to this message? I would never report anybody for something like that, even if I thought they deserved it.
F: Anger
A: Defend yourself, tell PD about confusion with the jeopardy situation, and mention that you didn't think this was a reportable offense. Replay the situation over in my head and continuously judge the coverage person. Find all of the ways in which the other person could have communicated better. Snap at my husband about something unrelated because I'm feeling anger. Tell yourself a story that now you can never let life outside the hospital interfere w/ perfectly meeting all work obligations.
R: You punish yourself

I want you to get really curious about who is actually punishing you. Did your PD give you a consequence? Or not believe you? Are you being held back, remediated or objectively punished for this? If so bring it back for clarification! Or is the punishment allll the thoughts you have about what others think about you (and then the immediate knee jerk about how mad you are at them?)

I love that you are looking into an intentional model. It's always nice to explore options here, and now you have a really good one. Buuuuuut that A line is telling me that you don't actually believe it yet. And that's totally fine! It's just good data to have that this isn't the right model for you right now.

And yes, turning TOWARDS your anger and processing it is always a great option.

But I want to actually turn towards your IM "A" line for a moment since it's really giving you great information about your values, that deserve to be nourished.
You state:
-I would want my co-fellows to be able to send a late sign-out to me so they could attend events, complete consults thoughtfully, etc.
-I don't want to come off as either passive-aggressive or confrontational.

What I read here, underneath the anger, is a real desire for connection and care, for both you and your colleagues. And it's a big light shining on your current model, that you aren't feeling that at all right now (either for yourself or for your colleagues). So of course you are angry and hurt.

But what if instead of going into DEFENSE mode, you just trusted yourself immediately. What if you trust that you know exactly the type of person you want to show up as, and that includes how you acted in this situation? You took care of yourself and your colleague, right? You know this. If you trust this fully, and you acted from a place of your values, how would you show up?

C: PD asks you about the sign out situation on Friday
T: "Oh, right! That moment where I was acting from my values of being a whole, integrated person and definitely didn't put any patient care at risk. He is just following up to get my side of the story."
F: ??
A: ??
R: have your own back no matter what. Move towards creating a culture of care and connection for you and your colleagues (rather than punishment)

I am bringing up a different perspective on motherhood and physicianhood, and I understand this is not a popular perspective. Nonetheless, I struggle with this issue regularly. When I hear women physicians complain about not having enough time to spend with their children, lack of maternity leave, insufficient sick days, daycare expenses, lack of life balance, etc., my thought is… “But isn’t this what you wanted? Isn’t this the path you chose?”

I appreciate that optimal timing for child-bearing and medical training align poorly for most trainees. I also appreciate that innumerable factors determine when and if women can even have children. Most of my colleagues make tremendous sacrifices to coordinate childbirth around their clinical duties and training, and I truly commend this – I could never be a good mother and a good doctor.

That said, I get tired of hearing “supermoms” complain about how certain aspects of their life are falling through the cracks and watching them exhaust themselves trying to hold it all together. It is impossible to be a full-time mom and full-time physician – there simply aren’t enough hours in a day. Chances are very likely that if you are a mother, you have a lot more support than a non-mother woman physician (e.g. a partner, involved family members or babysitters, a housecleaner, etc.). I am single and don’t have any children. No one ever makes me dinner, helps me with laundry, picks up my groceries, or supports any of my day-to-day activities. My life is far less complicated, yes, but I toe the line alone.

I get tired of working harder when my colleagues are out on maternity leave or home with their sick children. I get irritated that I am repeatedly asked to swap holidays so moms can enjoy Christmas with their children (I want the holidays off too!). I don’t like doing more clinical work because my colleague has to pump.

This is a tough topic and I understand that I am in the tiny minority here. I am not criticizing the decision for physicians to have children. However, I am expressing that I am tired of supporting my mother colleagues who often have no regard for how their decision affects the rest of us who pull more than our weight to support you. And I am exhausted from hearing the same complaints when this was the path you chose.

C: Sometimes others’ decision to have children has a negative impact on my time and my life, and this is beyond my control.
T: I don’t like that I have to work harder to support others’ decisions to have children, and I don’t have a choice in this. I also wonder how I am a burden to those around me?
F: Annoyed. I also feel mad that there isn’t a forum to talk about this since it is such a taboo subject.
A: None.
R: The result is that I keep my mouth shut and this festers inside of me endlessly.

ANSWER:
Hello Friend.

Let's not let it fester. I'm glad you brought this here for coaching. I heard in your model that you wish there was a forum to talk about "taboo" subjects, and I'm really glad that you felt safe bringing this to this group and this forum.

Our job with coaching is to take you from where you are now, to where you want to be- as defined by you. Our job with coaching is also to help you discern where the narrative you tell about your interaction with the world around you is adding suffering.

As I read through your thought download, there are some signals to what kinds of things you value.
I can see that you value justice, and you have a strong sense of what's fair/not fair, what is right/wrong, and what is possible/not possible.
I also see a value of agency and having say in what happens to you in your work.

Do those values resonate with you?
Are there others?

Here are the circumstances:
- You are a resident and you don't have a child. You describe yourself as single.
- Some residents are partnered
- Some residents have children
- Individuals can take leave for reasons like parental leave, sick leave, extended personal illness, leave to care for an ill family member, sabbatical, etc
- In systems without redundant manpower, this can impact or change the workload of others.

It is not these circumstances that are making you feel mad/annoyed/tired/exhausted, it's that you think those circumstances aren't fair to you that is making you feel mad/annoyed/tired/exhausted.

There is a quote from Byron Katie. She says "When we argue with reality, we lose, but only 100% of the time".

The actions you are taking are disconnecting from people, judging them, and (judging yourself pretty hard too), and not creating the community YOU wish to have in your training. And these actions lead you AWAY from your values- you aren't being fair to yourself or others, and you are giving all the power over your experience of your work and life away to things and people outside of your control.

Alright my friend. I invite you to bring this back here again and again- it is important work to remember where your agency lies. With that, I have a few questions for you to think on and bring back if you're willing.

1. Knowing that the circumstances above may not change. How do you WANT to relate to your colleagues? If you are HERE now, what does THERE look like?

2. Knowing there is no "right answer" here, What is at risk for you if you hold onto this narrative? What is at risk for you if you let it go?

<3

For those of you who don't catch the reference, Arizona Robbins is a character from Grey's Anatomy (and no apologies for my obsession with this show). There are several moments where she has to talk to an authority figure and starts to tear up with the pressure. I am also someone who has a tendency to get overwhelmed by my emotions and sometimes I will cry during interactions at work. So now I jokingly use her character as a way to diffuse the embarrassment - "If Arizona Robbins can cry from time to time, then I can too!"

I feel the need to clarify that when I say "cry," I'm not bawling my eyes out - my eyes fill with tears to the point they will run down my cheeks. I know it comes from not growing up in an environment that was always emotionally safe, so I don't think less of myself for it or expect it to magically go away. Also, I truly believe that what I've dealt with in my past and how I've grown from that makes me a better physician for my patients. It does help that I don't cry in front of my patients.

I'm in my intern year and so far this has happened maybe 5 or 6 times. It pretty much exclusively with authority figures (#traumaresponse), Sometimes, it's because I'm detecting confrontation or if I'm reviewing a patient/professional interaction that I'm disappointed about. And I can retroactively make sense of why these interactions feel emotionally intense. For example, last week I was precepting a clinic patient and the attending interrupted me to ask "DO we treat X condition with X medication??" when I was sharing the patient's medical history. The condition and treatment plan weren't relevant to the patient's visit and it was an accusatory way to ask the question - it was reasonable to feel defensive in that situation. Or another time, I struggled to connect with a patient during a visit about her debilitating anxiety and she told me I was unhelpful as she left. While precepting, the attending provided a really helpful suggestion for being more emotionally present with the patient. I felt sad for how the patient experienced the visit and disappointed with myself. Looking back, I don't beat myself up for crying.

The problem is that I spend a lot of time ruminating over what I think my colleagues/attendings are thinking about me. I make up a story that they are talking about me - "you know she just cries all the time" or "how does she think she'll make it through residency crying all the time?" And I do actually have some evidence for this. During my first month this year as an intern, I called a code blue on a patient I had good rapport with and it was a rough day of multiple rounds of CPR. After we finally stopped resuscitation efforts and let him die, I found a breakroom and cried HARD. I had a very supportive team and overall it was a positive memory. Several days later an attending (same attending mentioned above with the pointed questions...). casually mentioned in the break room, "I heard you were pretty traumatized from working a code." Now my brain is convinced that people know me as the resident that cries all the time and judge me for it, including probably my co-residents. I'm even sitting here telling myself that all the other BT members are rolling their eyes while reading this, thinking about how pitiful I am.

C - sometimes I cry in front of attendings. attendings talked with each other about a time that I cried once.
T - everyone thinks of me as THAT girl who cries all the time - *cringe*
F - shame
A - ruminate about the times I've cried, stress about and avoid potential interactions with intimidating attendings,
R - feel more disconnected, miss out on learning opportunities, cry more (lol the cycle)

Intentional model:
T - it's normal to cry when we feel overwhelmed, and I can't control what other people think
F - acceptance
A - spend my mental energy doing something better than making up stories about what other people think
R - have the cognitive and emotional bandwidth to focus on connecting with my team and patients

I've identified this believable alternative thought to pay attention to, but it doesn't compete well against those self-defeating thoughts sneaking their way back in. Help!

ANSWER
Look at all of this beautiful insight! You write that the problem is not in the emotion or the tears, but rather in how you treat YOURSELF afterwards. This is great news, since you are actually in charge of how you treat yourself, so you hold the answer to this "problem" in your hands (and heart).

In this case - the work all comes AFTER the tears happen, since we both agree that the tears are a natural part of who you are. The thought that causes the problem is this one: "Everyone thinks of me as THAT girl who cries all the time."
I love your intentional model, but as you point out, it doesn't hold a flame to the unintentional thought, and likely because you have been thinking and believing the first thought for A LOT LONGER than this new one. So only natural that your brain wants to hang on to it.

The "work" is to poke holes in the unintentional thought - and keep gently untethering it until it can't hold it's own anymore.

-Do you have OBJECTIVE evidence that people think you are "bad" "wrong" "shameful" etc. when you cry?
-Has anyone ever told you not to cry about a patient when you did?
-Has anyone ever commented that being "that girl" that cries a lot is bad?

Next level:

-What is good about crying often?
-What are you grateful to your tears for?
-What part of you is unlocked, protected, nourished, or set free by your tears?
-Do you feel compassion for anyone that can't cry when the feel things?
-How is it that you are setting an example for your colleagues, supervisors, and students?

Bring it back!

My relationship took quite a hit during intern year because of the schedule (my partner was not in medicine) and we ended up breaking up. I am hoping to be able to build a meaningful relationship and family but I am worried about it failing again because of my schedule. What tips or suggestions do you have to balance work, home tasks, personal health, and a relationship? How can I protect any future relationships while I am in medical training?

ANSWER:
Hi there, friend, sorry to hear about your breakup. Let's look at your thoughts in a model to start unpacking the ones that are getting in your way:

C: Had a breakup with prior partner. You are a resident.
T: I want to be in a relationship, but it might fail again because of my schedule
F: ??? (anxiety? fear?)
A: worry, try to protect yourself and your future relationship before it's even started, look outside of yourself for the answer, make medical training something that is a "negative" in a relationship
R: You fail ahead of time

I'm going to tell you something that I really want you to mull over: It's not your schedule that is the problem here: it's your thoughts about your schedule! Sometimes, we use "self care" against ourselves when we make a story that we have to have all the life areas in perfect balance in order to feel ok or get what we want. In this case, you have a belief that there is some magic recipe of work, home tasks, and personal health that will "protect" your future relationships from "failing"- right?

The reality is that there is NOTHING that can protect (or cause irreparable damage) to a future relationship. That is because you can't control the other person. All you can do is show up as yourself, in alllllll your authentic work/home/health glory that is true for you in any moment and let the other person see you.

The trick to getting into another meaningful relationship is (you're not going to like it) ..... being willing to let it fail. Being willing to feel any feeling in the future (regret, loss, disappointment, grief, etc) knowing that there is no escaping these feelings as a human. In fact, the irony is that the more you try to protect yourself from them, the less connection you will have.

-If you were willing to feel any feeling, how would you show up towards your dating life?
-How would you show up if dating and relationships were less serious that they seem to you now?
-What is wonderful about diving full steam ahead into a new relationship?
-What is scary?

Hi. I’m sorry for the mess that is about to be this Ask for Coaching submission but I feel like I might benefit from your perspective. This is going to be the messiest model ever because I’m all caught up in this issue, though I will say I’ve been able to decreasing my frequency of uncontrolled spontaneous tears over the last 10hrs after talking it out with a friend over the phone. Please feel free to edit this down for the posting with your response- I know there are way too many details here.

C: We have had a nanny since late summer who I overall trusted and did a good job taking care of my girls; she has two jobs and we could tell she was a bit stressed so we offered to pay her more money so she could work exclusively with us, essentially, we were willing to pay for her flexibility so she had fewer responsibilities to her other nanny position. She initially agreed but ultimately used our offer to increase her salary with the other family and decided to keep working both jobs. We have been very flexible with her as I was on an easier clinical rotation in January, but we had planned (since December) to take her for more time starting this week as I embarked on the hardest rotation of my fellowship and am preparing to take my oral board exam in less than 4wks. On Sunday night, she texted us at 10:37PM that she would no longer be working for us due to general life stressors and some family issues on her side that she felt needed more of her attention. This left us without any help for this one of the hardest rotations/months of my training and we felt blindsided, which was hurtful. My husband sent a text the next day expressing his bewilderment: “there will be a day when you will need help and will be left stranded alone and you will remember what you did to us.” She responded with absolute spite making false claims about how we mistreated her, saying that she witnessed my husband beating my children (which is absolutely untrue), that our home was “toxic,” call my husband a misogynist, and that we didn’t compensate her well enough etc.

T: The thoughts are hard to pin down in association with many of the initial feelings that came all at once. Over the last 12-18hrs my predominant thought is “Why would she say these things/do this? This doesn’t make any sense, I didn’t see any of this coming.” Another thought is “How could I have been so wrong about this person” and “I can’t trust anyone else again; I thought she was good, she loved my girls, she told me so many times; how can this have happened, how did I judge this person so wrong? How did I let her take care of my kids if that’s what she really thought of my family.”

F: My first thoughts on Sunday PM were blindsided, astounded, hurt, surprised, anger, annoyed; I felt manipulated after all that we had tried to do for her. After getting the spiteful message on Monday PM while rounding I broke down, had to step out of rounds, was hurt, upset, angry, confused. The feeling that I need help navigating is confusion- why would someone say such hurtful and untrue things?

A: I have been crying and feeling my negative feelings so much. My emotional bandwidth is so low with this rotation that I’ve been dreading (which is going absolutely fine so far), the pressures of needing to study, knowing that my husband has to bear the burden of childcare, my own family issues after getting some bad news on Friday which I thought I was going to get coaching on this week until all this happened. I have been going back and forth in my head about the need or not need to respond to these hateful words and my own motivation for doing so if I did decide to respond etc. If she apologized I would feel marginally better; if she doubled down I could just settle on hate/anger which is easier to navigate than confusion and shame. Shame has slipped in this somehow even though I know that I/we didn’t do anything wrong, and all of her accusations are baseless. I’ve shared the situation with a close friend who was able to reflect back that this message that she sent was “absolutely insanity. ”

R: This model is completely mixed up; but I’m going to say that my result is that I’m trying to figure this out; trying to navigate my next steps forward, trying to feel less confused and hurt. Meanwhile I have so much other shit to be doing instead of crying (as I am again now), which is not to say that I’m not letting the emotions, but just that I need to find a way to put this in the past so I stop falling into despair and can anchor on some next steps to keep moving forwards.

ANSWER:
Ohhh my friend, you are IN IT. And of course you are. A lot of surprises have happened in a already crunched time in your life. I'll first just say that this..... what you are doing now..... is exactly what it looks and feels like to take care of yourself when things are super hard. Thank you for vulnerably showing the process to us all.

Ok- this is a great model. And, as you identified, it's "all mixed up" because you have a lot of models on top of eachother all crowding each other out for room. I invite you to separate them out, and I think the easiest way is to look at ALL of the feelings you have and see if you can get a separate model (and one main T) for each F. So you will have:
A "blindsided" model (probably encomapses surprised, and astounded)
A "hurt" model (probably encompases despair, and sad)
A "anger" model (probably encoampases, upset, annoyed and manipulated).
A "shame" model

Since you specifically asked for help navigating "confusion"- let's start there.

C: Your nanny quit, and you did not expect this. She texted words including that you: "mistreated her" "she witnessed husband beating children" , "home was toxic" , "husband a misogynist" and that you "didn’t compensate her well enough" (make sure these are totally verbatim accurate, and fix if not, it matters!)
T: "These words are hurtful and untrue, and she shouldn't say these things, I can't imagine a person saying these things"
F: confusion (hurt)
A: spin in confusion, go back and forth in head about how to fix this, how to get relief, imagine her apologizing or doubling down, look outwardly for an answer (friends, re-read texts I'm guessing), TRY to feel less hurt
R: You aren't imaging the world that you live in, you are stuck resisting it

Ok my dear, this is good feelings work. Perfectly timed for feelings week here - but I wonder if you have a bit of an agenda in your processing.... are you expecting or hoping that the feelings will go away if you "do the work"? Because they may or may not.

Sigh.

And... once they do, some more weird, unexpected and unpleasant feelings will come for you.

Sigh.

It's almost like, the more you "try" to not fall into the abyss.... the closer to the abyss you get.

The way out is counterintuitively to stop trying to get out. You are wanting the world to be different. You wish that people didn't do hurtful things. You wish that people only did things that made sense to you. You are striving for a solid ground and predictability in a world that isn't built that way.

The truth is that your ex-nanny said those words, and you never get to know why. You never get to change the words, the past, or how she thinks/feels. Humans are always going to be flawed humans and that means that they lie, manipulate, and hurt others all the time. It's unfortunately how we are built. In fact, humans also murder, rape, and destroy on the reg.

Humans also misjudge others. Humans (including yourself) get it wrong about people.

It makes the world a scary place, but also a beautifully complex and hopeful one. Both at the same time, and you don't get to choose one and not the other.

Now look, accepting that she said these things does not mean that you accept her. Or believe her. Or blur your boundaries. You know what is true, and now we just need to find out a helpful way to think about her so that you can move through your day.

Let's try a result model- fill in the blanks and bring it back.
R: You accept the reality and are not confused by it
A: what does this look like?? Get specific
F: what feeling would cultivate these actions?
T: what *believable* thought creates this F?
C: Nanny quit unexpectedly and texted the things.

Ok - as you point out, this seems to be a pivotal event for you, it brought up a BUNCH of models to work on. This is good news! There is an entire curriculum on your brain in this one event, right? Think of everything you will be able to learn about yourself here.

Please bring back your other models here so we can do it together.

We've got you <3

My residency program has a practice during lectures and cases where we go down the line and each answer questions (about anatomy, study interpretation, management options, etc.) I find that every time a question comes to me, my brain freezes and even topics I'm familiar with are hard for me to access. I've gotten things wrong or said I don't know for questions that I would expect a medical student to be able to answer, Then afterward, I get into a spiral of feeling like I'm the weakest resident in my program and worrying that people make fun of me behind my back. I often overhear discussions about which residents are weak vs strong, and it makes my anxiety worse. This makes me want to skip lectures (which is possible) and in general keep quiet and hide from other residents to avoid criticism. Any tips?

ANSWER:
Thanks for bringing this here!
There are two options to coach through this -
1) we can try to break down the moment when your brain freezes to see if there is a thought getting in your way. It looks like this:
C: Question is asked of you in a case conference/lecture
T: ??
F: ??
A: freeze, say the wrong thing even when you later realize you had the right answer
R: ???

If this is a new phenomenon, then it's possible that impostor syndrome is at play here and I wonder if there is some voice that is telling you that you don't know that drowns out the one that does. Fill in this model and bring it back if that is the case.

2) We can also look at your reaction to this process, which is a separate model. I wonder if you have a circumstance of "stage fright" or some other phenomenon that happens to you in settings like this, a history of it may shunt us to work on this:

C: Your brain freezes when asked to answer something publically
T: Oh no, they are going to think I'm a "weak" resident
F: Anxious
A: spiral of feeling like I'm the weakest resident, worry that people make fun of me behind my back. Use residents talking out of context to mean something bad about yourself. Consider skipping lectures all together, and in general keep quiet and hide from other residents to avoid criticism.
R: you weaken yourself

Can you see here how your reflex to pull away and avoid is making things worse? You are disengaging from learning and fulfilling the prophecy. I'm sure that's not what your inner critic means to trigger you to do, but unless you see it, you may fall into the pattern.

Diving in here, I wonder:
-Do you think you are a weak resident?
-Is it necessary for "strong" doctors to always be able to be skillful public speakers?
-Is it possible to be a great doctor with stage fright?
-How do you *want* to act if it's true that your brain freezes in these situations? What is possible here?

OK, I tried the result model and this is what I came up with.

C: Nanny quit unexpectedly and texted the things.
T: Our nanny quit without giving us time to find other help, bummer
[and I will stop thinking about all of other things; I will just stick to this thought]
F: Acceptance
A: I stop thinking about it and move on; I stop trying to make sense of what happened
R: You accept the reality and are not confused by it

If I take this model and do my best to implement it, to stick to this thought, why is it still important to flesh out all the other models? I was listening to some of the podcast calls from wk 1 where you advised three people to “lean towards” the unintentional model and get curious about what it is that their brains were offering; is that what I should do here by elaborating those other models? It seems counterintuitive to put effort into cleaning up the other models that have the more complicated circumstances/thoughts that I don’t want to face/think about. But doing that is the work. …But why?

ANSWER:

You always get to decide how much thought-work to do.

You wrote "I don't want to face/think about" the circumstances involved in cleaning up the other models. If you truly believed your result model, why would you not want to think about the other ones? What is wrong with them?

Now, I will write it again: you always get to decided how, when, where and how much thought work you do, and if now is not the time to unpack the heavier stuff, then table it and like your reasons.

If this result model is believable to you and working, then great! You are done. You can absolutely let it be that easy. Sometimes, there is one "ah-ha" moment that is powerful enough to change a thought in the moment forever. But other times, our brains try to pull us back to the initial, automatic feelings since that is what they are programmed to do.

How do you know? Only by practicing the new T. If you find that that new model is working for you then go with it and be free!!

If your brain tugs at you or you find yourself resisting the circumstance again, then listen to that too. The biggest signal that doing the "work" is actually easier than not doing it is if you find yourself trying to get out of a feeling. Stay in tune with your thoughts and body, and you will hear the answer here my friend.

I have an IRB for a project I’m excited about that I need to complete but just have an inability to sit down and do it. I have procrastinated it for months even when I have time. The easy answer is just sit down and do it but it’s just not easy. I know it will make everything a scramble at the end and if I dedicated a couple hours, it would be done already. How can I get over the mental block and sit down to do it.

ANSWER:

The way to get through this mental block is to stop thinking that you "have an inability to sit down and do it." That thought is totally blocking you, and it's optional. And it's also a lie that you are telling yourself - right? You definitely don't have an inability to sit down and do the work... the truth is just that you don't want to.

C: Goal of IRB submission being done
T: I am unable to sit down and do this
F: ?? (resistance? avoidant? blah? demotivated?)
A: procrastinate. Think about it for months, feel the weight of it, dread it, and ultimately scramble to do it at the end in a way that feels even worse.
R: You make this harder for yourself

Ok, sister.
The answer here (if you do want to get it done) is to put it on your schedule for next week (or whenever makes the most sense), and then simply HONOR YOUR SCHEDULE.

When the day and time comes for you to follow your schedule and the IRB submission is sitting there, you can be sure that your brain will throw you a pity party tantrum and give you allll sorts of alternatives that sound like more fun, but YOU are in control here.
Now that you know that procrastinating is not making the IRB go away, but only prolonging the pain, you can gently redirect your brain, allow and process the resistance, and then instead of acting from it, watch it pass and GET THE IRB DONE AND DUSTED.

Please update us when you do this work! <3
Simple, but not easy. The first time you practice this is the hardest, but the good news is that building this muscle (of allowing resistance to be there and still getting after your goal) makes it easier and easier in the future. You've got this!

Both of the prior responses have been really helpful, thank you. I took my intentional model and ultimately settled on a slightly different thought that rang slightly more true and got me to the same place.

C: Nanny quit unexpectedly and texted things.
T: I accept this
F: Early acceptance
A: I fall into thinking about it less often; I feel like I’m moving towards moving on; I’ve stopped trying to make sense of what happened
R: I’m accepting the reality and am no longer perseverating on figuring out the why

This, + a little bit of time and feeling the feelings really set me in a better direction. Interestingly, last evening I noticed that despite keeping this model in the center and giving this new thought the majority of my brain space, another model had sneakily kept slipping back in… When I dropped all the flustering feelings of confusion the thought that successfully stuck around was: But how could I have gotten this so wrong.

Unintentional model:

C: Nanny quit unexpectedly and texted things
T: But how could I have gotten this so wrong? (i.e. misjudging her with the underlying implication that somehow this was my fault that I should have seen this coming or been able to pick up some clue that she had all of these thoughts/perceptions/worries that she never once expressed or referenced despite us having a super open communication style).
F: At fault
A: Blame myself despite the fact that cognitively I know I didn’t do anything wrong nor could have I done anything different
R: Feel like shit

Here, it seems like the problem is that my thought But how could I have gotten this so wrong? put all the responsibility of this problem on to me. So I decided to switch it to a more factual ‘I got this wrong.’ No blaming. Here is my new intention model for this thought, let me know what you think.

C: Nanny quit unexpectedly and texted things
T: I got this wrong (or I judged this situation wrong)
F: Acceptance
A: Accept that we all make mistakes, things happen that aren’t in my control, acknowledge that there is no need or utility in blaming myself
R: Moving on

I think looking at this unintentional model showed me how quick I am to put blame on myself in some way; that my neural pathways are well worn to ask myself what I could have done differently or should have done differently to generate an alternate outcome. But in this case after asking myself the question over and over again I really don’t think that I could have done anything differently so it wasn’t helpful to continue to try to blame myself.

ANSWER

Do you think that you shouldn't ever make a mistake?

I mean - let's say just for argument's sake - that you did miss something obvious here (we both know you did not).
But even in that case - so what?
What are you making that mean?

Can you let yourself be "at blame" here, and not make it mean that there is something wrong with you?
In fact, what if you *could* have done something different, and you figure it out and learn from it - are you allowed to move on as a whole, worthy, valuable person? Or must you berate yourself out of fear that you'll do it again (or somehow aren't whole and worthy because of it)?