Hi there, I recently had a 1:1 coaching session with Dr. Mann about delineating my values, especially with regards to feeling burned out at work when confronted by systems based issues. We had discussed specifically when patients are added last minute to my schedule at clinic without notifying me, how it feels like the system only wants to add patients to my schedule to increase their profit margin rather than respect my time. We talked about my purpose of helping vulnerable populations, and values of connection, feeling grounded in helping others every day.
Thinking more about this, I think what I also struggle with is that I have values OUTSIDE of work that come in direct conflict with my work. In medical school I used to think that my values in work trump all else, but as I've gone through training I've become more protective of my time outside work, not just as a break from work but productive on its own to other means (getting outside to feel grounded/less stress, athletic pursuits, building community and relationships, travel/exploration). So, the thought model I have when I am asked, (or just volun-told) to stay at work late (which being salaried, is not paid extra) is:

C: a late consult comes in at 4pm (pushing my day to 7pm or later depending on other work not yet done), or a patient slotted into my clinic schedule at 4:30pm
T: the system is taking advantage of me and my hippocratic oath to take care of patients, but at the expense of me being able to maintain my goals outside of work (eg making it to the climbing gym to meet my climbing partner, going for a run before it gets dark so I can get some sunshine, meeting a friend for dinner, going on a date, having enough energy to be social and build community)
F: annoyed, angry, exasperated
A: become stressed, not as happy at work, become short with colleagues/ coworkers especially late in the day
R: Feeling burned out with less job satisfaction

Would love to hear any insights about this conflict of values inside and outside of work, thank you!!

ANSWER:
Hello! Yes let's keep pulling on this thread!

Great reflection here. Isn't it interesting to see how your values change over time? Why might this make sense?In what ways does it also make sense that navigating your own changing values and ideas around productivity creates internal tension for you?

I want to do an exercise with your model to get a few layers deeper. Your model above makes a lot of sense. When you think "I'm being taken advantage of", you feel annoyed/angry/exasperated and the rest of it flows from there as you outlined. What I'm going to do now is get really meta and move A LOT of things up to your Circumstance line so we can see what you're thoughts are about that. Some of what I'm going to put on the C line might not be 100% rigidly objective or factual, but we are going to allow it for now. You with me?

C
- 4pm consult or 430 clinic add-on means a later departure and later getting home.
- Hospital systems weren't built to prioritize clinicians' time away from work (It's true, right? they really weren't)
- It's possible even, that hospital systems DO take advantage of clinicians- knowing we hold our Hippocratic oath, and other values of service, caring for the underserved etc, so tightly that we can often prioritize this over our time/self-care/wellbeing
- You feel frustrated, angry, and exasperated sometimes when you think about your relationship with work. You might even be "burned out" and finding diminishing job-satisfaction?

OK, so if we allow all those things to be true, I'll ask "now what?".
If all those things are happening, what does that mean to you or about you in relation to your work?

"If all of that is true, that means __________________"

Then let's put THAT into a model or two.

I'll be here when you're ready to bring it back.

<3

So...after submitting my last thought download, I went to bed, woke up the next morning, and didn't feel nearly as bad about the night as I had earlier. Because I may not think my current coworkers are perfect, but I do feel more accepted and free to be myself with them than I did in residency. I dragged my feet a little coming back to this because it started to feel a bit like an overreaction. But I'm glad I did because I think that underneath this may be a deeper, more important model that I didn't think about.

One of the follow-up questions was "Why is it ridiculous that your colleagues can't see what you see here? Does it make sense to you that they are blind to it?"
My immediate response was, "It isn't ridiculous at all! One of the number one drivers or whether or not someone successfully matriculates into medical school is how much money they have available to throw at the applications process. The field basically self-selects for the exact kind of person who would have no clue what it was like to be in your 30s and have never gone skiing." I think the general acceptance I felt in fellowship before and at work now raised my expectations. But in general the statement stands.

And that triggered a whole cascade of thoughts. Things about stereotypes and justice and about all the unfair expectations that I live under and navigate on a daily basis. And that led to even more emotions (anger, sadness, grief, regret, shame, etc.). But deep, deep, deep down under all of this, I remembered a thought that (surprisingly!) has been kicking around in my mind pre-BT that led me to this model:

C: Colleagues at work sometimes discuss topics that leave me feeling isolated
T: I get to decide how to navigate this in the context of what feels right for me.
F: Neutral
A: Remind myself that times are always changing and even though it feels like my only available options are to be angry (and risk getting negatively stereotyped for it) or be funny (and risk never being taken seriously) that may not always be true. As society changes, my options for dealing with workplace nonsense may change, too.
- Remember that humor is a mature defense mechanism and recognize that making a joke may feel like I'm making light of something serious but it's also a great way to get an uncomfortable point across to an audience that otherwise might not be receptive
- Remember that anger is sometimes justified and expressing those feelings is an option even if it does sometimes make people uncomfortable,
- Realize that there's nothing wrong with doing nothing, Every relationship doesn't serve every need.
- Consider how (or even if) attending these get togethers serves me at all
- Consider investing more time in making/maintaining relationships that do serve my well-being
- Also think of how exhausting it can be to always be advocating for fairness/justice/acceptance. And also think of how painful it can be to bring up past experiences in hope of making people understand me better. And remember that there's no requirement that I take on that burden if I don't want to.
R: Stop ruminating and move on with life while deciding how I'll deal with it next time

Is this the most dominant model? Nope, not even close.
Does it make any of this less painful to think about? Also hard no.
But this tiny glimmer of a thought way deep inside does seem to come the closest to honoring both what my values are while acknowledging all the feelings that come up. Even the ones that aren't so pretty.

ANSWER
Woah - truly, I have chills. I am so happy to be able to publish this model that so many people will benefit from. I have absolutely nothing to add here except to point out that what you have done is to give yourself agency and authority in a landscape and culture that otherwise did not. I also want to highlight that teeny tiny little thought in the beginning of your response; you wrote "I dragged my feet a little coming back to this because it started to feel a bit like an overreaction." Judging yourself here as having an "overreaction" almost prevented you from unroofing this diamond of a thought model, and pure empowerment that unfolded. And what is so interesting is that your action line in this new model is the EPITOME of self-compassion and non-jugement. I couldn't have written what self-comapssion looks like any better that you did here - it is truly aspirational.

And for all of our readers - I want you to notice how this use of radical self-compassion is actually empowering this person; it's creating forward momentum, where as the self-judgement only creates stagnation (and also feels a whole lot worse). Sometimes it's tempting to judge ourselves harshly according to the myth we were sold that it will make us better... but this is clear evidence that self-compassion is the better, more effective fuel.

Thanks for showing us what is possible here!

C- I am a new attending in a health care system that I did not train in. My primary clinic patient load is ramping up. In prepping for my clinic for tomorrow, I see that I have more patients than past weeks, I do not know most of the patients, many of them are very sick, and some have conditions I have never encountered.
T - immediate thought: I can't do this, this is going to be horrible. More nuanced thought: I'm going to not know things, run late, be exhausted/overwhelmed, and may miss things.
F - dread/anxiety
A - read up on the most complicated patients as much as possible, cancel plans with friends in order to do this prep and because I feel so stressed, am not present with others because my brain is ruminating on these patients, reach out to friends to vent about how hard primary care is and to ask for advice but then don't have the capacity to actively listen, think about how I should quit medicine
R - I am also making my evening off unpleasant

I am trying to make my dread less intense by trying a new thought: this is going to be a difficult transition, and it will get better with time. And using evidence of other difficult transitions I've gone through that have gotten better with time to help convince me that this thought is in fact true. It's working a little bit, but not consistently. I'm still very nervous that clinic will be really rough and that I will feel very badly during it, but I think the intense dread has dulled a little (maybe?!)

ANSWER:
Hi Friend, So glad you brought this here.

Great awareness in your model. AND great work asking yourself to normalize that transitions are hard and that you've managed hard transitions before.

I notice that you said this is working a little bit, but that you're "still very nervous that clinic will be rough, and that [you'll] feel badly during it".

Let's try an experiment where we allow some new things to go on the circumstance line

C- you're x months into your position as an attending in a system you didn't train in. Your patient load is ramping up. Patients are complex and sick sometimes, and sometimes you haven't encountered those dx before. You are working on your thoughts around clinic and it's helping a bit, but sometimes you are still nervous and worry about feeling bad during rough clinics.

OK if we let all that be true, including the fact that you sometimes feel nervous, and sometimes clinics are rough, and sometimes that won't feel good.... what comes up?

Do you think you should never feel nervous about clinic? Why or why not?

Do you think all clinics should be smooth? why or why not?

If you give yourself credit for a lot of this being uncomfortable because of how deeply you care for your patients and your work, what makes sense about why you're feeling this way?

Bring it on back here when you're ready <3

C-My clinical nurse of 2 years has not been able to independently answer most patient questions despite seeing the same clinical scenario on repeat. I have written him a guidebook to try and uptrain him and have given him feedback in the moment on many patient scenarios. Despite this he continues to essentially forward me 80% of the messages rather than take care of them, . The above scenario does not occur when a colleague nurse is covering for him. I have asked leadership to change my nurse and they have replied that they cannot. For context: I am 60% clinical and 40% bough down for a role in education.

T-He is unable to incorporate feedback and work as an effective member of the care team and is adding to my clinical burden and decision fatigue, rather than helping.

F-Frustrated, Overwhelmed, Annoyed

A-I am less motivated to continue uptraining him as it has not worked for 2 years. I start reading and addressing my own in basket before he even gets to it just to avoid seeing his messages that anger me/trigger me to feel the above. I am also thinking about reducing my clinical footprint in the academic institution as I do not have adequate support to care for patients

R-I am and unable to close my progress notes on time/address other non-patient facing work that I do for my academic institution. I am making decisions to alter the ratio of my job composition based on a single individual.

ANSWER
What a relatable model- so glad you brought it! I'm going to tighten it up a bit:

C-Clinical nurse of 2 years forwards me 80% of patient messages with out attempting to take care of them. I have written him a guidebook and have given him feedback in the moment on many patient scenarios. The above scenario does not occur when a colleague nurse is covering for him. I have asked leadership to change my nurse and they have replied that they cannot.

T-He is unable to incorporate feedback and work as an effective member of the care team and is adding to my clinical burden and decision fatigue, rather than helping.

F-Frustrated, Overwhelmed, Annoyed (Pick one here- which is the predominant feeling when you think this thought?)

A-I am less motivated to continue up-training him, point out to myself how it's not worked for 2 years. I start reading and addressing my own in basket before he even gets to it just to avoid seeing his messages that anger me/trigger me to feel the above. Consider reducing my clinical time because of this. I am spending time in my in-basket (and in ruminating thoughts about the nurse) instead closing my progress notes on time or addressing other non-patient facing work.

R: Your thoughts and feelings about this nurse are adding to your burden and fatigue, rather than helping.

Ok. I can tell how frustrated you are - mostly we can boil down this whole thing to your thought that your "nurse should be different than he is." Right? And I bet everyone reading this believes you - of course he should! And. He's not. And it appears, at least for now, that he's not going anywhere - he will be your circumstance for the time being unless you go somewhere.

Now - this may be a perfectly reasonable decision (you leaving) - however, I will just point out that these people that don't behave as they should... they are EVERYWHERE. It probably won't be your next nurse, but it might be an MA, patient, family member, or colleague. People are always going around not doing it right. Yes, occasionally, we need to have personal boundaries about what we will and will not tolerate (for instance, if your nurse was clocking you in the face regularly, it would be almost unquestionable that you should go ahead and leave, right?). We all get to sit with what boundaries we want to create in life, what is reasonable, and what ultimately is disconnecting. If this is a situation where it serves you to leave, then by all means, I think you should have your own back about that (and we will too!).

And. If this is not a deal breaker, then it's definitely worth exploring if there is a different way that you can think about your nurse to decrease the amount of emotional anger you are carrying constantly. The benefit of this method is that the lessons here are translatable in so many other realms when you might not be able to change your C as easily.

Some questions to try to untangle this:

-If you dropped all expectations of your nurse for one day, what are you afraid will happen? (get really specific here... let out all the ugly and scared thoughts, I would imagine you are worried that your inbox work will only escalate, and perhaps he'll start slacking off in other domains as well... what else?)
-Is there anything positive that would happen in that one day? (get creative)
-If you decrease or halt your clinical time, what are you afraid will happen (again, get specific. Are you afraid of other's thoughts? Of your institution not being held accountable? that you'll miss clinical care? That you'll make less money? What exactly is keeping you?)
-What's in it for you to continue to try to teach your nurse (obviously, in a different way than you've tried before, considering that didn't work)? How could this be beneficial for you?
-Do you believe that people shouldn't have to work with incompetent people (those not meeting minimum standards)? for how long? Why or why not?

I am having a really difficult time moving past my current thought model. I'm able to identify each of the CTFAR components of my current thought model, but I am having a really hard time changing the A and R in my head. I feel like the ideas I come up with are just positive self-talk (maybe even gas-lighting) that I know won't last. How do I develop actions that will last? For instance:
circumstance- Department head is an Authoritarian leader
Thoughts: This isn't right, no one is being heard, nothing is going to change, I'm not skilled enough in leading up.
Feelings: frustrated, insignificant, exasperated, fearful, dissatisfied, distrustful.
Actions: ; less patience at work and home; worry; difficulty sleeping; not engaging in healthy activities; questioning my decision to be here
Result: Avoid getting involved/pulling away; turning down potential opportunities so I don't have to work with this person as much. [still learning the Model--not sure I completed the model correctly!]

ANSWER:
Wow- you are right on time with this important question about coaching. To be clear - YES!!!! If you don't believe your new "T" or if you feel "stuck" in a current model, then forcing a new one is gaslighting yourself. This is also called positive toxicity, and we do not want to do this because the outcome is always that your brain reverts (sometimes even more intensely) to the original model which may be painful.

I want to make sure you all know that there is no rush, need or urgency to ever get out of a model. Most people (who don't have access to coaching or a practice of self-awareness) stay in them forever. There's no timeline for transformation here, and if your brain is committed to the first model, that is a sign that there is more work to do there - more thoughts to uncover, and more of yourself to get to know before you can move past it.

Take a deep breath, and let's settle into this model! I'm going to refine it, since your circumstance above is actually a thought. To have a true circumstance, it's gotta be neutral, and everyone (even the department head) would have to agree on this.

C- Department head exists
Thought: This is authoritarian leadership, no one is being heard, nothing is going to change, I'm not skilled enough in leading up.
Feelings: (pick ONE predominant feeling): frustrated
Actions: less patience at work and home; worry; difficulty sleeping; not engaging in healthy activities; judging the leader, judging myself, questioning my decision to be here, turning down potential opportunities.
Result: You are stuck in a loop: your brain and experience is not changing.

Ok. I want you to write back and let us know how this model feels to read.

-Do you have a belief that you should not ever be subject to authoritarian leadership? Why or why not?
-What skills do you believe you lack that would make this better for you?
-What need is your frustration pointing to here? Be specific (is it respect? autonomy? having a voice? innovation? what feels like the biggest need with this C?)
-Where can you meet this need (perhaps in other areas), big or small, today?

After that, I want you to try a week where you add the phrase "I'm noticing the thought......." before your T line here, and don't try to shift the T at all other than this. Just continue to add this phrase - everytime it comes up for you.

C- I was informed that the home I’m scheduled to move into in a few days won’t have any blinds up because they are missing “the parts needed to hang the blinds.” They offered to postpone my move-in date by one week. They do not know when the parts will arrive in the mail.
T- The management company is irresponsible for not having the home ready for a tenant who already paid a security deposit and signed a lease. I am stuck in this bad situation because I already hired movers for later this week and I can’t postpone the move because of my work schedule.
F- I feel annoyed and angry that I am not going to get what I expected when I signed the lease (ie. A livable home with privacy). I am also annoyed that they told me on such short notice after my move has already been set up with a moving company.
A- I am having negative thoughts about the management company and dreading that I won’t have blinds for several days or maybe weeks.
R- feeling of resentment is making me feel negative and not have a good day. I am having a hard time focusing on anything else.

Hello friend!
Thank you for writing in. Oooooof! I feel this one big time. I'm so sorry this is happening.

Kudos to you on your model- this is great work. This is also a wonderful example of how we can apply coaching to all aspects of our lives.

Let's look at your model.
C- I was informed that the home I'm scheduled to move into in a few days won't have any blinds up because they are missing the parts. There was an offer to postpone my move in date by one week and they do not know when the parts will arrive. GREAT C- this is factual information that we all can agree on.

T- I am stuck in a bad situation. Pick ONE thought here. You can do additional models with your other thoughts- you may notice if you say each of these thoughts to yourself that the feelings you feel are slightly different.

F- annoyed/ angry - pick which one resonates here the most. For our purposes we will go with angry

A- FILL THIS IN WITH ALL YOUR ACTIONS
have negative thoughts about the management company
dread moving into new place
ruminate about this situation
(what else are you NOT doing?)

R- You stay stuck. You do not look for options - you burn out all of your energy and give up all your power to things outside of your control.

How does this model resonate with you?

NOW-
How do you want to feel about this?

The good news here is that you get to decide how you want to think about it. That can be angry- it does not have to be anything else. Sit with this anger for a few moments. Maybe 2-3 minutes. Can you describe it?

Once you have felt the anger and understand the results in that model you get to choose if you are ready to think something different.

Try this thought model on-

C- I was informed that the blinds will not be in place in my new apartment.
T- I will figure out how to handle this
F- neutral ? Does this thought feel true?
A - what might you do here- look at options, advocate for yourself...
R You look for ways to support yourself / consider options

Let us know what you think of this and write back.

I brought a model to the faculty coaching call earlier today and I wanted to write in that I think I found a new solid T line for my intentional model! I couldn't quite come up with a T line that rang true, but I've generated this one which I think is going to work well.

C- My admin has incorrectly scheduled several meetings, makes false statements and sends me incorrect information
T (old model)- Ugh. Why isn't she able to do her job? Ugh... Why do I have to do her job on top of my job???? ...She's so unreliable, I can't trust her, she makes my life harder..... UGH.
T (new model) - I'm choosing to schedule this meeting/do this task for myself.

Will let you know how it goes!

ANSWER:
Hi! Great to see you keep pulling on this thread.

What do you think that model would look like?

C- You have an administrator. There have been errors in the scheduling. Communication and information is not reliable.

T- I'm choosing to schedule this meeting/do this task for myself

F- __________________(can you imagine how you might feel thinking this?)

A- ________________

R- ________________

If you try this on in the real world, do you meet resistance to it? if so, why?

New attending here. I've thought about submitting entries many times over the past four cycles of BT but I never did because usually by the time I write it out, my thoughts are organized enough to self-coach through it lol. But I'm trying to embrace slightly more vulnerability this time around. So I thought I'd submit something that doesn't feel as "clean" (for lack of a better term) in my mind.

I went to an after-work hangout today for the women attendings in our department. Not many people actually showed up, but there were a handful of us. It was nice. At first. But then the conversation drifted to talking about all the overseas trips everyone wanted to take/had taken. And the best ski destinations in the country. And I have to say, I felt very left out of that conversation. They were sharing their best tips for smooth overseas travel; I literally don’t even own a passport. It just got me to thinking about how being a black doctor is just so hard. I thought about how much I don’t fit in with other people in this field. And this has been such a huge energy sink for so many years now. Today was an unpleasant reminder that the energy sink isn't done just because I'm an attending now. And I thought about how tired that makes me. And how angry that makes me. Usually, I’m pretty good at putting hard things into models, but not this. I don’t even know where to start with this one. I’m dreading anyone bringing up how bored I seemed at dinner because I feel like an overfilled balloon ready to pop and explode all of my anger over how ridiculous it is that anyone couldn’t see what the problem was here. I mean…do people really think everyone goes skiing?

ANSWER:
Hi there -- thank you for bringing this internal conversation you are having here. And your reflection at the beginning is so powerful, sometimes just writing down and then organizing our thoughts is enough to create space and get relief!
I see two separate models here, I'm going to lay them out for your and let's pick one to go through first.

#1
C: You are a black doctor. Racism, bias and underrepresentation in medicine exist. Other doctors were talking about international travel and skiing, and you don't have experience doing either of those. You had an *expectation* that the energy sink of feeling left out would decrease once you were an attending.

T: "I don’t fit in with other people in this field, yet another example of how being a black doctor is so hard."

F: Tired (is it emotional exhaustion? excluded? lonely? something else?)

A: Say nothing, think of all the ways you are excluded, add this one to the list, isolate, disconnect

R: You further disconnect from your colleagues and compound the "hardness" proving to yourself this will be a lifelong challenge

#2:
C: You are a black doctor. Racism, bias and underrepresentation in medicine exist. Other doctors were talking about international travel and skiing, and you don't have experience doing either of those. You had an *expectation* that the energy sink of feeling left out would decrease once you were an attending.

T: "They shouldn't be talking about these topics - this is ridiculous that they couldn’t see what the problem was here"

F: Angry

A: Resist the conversation, bottle emotions during the conversation and say nothing, judge colleagues, stew, ruminate, disconnect.

R: overfilled balloon ready to pop and explode anger (yet, you don't and instead sit with it alone later).

My friend, these models are so relatable, for anyone that's felt left out and angry about it, and especially for those that are minoritized in their field - again, thank you for bringing this. It occurs to me that the very action of bringing this here is likely helping so many people feel connected, seen, and included when they share similar circumstances to you.

But with your two models, I want you to notice how your thoughts (which, are true! yet painful) are causing you to further disconnect in a space where you already feel left out. Ouch. Let me be clear, there is nothing wrong with this. You are justified, correct, and a good person in both of these models, and also - they aren't serving you in the way you are craving, right? The place to start is by gently questioning the thought lines - but I want you to be very careful not to gaslight yourself here into rose-colored-glasses-ing the C line, ok? We aren't trying to get rid of "tired" and "angry" (they both point directly to values near and dear to your heart), only trying to also pull in some models that get you closer to the connection you crave. Try these questions and bring one of the models back:

#1:
-What would it look and be like to show up in this conversation as your authentic self? What would you say, think, and do if you were really being you in this conversation?
-Why (specifically) did you believe that this feeling of not fitting in would get better as an attending? Can you turn towards the grief of this belief being lost? What does that look like?

#2:
-Why is it ridiculous that your colleagues can't see what you see here? Does it make sense to you that they are blind to it?
-What does connection mean to you?
-When your colleagues talk about topics you don't have experience with, do you feel connected to others that are not present? Can you connect with yourself? What would that look like?

Thought download:
I am a mom to two little girls and am also at a point in my career in academic medicine where I feel like I have a lot of opportunities in my career at my fingertips if I engage with them. I find my self feeling constantly guilty no matter which one I pick - more time at work = not as good of a mom and should have picked my girls up earlier from daycare and am missing out on invaluable time with them. More time with kids = missing out on opportunities that would allow me to meet my career goals and distracted time with the kids. I know it's flawed logic because I feel guilty no matter which I choose, but have a hard time actually getting rid of the guilty all the time feeling.

C - I am the mom of two girls. I am also a doctor at an early stage in my academic career.
T - i can't do both of my roles well and have to make choices large and small about whether I'm going to choose my mom role over my doctor role or vice versa.
F - guilty and sad that I can't do everything in both roles
A - I choose differently on different days. Some days I leave work behind to pick my girls up early (but then feel guilty that I didn't work harder or longer). Some days I pick my girls later and spend more time on work, but then worry that I'm not being a good mom and am missing out on time with my young girls that I can't get back.
R - I feel guilty all of the time instead of proud of the things that I'm accomplishing., whether at home or at work.

Hello! THANK YOU for bringing this here.
Before we look at your model can you do something?

Sit back in a comfortable chair and take a super deep breath.
Now- tell me- how does guilt feel to you? Where do you feel it? Can you describe this feeling? Does it have a color, a taste or a shape?
Is it sharp or dull?
Now let this feeling simmer for a minute.
Ok- now you know exactly where and how guilt feels like to you. We are going to come back to this in a minute.

Amazing model here!
Let's look at it ....

C- I am a mom to 2 girls and a doctor in year ( # ) of career.
T- I cant do both of my roles well.
F- guilt
A- choose differently on different days, feel guilty, worry about being a good mom, do not celebrate yourself in either role, less present when with children.
R You give yourself more evidence that you are not a good doctor or mother. You do not acknowledge what you bring to each of these roles and what you have achieved.

What is a "good mother" mean to you TO YOU?
It's OK to let your brain go here, if you could write the job description for "good mom" what would all the expectations of the job be?
Does a good mother spend every second with their children? Does a good mother have a job or outside interests? IF so- how much time is ok to spend on these?
When a "good mother" is at the playground with her children - does she never look at her phone ? IF she does, can she answer a call?
Think about these questions- you have a list of expectations and rules about what makes a good mother and it is often illuminating to list these.
Get as detailed as you can

Similarly, what does a "good doctor" mean?
what does it mean about you as a doctor if you choose to say " not now" to an opportunity in order to spend time with your children?
Does a good doctor say yes to all opportunities? Does a good doctor take sick days?

Once you write out these "rules" you have for yourself, bring them back here and we can go through and see if you want to keep/scrap/modify them so that they can be based in reality 😉

Lets try this model:
C- I am a mom to 2 girls and a doctor in year (#) of career
T Sometimes I will need to make choices
F- how does this feel? curious/open/ ?
A- what actions or inactions can you imagine this generating?
R - Can you see a result here where you can navigate your choices with intention? With kindness for yourself?

Let us know what you think!
Back to the feeling of guilt for a moment.
When you are faced with a choice- you now know what guilt feels like. You know because you sat and processed this feeling. You are an expert at this!
SO- you get to decide if this is the place where you want to come from when you make choices.
You get to say- oh- here is guilt- I see you! OF COURSE I am feeling guilty. I am feeling guilty because I am thinking ....

Play with this and consider doing a 1:1 call to talk more or bring it back when you're ready!!!

As a physician-scientist, I often feel rusty compared to my clinical colleagues when attending on service. My teaching evaluations have generally been acceptable and I've not gotten clinical feedback regarding my care, but always feel like I do not know enough or can't answer student questions in as much detail or as good a way as my full time clinical/medical education colleagues. This leads me to be hard on myself about not living up to what I expect to be a "good attending".

C-I don't attend on service as often as my clinical colleagues.
T-I don't know as much as my purely clinical colleagues and am not as good a teacher or physician as they are. Nurses and trainees think I am not as strong clinically than purely clinical colleagues.
F-Shame, disappointment in self, upset at self
A-Get more nervous on service and question self when answering things, ruminate about decisions and overcheck things after service
R-Become more distracted on service when worrying/ruminating, desire avoiding clinical service time due to feelings and then end up feeling rustier

ANSWER:
Hello! So glad you brought this here. I know this is a thing so many people will relate to.

Nice job on your model- Lets spend just a few minutes making it tidy.
C- Get as factual as you can here. This helps to really see what narrative our brain applies to them.
- you spend X weeks per year on service.
- (could include something like - the average time on service isn my group is___, or the range of clinical time on service in my group is ________, if you know that info)
- you are a physician-scientist
- You have gotten evaluations without comments on your clinical care.
- Learners ask questions

T- try to avoid compound sentences here, that way we can look at one thought at a time
"I don't know as much as my purely clinical colleagues"
" I'm not as good a teacher or physician as them"
" Nurses and trained don't think I"m as strong as the purely clinical colleagues"
"I can't answer clinical questions in as much detail as my full time colleagues"

You could put each of these Ts into its' own model, if you want. But for now just choose ONE. I'll go with
"I'm not as good a teacher or physician as them"

F- Choose ONE here. (I know, so hard!) Let's go with shame in this example. Does that feel right?

A- (what does shame want you to do or keep you from doing?)
- ruminate about decisions
- overcheck things when you leave service
- be hard on yourself (what does this look like in practice? name calling, judging, blaming?)
- distract yourself with ________
- make a list of reasons to justify doing LESS clinical time

R- you don't support or acknowledge yourself as the physician/teacher that you ARE, and probably don't enjoy the experience the way you'd like to.

It makes a lot of sense, given what we do, that your brain naturally defaults to comparing (and despairing) between yourself and your colleagues. It also makes a lot of sense that when you believe the thought that you aren't as strong as them, your experience of clinical time looks like it does in this model.

OK so now what? We know this is your starting point but it doesn't have to be the ending point.

Let's take this opportunity to define what "Good enough" means to you as it pertains to your role as an attending on service. I invite you to make a list of everything a "good enough" attending knows, does, thinks,doesn't do. Get as JUICY as you can. It's OK to let your brain run wild here and be as perfectionist as you want to be. We will get curious about each of these facets after you've gotten them all dumped out of your brain and see which ones you want to cut/keep/modify.

OK?

A "good enough attending".....
-
-
-
-

Bring it on back here when you're ready.

I am a physician-scientist, critical care physician met my wife in medical school. She went into a field with higher reimbursement and better lifestyle. She is in private practice and makes 3x what I do (she works hard but mostly can leave it at work with normal business hours). I spend a decent amount of time doing work at home (mostly research- especially around the time of grants, manuscript prep, or presentations). Also have to travel for meetings (which are ok but would rather just be at home). Clinical time ~7-8 weeks per year 7 days 10-14 hour days. We have two young children. I really try not to let my work at home interfere with help with child care or quality time with children. At times my wife has statements about how underappreciated I am by my work and undervalued (ie do not get paid enough, asked to do "extra" unpaid things due to "academics")

C-My work to reimbursement ratio is far below my wife's.
T- My work and aspirations are not valued by wife
F- guilty, defensive
A- justify why my work is as important than hers, try to do extra childcare/house management on time off, never do anything on weekends with friends that does not involve whole family (making up for time gone during meetings)
R- At times have arguments with wife or resent her. Feel that sometimes I do not have a life of my own outside of work/family. (sacrificing hobbies, friendships).

ANSWER:
Hello! Thanks so much for bringing this here. Well done taking a crack at a model!

Since we are very early in the program, we like to spend a little bit of time "cleaning up" the model so we can really what's happening.

A few rules
1. Circumstances are like Vital Signs. OBJECTIVE, clear, neutral, facts.
2. Choose ONE thought per model (great job on this).
3. Choose ONE emotion per model. (of course there may be more than one emotion happening, that's OK, we just look at one at a time)
4. Nice and Juicy A line- NICE JOB HERE! Lots of verbs. I love to see it.
5. Result is always for you. Nice job here too.

OK Here's what I'm picking up.
C- You and your wife met in medical school. You are a physician scientist in Critical Care. She makes "x" per year, you make "y" per year (just the facts, remember). You travel to conferences, apply for grants, write manuscripts, and give presentations outside of your clinical time, including on nights and weekends. Your clinical time is 7-8 weeks/year of 7 10-14h days in a row. You have two young kids. Sometimes your wife says words about your work.

(checking in here. Do all those statements seem factual?)

T- My work and aspirations are not valued by my wife

F- Choose ONE emotion here. I'm going to go with DEFENSIVE
(you could run a different model with GUILTY which would have different As and a different R)

A- Get JUICY. WWhat do you do/not do when you're operating from defensiveness?
- justify the importance of your work
- argue/build your case
- Look for ways she's got it easy, maybe invalidate her work (if not out loud, then in your head?-- I may be off base here, but sometimes we do this when we are defensive)
- what else do you do that builds a wall?

R- The sum of those actions, I suspect, is that you are out of alignment with who you want to be as a partner, and as an academic.

The first step is to just recognize and allow this model to exist with no judgement blame or shame. Look at how it makes sense that you feel defensive when you think she doesn't value your work. We aren't going to be in the business of changing this thought right away. Let's start by just asking a few questions to understand it a little better.

A few questions for you to consider, and bring back for more when you're ready.
- What comes up for you when you read that model back? Why?
- what values do you hold that feel in conflict here? How/why?
- What are you most scared or worried about here? In what ways does that worry make sense? In what ways does it not make sense?
- What does "value" mean to you in this context?

Please bring anything back here for more when you're ready. This is an important thread to keep pulling on.

I am not sure how to apply for a promotion when I know that a colleague is too, I don't want it to be contentious or a competition necessarily but its something I think I would be good at. I worry that the optics won't look good, like a me vs. them and that I might be labeled as the bad guy or greedy. I want to get ahead of the dialogue and not catch people off guard that I am also wanting to apply, but don't know how to do that.

ANSWER
Hi there! Thanks so much for for being the first in your cohort to ask for coaching here - wahoo! First things, first - let's put this lovely thought download into a Thought Model so we can better understand if there's any thoughts that are getting in your way:

Circumstance: Goal of a promotion. Colleague is also applying for this promotion.
Thought: I would be good at this but don't want it to be contentious or a competition since the optics won't look good, and I could be seen as "the bad guy" or greedy.
Feeling: (??? Which feeling does this thought create? Is is nervous? dread? Something else?)
Actions: Worry. Ruminate on how to get ahead of the dialogue and prep people, but ultimately spin in confusion about how to actually do that. (??? What else are you doing here? Not doing? Have you talked to anyone? Complained? Are you perseverating on this? Are you disconnecting at all from either the promotion idea or from your colleague, even in your head?)
Result: You pre-label yourself in your head, and experience bad outcomes when they haven't' happened yet.

Isn't this interesting? Your brain is trying to protect you from things other people could think about you, and from bad outcomes. But instead, it just has you experiencing them in your head when they haven't happened yet. Here's secret #1 of your personal coaching curriculum: you actually can't predict OR control what others think about you. It sometimes seems like you can, but you really can not. And you are spending a ton of energy here trying to control the optics, which are not in your control. You know who's optics you can control though??? You guessed it: your own <3.
I hear values of both ambition, career orientation AND friendship/collegiality in your thoughts. Here, you are thinking that those are opposing, but let's explore how they may be aligned.

How would someone show up as their best self for the promotion, and their best self in a peer-relationship? What does that look like to you?

Bring it back here and let's move you closer to that goal!

Welcome to Ask for Coaching!

Here is a guide for how to get the most out of this type of coaching:

1) Title your question with something memorable for you. Unless you identify yourself in the title or in your request, your coaching request will be anonymous to other readers. If you want (and to make it easier for you to search and find your old posts later), you can add a tag unique to you (Ex: #abc)

2) Think of a topic you would like coaching on and do a thought download on it here in this space.

3) Try to pull out a thought and run it through a model (C-T-F-A-R) right below your download. It doesn't have to be perfect, just give it your best shot.

4) Hit "submit" at the bottom and one of your coaches will reply HERE within ~ 1-3 days. (Your request won't show up here until we post it with our response)

5) Come back here and search for your post (try to remember the title and scroll down until you find it), and you will see our answer in the text below your question.

6) Read the questions and coaching your colleagues receive - chances are lots of the coaching topics here will apply to you too!

7) Use this as much as you like, 24/7, for coaching on ANY topic. There's no wrong way to do this. There are no gold stars or failures. The more you ask for coaching, the more you will learn, grow and benefit from this course. We will keep our answers succinct and offer 1-3 questions for you to consider and bring back for more coaching. Feel free to respond back in a new post (there's no way to respond in a "thread"), or consider bring any follow up to a group coaching call.

8) Remember that this space is completely anonymous and of course confidential to our group. It's totally fine (and welcome!) to share successes, give support, shout-outs or love to your colleagues here too, doesn't always have to be a place for problems.

Coaching opens on February 3, Bring it on, friends!

Thought download: About two years ago, I was asked casually if I might be interested in giving a talk at some point on a large platform about something I was just starting to learn. I said sure... someday. Now, suddenly, I find myself on the schedule for a very specific date in the very near future. I do not feel I have really developed the expertise - would still describe myself as an advanced beginner. The date is rapidly approaching. My initial feelings when I saw myself listed on the schedule were resentment that no one asked if that would work or if I would be willing to do this specific day. Also, terror at the challenge of trying to prepare and put it together. Also, embarrassment that I still have not developed more expertise in a skill that I would love to master. One might wonder why I didn't say "I'm sorry. I see myself listed on this date and that won't work for me." I think partly, I thought this would be a challenge I might be able to meet and also partly I recognize that this is a "gift" of an opportunity to build out a CV. I worried about the optics of having to say "no, I actually can't commit the time to this right now" or "no, I actually can't put this together yet."

Unintentional Model:
c - I was signed up to give a presentation without specifically agreeing (did provide a generic agreement in the past). I did not promptly reply saying "no" (which is my own mind means I have agreed implicitly).
t - I'm not really qualified to do this (this feels SOOO true that it may actually belong in the circumstances). This will take a tremendous amount of time and energy on my part. We're heading into the holidays. I have a lot on my plate personally and professionally.
f - resentment, embarrassment, fear, frustration (if I"m being honest, mostly frustration with myself that this doesn't feel like an easier task)
actions/inactions - delay, procrastinate, ruminate, feel anxiety, miss the opportunity to say no, but continue to fantasize about sending an email backing out of it even though the date is now inching closer

Intentional Model:
c - I was signed up to give a presentation without specifically agreeing (did provide a generic agreement long ago in the past). I did not promptly reply saying "no" (which is my own mind means I have agreed implicitly).
t - This feels intimidating and like a big challenge, but I think I am capable of doing it.
f - somewhat apprehensive??
actions/inactions - found a colleague to mentor me, try to outline what I will do and make a plan for it -> admittedly, still pretty certain that I am also procrastinating and might fall on my face.

I'm living somewhere between the intentional and unintentional model in terms of my actions. Feeling nervous that unless I suddenly made this my number one prioritity, it will not be a positive experience. Ultimately, feeling dejected about the entire situation.

ANSWER:
Hello Friend!
Fantastic model making! You are on to your brain and bringing lots of curiosity to your thoughts here.

Let's look at your models:

unintentional model:
C- I was signed up for a presentation on X date. (Keep this factual)
T- I am not qualified to do this.
F- Frustrated/ resentment/embarrassed - what feels true to you here when you say the thought out loud?
How might your actions differ from a place of frustration vs a place of embarrassment?
A- delay, procrastinate, ruminate, do not say no but fantasize about sending an email backing out of the presentation
R-You do not consider ways in which you ARE qualified and do not take steps to do the presentation.

Intentional model:
C- I was signed up for a presentation on x date.
T- I think I am capable of doing it.
F- apprehensive
A- found a mentor, outline and plan, think about procrastinating but keep on preparing. What else do you do or not do when you are unsure you can do this?
R- You foster thoughts of capability and move in the direction of preparedness.

Great observations to say that you are living somewhere between these 2 models.
Let's look at that.
How do you want to feel about this presentation?
Is there a way that you "should feel"?

If you were to say no and send an email delaying or cancelling what would that mean about you?

OK- one last model for you to think about.

C- I was signed up for a presentation on X date
T - I need to make this my number one priority or else
F- How does this thought feel when you say it? Pressured?
A- What do you do when you feel this? What do you not do?
R- What /who are you making a priority at this moment?

Please let us know what you come up with here and bring you thoughts and models back to ask a coach.

Thought download - I recently went to a conference that was wonderful. So many ideas, interesting projects, conversations. Even in the moment, I had a fear that I would walk away with a huge to do list and energy for all of these things and then would do nothing to follow up. This seems to be a recurring theme after meetings, educational sessions, etc. I struggle to put anything into action or even take the next step.

c: I have many ideas and projects that I am hoping to start and feel periods of energy and enthusiasm for tackling these. For months, the same tasks will sit on my to do list without any progress or time invested in moving them along.
t: Am I a fraud? Why can't I seem to get anything going? How can I organize myself to do one thing at a time? Why am I even writing these ideas on a list knowing I won't look at it again?
f: Embarrassed, ashamed, overwhelmed.
actions/inactions: I suppose the inaction is actually the literal circumstance here.

My intentional framework has tried to be:
c: see above.
t: I have a lot on my plate. Progress will come. Be kind and patient with myself.
f: forgiving
actions/inactions: still mostly inaction... Contemplate what may be getting in the way of moving forward (family obligations, work life, inability to get big chunks of time, lots of demands on time) -> note: these all do still feel a bit like excuses and even if I totally accept them as fact/circumstance and forgive myself, my fear is that I'm missing something here. If the goal is to change the inaction, neither my intentional nor unintentional framework seem to be motivating behavior change....

ANSWER
Wow - what an insightful reflection you've done here! I can't tell you how many times I've created an intentional model only to find that that's not exactly what I want either - such good work.
Also, you did the hardest part of realizing that beating yourself up (and failing ahead of time with thoughts like "I'm a fraud" "I can't seem to get anything going" etc.) doesn't work at all.

Let's put your GOAL in the R line of an intentional model and work our way backwards. I want you to bring this back and fill in the blanks:

R: Move forward in a tangible way on one of your ideas and/or projects

A: (what would action here look like? write our every single little minutia like sending the first email, or what you need to look up. Also, what do you need to stop doing to get this done?)

F: (now, what do you need to feel to fuel your A line? You mentioned enthusiasm...does that feel right here?)

T: (the money line. What though can you think and BELIEVE TODAY that creates this feeling?)

C: You have ideas and projects that you'd love to get going

To get your juices flowing on that T line:

-Imagine you are your future self, 10 years down the line, looking back on this project being successfully completed. We don't know how, or when, but we know it's a total success. From this perspective, what would your future self tell your current self today?

-What is an idea or project that you HAVE successfully launched before in your life? (could be anything- from applying to school, to decorating a bathroom, to starting a new habit). What thought did you use to get this one done? How did you organize yourself that time?

-Answer your own question: "Why ARE you writing these ideas on a list knowing you won't look at it again?" What is the use of writing ideas down even if you don't reference them? What does it generate? Is it true that that's a useless thing, or could it be a key ingredient to future action despite not being tangibly used in the future?

<3 Bring this back - this is the PROCESS we all need

Thought download: My husband and I seem to have a recurring argument and I'm interested in changing my reaction and approach to this and understanding it differently. A perfect example happened yesterday - husband is interested in taking on a little passion project/side hustle. He has a list of evenings where he would be able to try to coordinate this. We look at the calendar together and lo and behold 90% of the dates that are options for him coincide with evenings I need to work late. We have young children, limited support system and not a great situation for reliable childcare in the evenings. I have some control over my schedule if I know long in advance, but last minute adjustments require a lot of energy and effort to trade. He gets frustrated, angry, irritated and says things like "This is why I can never get anything going. I can't do anything or make any plans with your job. This is what it's like to be married to someone who always has to work at night." I get defensive and I immediately start trying to solve things - "I can swap this, I could pick up a late shift here and be free there." He says "That's not great either. It will be hard on the other day you work late." I get mad and start saying "I don't want to work late either. I'd prefer to be home every evening. There's not a choice that I can just NOT do late work." We talk about getting a babysitter or asking someone to watch the kids - there are reasons he doesn't like that idea either (have to pay someone else so he can go do something to try to eventually make money, but cuts into the margin; need someone who we are comfortable with picking up and driving our kids to get them home after school; hard to know the hours we would be offering because my schedule can be unpredictable - even on a late day, I can sometimes get home early). We both walk away in a huff and annoyed.

c: I have to work late sometimes. My schedule can be unpredictable and I cannot leave work on a given day until I am relieved. This means there are x evenings a month where I'm not home by dinner and y evenings a month where I'm not home by bedtime and I cannot say with certainty when I'll be home on any given day. My husband's work and interests can conflict with my work schedule at the last minute and he invariably has more flexibility even when he wishes that wasn't so. Someone needs to be home with our young children. We do not currently have a deep bench of babysitters.
t: why is he acting like I've done this on purpose? if only I knew about his schedule in advance, I could solve the problem. Acknowledging his resentment of my work and thinking that he doesn't acknowledge any of the positives. Lots of thoughts or feelings about wanting to solve the problem (which should be a solvable problem...); wishing I had more support; feeling afraid or overwhelmed by the prospect of needing to find childcare, coordinate lots of schedule changes, etc.
f: defensive, frustrated
lots of inactions: do not find extra childcare, do not commit to figuring out which shifts I should change, let the calendar keep rolling and the resentment/frustration simmer, repeat above scenario (with some other collection of details at some point in the future when invariably a similar situation occurs)

ANSWER:
Hello! So glad you brought this here. First off, GREAT JOB having awareness here and opening yourself up to thinking about (and experiencing!) this differently.

It makes sense that this is charged. You've probably rehearsed this argument 100 times, or more!

Nice job on your model. I can tell that the C line isn't quite neutral so I'll try to help with that. On your T line, try to pick just ONE sentence. Then on your F line, just ONE emotion/feeling. Of course you have more than one model running in your brain, but for the sake of this process, it's helpful to just look at one at a time. I'll help start the different models, which one feels most important to explore first?

C- You have a job. Evening hours can be unpredictable, and sometimes you aren't home by dinner/bedtime. Your husband also has a job and other interests, which are also at nights. Your kids need a grown up to be with them. You and your husband both experience the human emotion of frustration. (I'm willing to bet everyone would agree on these ;))

T1- He's acting like I do this on purpose
F1-?
A1?

T2- If I knew his schedule in advance, I could solve the problem
F2-?
A2?

T3- I acknowledge his resentment of my work, but he doesn't acknowledge any of the positives
F3?
A3?

T4- This should be a solvable problem!
F4?
A4?

T5- I wish we had more support!
F5- ?
A5?

T6- It's overwhelming to find childcare and coordinate schedule changes
F6-?
A6?

OK- so let's see if you can pick ONE of those models to flush out a bit more. Which of these thoughts do you think is the stickiest for you right now?

I suspect that the result of most of these Ts lead you away from solving the problem and also away from being in connection/aligngment with your partner, which is why it's so tender!

Bring it back here, friend and we can keep exploring this. It's important work!

I was asked to do a thought download after my first week and here it is:

This week was super hard, but has been getting better. I did have many thoughts of "I am drowning, I can't do this, I don't belong, I tricked them into thinking I was a good fit for this position, people think I am stupid, I am burden". And when I was in an anxious, negative thought spiral it was very hard to break out of that negative head space. When I was in a more grounded place and started to have some of these imposter syndrome/insecurity-based thoughts, I could remind myself of the evidence to the contrary in somewhat effective ways. This looked like - "This feels bad because it's my first time doing this and I'm in a brand new system seeing patients without much ramp up as a brand new attending. It is NORMAL to feel out of my comfort zone. There are so many things to learn and I will learn them with time. I have been in new systems/roles before and I did well and I can do it. I do belong - my boss created a new position that fits my professional interests and advocated for me to be have more procedural time. I did a fellowship in this area and I got good training - I can do the clinical work, it just feels overwhelming right now because so many things are new. I am in fact super excited about the balance of work ?I'll be doing and the patient population I'll be working with." etc etc.

I am trying to stay in the more grounded and logical headspace, but I find myself sometimes slipping into the anxiety spiral. Today for example, was my first day on L&D as an attending. The environment is much more supportive and collaborative than where I trained and I overall had a good day learning how things are done at this institution, working with residents and caring for patients. One of the patients whose delivery I was involved in today almost needed a c-section and I froze and did not do a good job managing her care during the urgent situation. The team was super helpful and supportive and the patient was fine and ultimately had a great vaginal delivery but my negative self-talk really kicked in. I was telling myself that I should have known what to do, how could I teach residents if I am not confident in own skills/knowledge, that people were probably all talking about how dumb and incompetent I am.

The things I have noticed help me stay/get out of that head space have been 1) meaningful patient interactions 2) genuinely kind colleagues 3) deep breathing (sometimes). Patient care, while at times stressful, has been a great reminder of what I love about medicine and why this FFT anxiety is worth it. And its been really helpful getting external affirmation from colleagues who have normalized that learning the system is challenging, have answered my questions without impatience and have even told me how excited they are that I have joined their team.

I feel like I have two models - one where my circumstance of being a new attending leads to negative/imposter syndrome thoughts and then anxiety/fear and worsening self talk and another where my circumstance leads to the thought "this job will ultimately be so great, it will just take time for to feel comfortable" and I feel more excited and hopeful. I'm struggling with how to stay in the more positive model/mindset and not let the anxiety spiral take over.

ANSWER:
Hello, and WOW.

Thank you SO MUCH for sharing this reflection. I love how you are holding yourself so gently during this time! Really, I invite you to read back through that and see where you can give yourself credit for all of the work you are doing to take care of yourself right now. Some tricky thoughts are popping up, and that's to be expected, right? Your brain is gonna brain.

In month 1, we introduced the concept of the 50/50, the idea that if we are LUCKY, about 50% of our thoughts and emotions will be positive/comfortable and 50% will be negative/uncomfortable.

What if the work here is to gently notice when you are in the uncomfortable 50 and then with patience, guide yourself back?

This is what I already see you doing based on your reflection here. And

What if nothing has gone wrong here?
What if sometimes your brain offers you impostor thoughts?
What if sometimes you have an "anxiety spiral"?
Now what?

Bring it on back here, friend!

For context, I would say that mostly, my experience in school and training came pretty easily for me and I was highly successful. I don't think the arrival fallacy feels quite right - I've enjoyed the ride and savored it AND I have also fully enjoyed my life outside of school/hospital. But, I’m pretty private - I have kept my personal life/identity/self very separate from my professional self, which was usually nicely packaged and tucked away outside of the hospital. As I've transitioned into attending-hood and grown my family, I have tried to start showing up as the authentic version of myself in more spaces - I think this is important for career longevity. Also, life just feels so so so full between patient care, academic responsibilities, young children, maintaining relationships, etc - it doesn't feel like there is enough time or energy to keep things so separate. I also recognize that I really prefer a glass-half-full outlook and I am intrinsically pretty happy - I think one fall out of this (or maybe the reason I am that way) is that I don't tend to dwell on negative feelings or emotions.

I'm really struggling to identify my purpose. This came up in another context not too long ago where I was challenged to think about a 5-year plan and a 10-year plan. As part of that activity, we were asked to identify core values and also to imagine our funeral and what we would hope was said about our professional accomplishments at the end of life. The part that was really hard for me is that I'm not 100% certain that my personal identity or values include much about my professional roles or life as a physician. This, I think, goes back to the first part about keeping things separate for a long time. My family and most of my “people” live far away - if I had a funeral at any point soon, I imagine it would be there. It wouldn’t upset me if absolutely nothing was mentioned about my professional life. My core values have much more to do with how I think about my family, the world and life outside of the hospital. When I think about the decision to apply to medical school, my thought process was much more of the “I have to work and this is interesting and exciting and feels meaningful.” I am not someone who grew up planning to be a doctor all of my life - actually, I grew up planning to be a mother first and foremost. Now that I’m both and life feels so full, I find myself constantly thinking about how I have only this one life to live. I think I love my clinical work. I think I love my academic work. I definitely LOVE mothering (though I am very, very grateful to send my kids to childcare outside the home and have some space to be other things too). But, day-to-day, I struggle with the balance between all of these pieces. I think that often shows up for me as doing the next most immediate thing, but failing to step back and think big picture about where I want to be in 5 or 10 years and how to get there. Instead, I am saying “yes” to things that are exciting, fulfill my sense of curiosity, help me feel like I’m growing and able to share that experience for the benefit of others. I am definitely doing way, way more than the minimum necessary. But, if asked what I would do if I had endless resources or a finite amount of time left on this planet (even as I write this, I’m aware that we all do), my instinct is that I would walk away and not feel the need to work a day more. I keep taking on more professionally - I’m enjoying it, but it’s such a hustle. I also recognize that every thing that I do means time that I’m not doing something else. Without a clear sense of purpose, I feel a bit paralyzed. I’m worried about winding up 10 years from now still without a clear sense of purpose and feeling like I’ve missed out on my children growing up. I look in the mirror some days and wonder how I got this old already. I also note a bit of feeling burnt out sometimes and worry that my current pace is unsustainable and also that I’m not currently able to focus my attention on the most important things (maybe because I’m struggling to clearly self-identify the most important things in my professional life). Interestingly, I am also struggling to live my purpose at home - my husband and I have been trying to identify our shared 5 or 10 year goals and being intentional about this feels overwhelming.

There is an expression that I learned somewhere along the way about “sliding or deciding” - like if your life is the consequence of actual decisions you’ve made intentionally one by one (deciding) or just sort of letting things unfold (sliding). I fear that I’ve done more sliding than deciding.

My model:
c: I’m a junior clinician-educator. I’m a parent. I have a busy clinical practice and we are understaffed (seemingly chronically). There are only 24 hours in a day and time continues to pass.
t: I’m putting forth a TON of effort in all areas without a clear idea of why and I am struggling to prioritize. I’m afraid to say yes and afraid to say no.
f: Lost? FOMO? Afraid?
Actions/inactions: Taking up space in my head and mental energy, feeling a bit of decision paralysis in all areas because it’s not clear to me where I’m supposed to be going, but I feel a bit like I’m at a turning point. Fantasize about moving my family to the middle of nowhere and becoming a farmer… Question literally every piece of my current personal and professional life. But, in spite of this, continue to say yes to lots of things and build a professional niche.

ANSWER:
First I want to highlight how we can have MANY purposes (purpoi??) in various facets of life. I see the following models for two that you pointed out:

C: My Life Purpose
T: I'm not 100% certain that my personal identity or values include much about my professional roles or life as a physician. My core values have much more to do with how I think about my family, the world and life outside of the hospital.

C: My Career Purpose:
T: “I have to work and this is interesting and exciting and feels meaningful.”

As for the model you brought, I'm just going to clean up the C line slightly:

C: I’m a clinician-educator __ years out of training. I’m a parent. I have a clinical practice. There are only 24 hours in a day and time continues to pass.
T: I’m putting forth a TON of effort in all areas without a clear idea of why and I am struggling to prioritize. I’m afraid to say yes and afraid to say no.
F: Lost (burnt-out?)
A: Do the next most immediate thing. Ruminate, thoughts take up space in my head and mental energy. Decision paralysis in all areas. Indulge in confusion rather than decision ("it’s not clear to me where I’m supposed to be going"). Fantasize about moving my family to the middle of nowhere and becoming a farmer. Question literally every piece of my current personal and professional life. Continue to say yes to lots of things and build a professional niche. Do way, way more than the minimum necessary. Fail to step back and think big picture about where I want to be in 5 or 10 years and how to get there, and judge myself for this. Look in the mirror and tell yourself a story about how old you are and how much time has passed. Rush yourself. Extend this mindset to other areas of life (marriage goals).
R: You slide rather than decide, and beat yourself up for it.

My first question for you is - what is your rush to figure this out? Can you "decide" to be in a figuring it out phase"?
One method you mentioned that you employ is to say “yes” to things that are exciting, fulfill your sense of curiosity, help you feel like I’m growing and able to share that experience for the benefit of others. This sounds like a great method to help you figure out where you are supposed to be going. Where is the problem here? Is it that you haven't figured it out yet? If so, again, what is your rush?

I wonder if your response to that question is: "I’m worried about winding up 10 years from now still without a clear sense of purpose and feeling like I’ve missed out on my children growing up." Why do you believe you need to have a "clear sense of purpose to be present in your children's growing up"? Are these two things linked in your brain? If so, it's obvious why you are putting paralyzing weight on this issue 😉

Finally, I noticed is that you say that if you had endless resources or a finite amount of time left on this planet you would walk away and not feel the need to work a day more. This is GOOD TO KNOW, but not the reality or context that you live in. Watch that you don't start to judge yourself for not doing that in your current life, when you don't have endless resources and a known life limit currently. I think most people would match your sentiment here, this is human.

I am early-career in academic medicine and have started taking on more leadership positions (probably more commonly held by those a bit further along in the promotion timeline). I anticipate the opportunity to continue to grow in this area fairly quickly and take on even more responsibility. I’m struggling with this in a few ways - one of which is an imposter syndrome piece. I have realized that I have an idea of what I think a person in these leadership roles should look like - and I can dress and play the part, but also, on my own time, there are some ways that I feel incongruous with this theoretical idea. I wear sweatpants to the grocery store (and to daycare drop off, and to the park, and the coffee shop, and, honestly, lots of other places...), I don't own a home, my car needs to be vacuumed, my to do list is crushingly long and the amount of time it takes me to get to personal tasks like hanging photos on the wall or scheduling a haircut is frankly embarrassing. (Of note, I could substitute 5 different details here - in spite of the title, it’s not actually about the sweatpants….) I feel like I'm hustling all the time and I'm not sure I have things put-together enough to "succeed" in these roles. I also wonder if I will be able/willing to meet the promotion timelines - I’m growing more and more interested in doing those things that I feel passionate about and less interested in investing time and energy into a task just to meet a requirement. I worry about the implications of this if I were in a significant leadership position.

The model:
c: I am early career and moving into leadership roles with the opportunity to continue to grow. I have not yet met promotion criteria. I am actually just a person.
t: who me? if only "they" knew what my life actually looked like, no one would think this was a good idea.
f: ?fear of being found out...? or, maybe, fear that this would mean I have to totally shift my personal life to meet the "image" of success? I'm not exactly sure what the feeling is that is holding me back honestly.
action or inaction: hesitation about charging forward. This hasn't really come to a head yet since I'm continuing to put one foot in front of the other, but the experience of thinking or feeling this way is taking up space unpleasantly in my head, making me doubt myself, and certainly not helping me...

ANSWER:
( Full disclosure- am wearing sweatpants as I type 😉 )

Thanks so much for bringing this here! I see so much awareness in your reflection, you're totally onto yourself. And of course, you're right, it's not about the sweatpants at all.

It sounds like your brain (specifically the inner critic part) has a very specific idea of what a person in leadership should look/act like, and it's offering (or yelling at you) about a lot of them!
- no sweatpants ever!
- own a home!
- car always clean!
- to-do list gets done. every. day.
- personal tasks should be done effectively/efficiently
- home should look like a gallery
- more...

Your inner critic things that if you do all these things perfectly you won't have to feel any of the discomfort that comes with learning new skills, leading people, and the dirty work of GROWING.

OF COURSE it thinks these things. It think's it's keeping you safe. Your model that you wrote out here is 100% spot on. This is a model where you believe the inner critic's beliefs about you and the result leads you AWAY from what you want (Growth, opportunity)

Another part of you knows this is not true. This part of you embraces challenge, opportunities, growth, flexibility, new things. We aren't looking at this model right now, but it's there too! It's the one that says "OOOH! This will be so cool!--> Excited--> raise your hand for new opportunities, try new things,---> expanding your knowledge/skills and opinion of yourself. That'd be a fun one to look at too!

Let's see what happens if we move the fact that your brain offers you impostor thoughts into your c line, and also add in that you have a human brain.

C- You are x years out of training. You have taken on y leadership position. Your brain can be relied upon to offer you a handful of "Impostor" thoughts that you are in a habit of giving airtime to. You have a human brain.

T- ?
F?
A?
R?

It's honestly a HUGE thing to have even brought awareness to this thinking habit you have. That's 50% of the battle right there.

One question to think on
- What do you think your inner critic is trying to protect you from?
- what do you think your inner critic needs to hear from you?

Bring it on back here for more!

Hello,
I am a chronic pain attending with board certification in addiction working at a university as well as VA. I have seen a lot of opioid mismanagement by physicians over the years, but most recently I see it in the name of "patient centered care" that I think actually boils down to "I am unable to have difficult conversations and so even though deep down I know better, I will continue prescribing". This frustrates me. Also at the VA, I go though requests from community pain clinics to do procedures on veterans that are inappropriate and makes me feel like they are actually just trying to make money off of vulnerable patient populations. All of this makes me feel very cynical and question who we are putting through medical school because it often does not seem like we are selecting or training people appropriately for the job.
C: Seeing patient care that is not evidence based and has been shown to cause harm and/or is lucrative for a clinician/clinic
T: Other doctors are tricking themselves, have giant egos, are are not paying attention to public health and/or are completely corrupt
F: cynicism and disgust
A: Difficulty respecting, trusting, and communicating with other physicians
R: Not sure if I should just put my head down and keep plodding along, take a leadership position to try and make change (or will this make it worse), or quit pain open a "wellness clinic" and give botox injections and MI coaching session w other like minded clinicians I know (just kidding I am the breadwinner for my family of 3 kids and am not business savvy so not an option).

ANSWER:
Thank you for submitting this question. Cynical is SUCH a great emotion to explore. I'm glad you brought this here!

To begin, let's look at your model- this is how we see in what ways operating from cynicism has results for you.

C-A circumstance is a fact, something everyone would agree on (even the attending you’re referring to!). You might with ALL of your being believe your circumstance as it's written, but it is a subjective statement.
NOW- You can say Dr X made a request for procedure X to be done to a veteran. Or Dr. X prescribed Y medication in this amount with that frequency. Guidelines state “[guideline]”. Those things are neutral/factual circumstances.

T: Dr. X is trying to make money off of a vulnerable population.
F: cynical
A: Think about how you cannot trust other physicians. Think about how you cannot communicate with other physicians. Judge. Look for evidence that supports your belief that folks are getting “bad” care. Don’t look for evidence that supports that folks might also be receiving “good” care. Spend your time thinking about things outside of your control (ie who is getting into medical school, the state of things, etc) Wonder what motivates other doctors and wonder if they are motivated by profit. Spend your time thinking about things outside of your control like how medical students are chosen. Think about quitting your job and working in a new setting.
R:You see corruption everywhere, and corrupt your own relationship with your work.

OK
Stay with me here- Are there any other ways to look at this?
Could you think of any reasons (even ONE) that Dr X is asking for this procedure?

Think about a specific example regarding a specific colleague. Perhaps an example where a patient was given opiate scripts.
What are you making this mean about this doctor? About medicine? About your own career path?

Let's say you put your head down and "plod" along. If this is your action- let's work backwards to get a model.

C (your specific example)
T -There is nothing that can be done (does that resonate for you?)
F hopeless? (How do you feel when you think that?)
A plod along (What else do you do or not do?)
R You miss what you can do, you do not see any positive outcomes and miss opportunities to educate and make a difference

Is there a problem for you in staying in these models? If so, what?

Think about this and please bring anything that comes up back here.

Hi! I completed a 3 year internal medicine residency and a chief year in the middle of the first COVID surge. I then completed a 1 year palliative care fellowship and am now in year 3 of palliative care attending at a large urban center. I clearly am somewhat capable at work. However, I have failed my ABIM exam 3 times. I have paid for a training course and UWorld and gone through. My last failure was by 30 points. I had to take a break this year because I failed three times and now have to sign up again for next summer. I was diagnosed with ADHD last year. I have serious imposter syndrome that is likely contributing to test taking (and while studying) anxiety, but obviously failing three times is feeding my imposter syndrome. How do I break this loop so I can study effectively and hopefully put this behind me?

ANSWER:
Hello friend !
I am so glad you brought this question to coaching.
Let's start by looking at your model:

C: Scored below passing ABIM test.
T: I need to break this loop.
F: Anxiety, pressure
A: What actions are you taking here? What are you not doing?
R: You continue to spin in overwhelm and effectively stay in this cycle.

Another T you mention is "I clearly am somewhat capable at work."
When we experience imposter syndrome we do not believe we are qualified for something despite evidence to the contrary.
You have listed some of your qualifications:
You completed a 3 year residency, a year as chief and a palliative care fellowship.
You completed all of these years with a diagnosis of ADHD AND you came within 30 points of passing your ABIM.
What else? I know there is more!
How else are you qualified to be right where you are?

A test score is a Circumstance. It is neutral. What you make this mean about yourself (thoughts) cause your feelings which in turn drive your actions.
Before moving on to new thoughts it can be helpful for you to look at what is going on in your brain right now.
For instance, what does it mean to effectively study?
What has to happen in a study session for it to be effective?
Has this changed for you after being diagnosed with ADHD?

Is there a way to breathe here? To pause, support and care for yourself here?

Please send us your response! We would also love to talk more in a 1:1 coaching call!

Thought Download: Woke up this morning feeling sad and a little anxious. I realized (trying to sit with emotions) that I have two types of anxiety. The "busy" kind, which feels like my skin is being pulled in different directions or there is noise all around me and my brain is using half it's energy (the back half of my head interestingly) to tune it all out. The other kind of anxiety is actually fear. I felt fearful this morning, like my chest was caving in. I am new faculty, and just graduated IM residency. I feel like I don't know enough about medicine for where I am in my career and that I'll miss things that are important for patients. The smallest comments from others make me feel like I did it wrong or that I didn't do enough. I am also definitely afraid that people will think/realize I'm not as great as they thought I was. An example I perseverated on this week was that I don't even know screening guidelines/recommendations or workup for TIA in clinic. and it feels like something I should know but have forgotten in the last few months when I took time off.

C- I don't remember everything I learned in residency, and specifically some stuff that should be the "fundamentals"
T- "I'm a bad doctor who isn't where I should be." Also, "I'm not as great as people think"
F- shame, unworthiness, sadness
A- Look up a lot more stuff for patients, spend a lot of time pre-charting (learning a lot which is good, but wish this were driven by curiosity not guilt), feel guilty during downtimes/weekends for not spending time learning, feeling like I don't belong so I act like I don't belong (also i'm an immigrant and already feel a bit like I don't belong in some groups).
R- Waste time on thinking these thoughts rather than just learning and growing--- frustrates me so much!

ANSWER:
Hello! So glad you brought this here.

What great awareness you are practicing! It's a real skill to be able to tease out these different ways your body is feeling under the umbrella of "anxious". This is emotional agility, friend. Keep it up.

Let's take a look at your model.
C- "I don't remember everything I learned in residency", I suspect does not feel neutral for you. But I"ll allow it here in the C line though because it's probably true (and is true for ALL OF US!- It's literally not possible to remember everything you learned in residency, right?). But let's rephrase it so it's neutral. Here are all the circumstances I can pick out.
- You are in your first year on faculty
- you took x months off between completing residency and starting your job
- It's not possible to recall everything you ever learned in residency
- you saw a patient with possible TIA in clinic and didn't immediately recall the guidelines/recommendations for next steps off the top of your head (does this feel neutral/factual?)

T- Pick ONE thought/sentence here. "I'm not as great as people think"

F- Pick ONE feeling/emotion here, that comes up when you think that T.
"UNWORTHY"

A- Great job here! so you're grinding yourself in pre-charting, veating yourself up during downtime/rest, looking for proof that you don't belong. What else are you doing? what are you not doing?

R- You nailed it! You are spending your time judging and punishing yourself instead of leaning into your values, which sound like curiosity, learning (among others)

OK- I promise nothing has gone wrong here. Your brain is doing what it knows best. You're finding yourself in a relatively new role, a new setting, with new colleagues, and your brain thinks it's going to protect you somehow by showing you all the ways you're not doing enough. This is all happening because you CARE- about your patients, about your role, about your work.

Before we try and get out of this thinking habit, let's spend a few minutes understanding why your brain might be so practiced at this.

From a place of curiosity ;).... I want to invite you to reflect on a few questions...
1. Why does it makes 100% sense that you are feeling anxious in your work right now?
2. If you had to write the requirements out for being a "good enough" 1st year attending, what would those requirements be? (on your first pass at this, don't censor yourself at all. Make the list exactly as it comes to your mind and be as detailed as possible. For example "A new attending should immediately remember the guidelines for TIA workup, A new attending should always_________, A new attending should never_______". Etc....

Bring either (or both!) of those back here, or to a live call for more, friend.

Jumping off from the faculty call from earlier today, I have this feeling cluster that I sometimes experience in my marital relationship of attacked/defensive/angry and I would love to be able to move from a React response to an Allow response *in the moment.*. I know this is going to be a big task. My React response always makes things worse, and choosing an Allow response in these moments feels so.... acquiescent... but I know that my reaction is not helpful so I am therefore motivated to change it.

When I feel attacked there is an instant tightness to my body, I want to make myself smaller which is then immediately followed by the feeling of defensive where I counteract the attack by making myself bigger, then anger rolls in along and defensive and angry is almost a pulsation that can be so hard to let simmer without reacting. When I feel attacked that is also associated with a hurt, the hurt then rolls into sadness and frustration, which are heavy and often follow after the React when I re-learn that the React does not help. So then there is sadness and frustration and despondence and I feel exhausted and spent and empty and if anger or irritation sneaks back in then I also experience a bit of restlessness.

C-
T- He's wrong about me.
F- Attacked/defensive/angry
A- React
R- Husband feels misunderstood because I didn't just acquiesce/agree, he Reacts, I React, he Reacts, we find physical distance to help calm the situation down.

In almost all other situations I can very quickly and effectively "let them be wrong about me" but I find it to be much much harder in the context of my marriage.

Intentional Model:
C-
T- It's OK to let him be wrong about me
F- Calm
A- Allow
R- Me accepting his perception sends the cue that I hear and understand him and the situation doesn't escalate

Maybe this is the crux. The thought that I need is more than just "let him be wrong about me," I think in this situation it feels very NOT ok to let him be wrong about me. Maybe I need to give myself some sort of permission that it's OK to let him be wrong about me... that letting him be wrong about me is not somehow going against my other values and beliefs.

OK. I'm gonna try it.

ANSWER
Great self-coaching here! Let us know how this thought feels in real life. What I'm more interested in first, though, is THIS MODEL:

C: Feeling cluster happens. You are interested in the Allow response *in the moment.*
T: I know this is going to be a big task. [...] Choosing an Allow response in these moments feels so.... acquiescent...
F: ??? (how do you feel when you think this thought about allowing feelings?)
A: my guess is that from this T/F is where you continue the cycle of reacting, out of some drive to not acquiesce? What else? Are you critical of yourself?
R: You continue to react, even knowing React response is not helpful.

Ok- my guess is that as long as you equate "allow feeling" to acquiescing, you will continue to choose another method (especially if you are anything like me, and feel incredibly strong in your value of respect and being heard).
So let's dig a little there:

-What does acquiescence mean to you? Why is it bad?
-In what ways is your thought *not* true? Are you sure that processing an emotion is equal to acquiescence?
-In what ways is the opposite true? (how does reaction cause acquiescence for you, if at all?)
-Have you ever acted with power and momentum after allowing an emotion?
-What are all of the ways that reacting to an emotion (or resisting/avoiding) lead to a non powerful/backwards result? Get granular here, if you want to stop the cycle, your brain will need to hear and believe all the ways this is not empowering, since I sense it doesn't quite yet.

I’m reflecting on a recent 1:1 coaching session and feeling frustrated. I have a never-ending to do list of tasks for work, parenting, and relationships, and it was suggested to me to do a time log and step down from leadership at work to have fewer to dos. Instead, I was hoping for a way to reframe my thoughts about my many obligations.

C: Constant and unpredictable tasks to be performed for work, parenting, and relationships.
T: I’m not enough. This is never-ending. I’m not in control.
F: Panic. Frustration.
A: Frenzied bursts of activity, reacting emotionally to feelings of overwhelm, reaching the end of my rope and dissociating with social media.
R: reinforcing feelings of panic and lack of control

ANSWER:
Love it - let's reframe!! I wonder, though, why you are struggling to reframe in the first place. Are there any upsides to believing this thought the way it is? Clearly the thought is compounding your suffering as you so eloquently show in your model. I would even venture to say that the result is that you have become somewhat blind to ways that you are in control, and have developed a confirmation-bias towards seeing only the ways that this thought is true. But- your brain continues to offer you this thought even when you see it's not helpful and the cycle continues, so I wonder if there are any reasons you can point to about *why* you continue to think this way?
It may be simply habit (you are not alone!), or it may be an underlying belief you are holding onto about what you think you are capable of, deserve, or should have. See if you can reveal this deeper thought to yourself.

Sometimes our brains are overwhelmed with the premise of reframing thoughts simply because it seems easier to continue to blame our circumstances for our feelings. I bet it feels really true that if you had less constant and unpredictable tasks in your life that you would feel better, but unless you change your thoughts, this simply isn't true. I can also tell from your T line that you are really believing that your circumstance (and/or your very self) should be different, showing that you might not be ready to move to a new thought yet, you are still heavily believing this current one. Which is just good to know!

Here are some questions to get you started in revealing your brain:

-Are there times when you do feel enough? How often/what percentage of the day do you feel enough and/or in control?
-What would feeling like enough be like? How would you know?
-What's wrong with feeling panic and frustration some of the time? Are you willing to allow these feelings without trying to solve or avoid them?
-Why do you believe you should be more in control?
-Do you believe this life should feel easier? Why or why not?

Please bring this back, this is such valuable work!

C: Work with colleague that doesn't do their fair share of the work
T: They are lazy. It's not fair. Maybe I shouldn't try either
F: Anger, a tiny bit of jealously, but mostly anger for what it does to the residents and faculty
A: Hold them accountable when I can. Do my job regardless, but cut back substantially
R: I resent them and they likely resent me.

This is a pattern that I've struggled with in my life. repeatedly in other realms of my life. Do you have any suggestions of how to stop this cycle?

Answer:

Hello friend!
Thank you for bringing this to Ask a Coach.
It's fantastic that you brought your model here for us to look over.

I am going to begin with your circumstance.
Remember that circumstances are neutral facts- facts that can be proven in a court of law or that 10 people in a room would all agree upon.  
Working with colleagues that "don't do their fair share of work" is a subjective statement.  You can believe this with all of your heart but it is still your opinion.
Now, you could write "Dr X did not do the thing" or " Dr X came into work at 830 and not 8 am" and these would be specific facts.  
Your T may still be "Dr X is lazy" or "It is not fair." -  What you are saying here is that when Dr X did not do the thing that it meant to you that Dr X is lazy OR it meant to you "it is not fair."
Pick one feeling for your F line.  How do you feel when you think that Dr X is lazy? How do you feel when you think that it is not fair that Dr X was late for work?
THEN- fill in all the things that you do or do not do when you feel this feeling.
Let's say that you feel resentful.  It sounds like when you feel resentful you decrease what you do at work and perhaps do not engage with Dr X. and are less engaged at work.   You think about how work is unfair and perhaps ruminate about this. You may think about all of the other unfair things that happen.   What do you not do? Do you bring your best self to work? How do you engage or interact with other colleagues?  
R- Our Result line will often reflect the T line. If our thought in this model is "It is unfair" -look at the actions taken in the model and see that you are creating more unfairness for yourself at work.  You are possibly less engaged with your colleagues and perhaps not allowing yourself to be fully known in your workplace.

You can play with this model and write back to us!

Here is something to think about- how do you *want* to feel about Dr X?
Some ideas- What does it feel like to think "Dr X is doing the best they can." or "Dr X is a person who has different work habits than me."
Plug these thoughts into your model and see what feelings come up for you.

Great awareness here friend- I can't wait to see what you come up with here.