I was on a weekly coaching call. Got coached and gave coaching on that call last week. This week no one raised their hand so after a some time in silence another participant who was also coached last week volunteered. Right at the same time I also said I’d be okay being a client

The coach said okay to the first person then with my name she said hmm you’ve been coached recently right and I said yes I was coached and also coached someone else on the call last week. She said okay. Then a third Person volunteered and the coach said she would work with the first person and this third person. So not me

I wasn’t itching to share anything in particular but I’m feeling rejected because why was I asked those questions when the first person was *also* coached last week?

I’m making this mean I don’t deserve to be coached, maybe I ask too much, am I too needy? Am I annoying my coach? Am I not the ideal client etc etc

I tried to sit with this since yesterday, allow it to be and hopefully pass but I still feel rejected today, why was this me called out in this way?

C: volunteered on coaching call and not chosen
T: I ask for too much coaching
F: ashamed rejected
A: hide ruminate
R: interesting - here I came and asked for coaching on this platform from which I expect a helpful result. I think the real result here is I’m not going to my “regular coach” for coaching here. I’m acting out of embarrassment not speaking up to her and not making sure I get the support from that group that I signed up for

Could use some guidance working through this. My goal is to always be supported no matter what although I’m having trouble believing that right now

ANSWER:
Hi there! This is meta-meta-coaching (coaching on coaching on coaching). 🙂

First of all, THANK YOU for being a person who raises their hand to be coached. You are an important member of our BT community and your willingness to share your real inner thoughts is truly valued not only by us but other participants as well. We very much want to be able to coach everyone who wants coaching, so I am sorry it didn't happen that way on the call.

You felt rejected after the call. You noticed yourself ruminating about it, looking for reasons the coach went with one person or the other, then judging and name-calling yourself (needy! annoying! not the ideal client). You noticed that you were spinning a bit in that, and you brought it here for coaching.

You said your goal is to "always be supported no matter what", and look at you supporting yourself by noticing this model, writing it out, asking for coaching on it here.

Let's look at the emotion of rejection. Is this something that comes up for you often? How does that show up for you?

What is the upside of being sensitive to (and on the lookout for) rejection?

Is there a downside? if so, what?

What would you like to do now?

The self talk about being needy/too much/annoying... what do you think is going on there?

If I reassured you that no one felt that way about you or anyone in BT, what would you think?

Let's keep coaching 🙂

C: I am an associate professor who is the leader of a subspecialty division in an academic medical center. Prior to this role, I was in the interim chief position. When we were looking for a division chief, the institution where I work held a national search to find a new division chief, with three people interviewed in person. My Department Chair offered one the position, then another person the position. In the end, neither could come to my institution, so then my Department Chair offered other people in my division the position of division chief (all while I was interim after I expressed interest in the chief role long-term). After a year of finding no one else, my Department Chair then offered me the permanent role.
F: I feel like I was looked over as a strong candidate and was not first in line but rather 4th or 5th in line. This makes me feel like there is not a lot of faith in my abilities as a leader.
T: I am just a convenient filler when no one else was available for the role
A: I second guess myself and my abilities.
R: I already took one leadership course, and I am looking for another. I don't feel like a success, though, and feel like I have to keep proving myself. I may take fewer risks because of this. I am not as confident as I want to be in this role.
===============================
Awesome example to bring here! I'm going to clean up your unintentional model a bit:

C: You are chief of your division. You were offered this role after 3-4 people were offered it and said no.
T: I was looked over as a strong candidate and was not first in line, so they don't have faith in my abilities as a leader.
F: inadequate
A: I second guess myself and my abilities. Look for leadership courses to bolster you, but even after these courses, still don't feel "like a success" and tell yourself that you have to keep proving myself. Take fewer risks, confidence diminishes.
R: You now look over yourSELF as a strong candidate.

Ok- your brain is trying to tell you that if your C was different (if you were chosen first), then your F could be different (confident)- but that's not the way it works. You can TOTALLY step into confidence with your current C, just by zoning in on that T line. In fact, if we don't unpack your thoughts about yourself, your brain would probably come up with reasons to tell you that you are a bad leader even if you were chosen first.

So instead of looking for EXTERNAL evidence that you are a success, you need to find internal evidence and then you will create that result for yourself.
Your brain is telling you the story that you are a "convenient filler" - but it's JUST A STORY. Not the truth. And this story is holding you back. Let's write a different story: and fill it with actual facts.

How about a story titled: "120 reasons I am a total badass success" or "A Cinderella Story: University's most competent leader changes direction of entire division" or "When my institution overlooked the best leader in the universe and I rose to my power in a mere 12 months"

In order to write this new story, we will need to find a different thought, or at least disprove the current ones as unifying truths.

-What other reasons can you imagine for your division choosing someone besides you first other than not having faith in you?
-We now know it's costing you quite a bit to believe you were "only a backup choice"- is there any reason your brain wants to keep hanging on to that thought? Is it benefitting you in any way?
-What evidence exists today (not from the past search, but from your current role) that you are succeeding as a leader?
-Is it possible that your division has complete faith in your abilities right now? What evidence is there for this?

Please bring your answers back along with a new story and thought model!

Hi coaches, would love some practical tips on how to avoid reacting immediately to strong emotions. The more thought-work I do, the better I am at noticing emotions and not reacting to them without processing them first. However, occasionally, my emotions are so strong that I react anyway, before I can even take a breath and work on just feeling them or processing them. This often leads to behaviors or reactions I'm not proud of.

To try to put this into a model:
C: I am a human who has emotions
T: When I have a very strong emotion, I often react in ways I am not proud of
F: ashamed
A: this shame often prompts me to dig deeper and do the thought work I should have done earlier and ask the question, "Why did I have such a strong emotion?"
R: eventually I learn from the experience which is good, but I am curious how to help my brain interrupt the strong emotion -> reaction reflex sooner

This leads to my next model:
C: I am a human who has emotions
T: Sometimes I react to strong emotions in ways I am not proud of. This is understandable because I am a human, but I am curious how to help my brain interrupt this emotion -> reaction reflex when the emotions are very strong
F: curious, interested
A: reaching out for help from amazing women in BT!
R: feeling hopeful that I can get better at this with support and practice

I'm guessing the answer is just continuing to practice feeling these strong emotions and accepting them, but any other practical tips would be much appreciated!

ANSWER:
WOW! This is such impressive and deep work! Great job here.

New C line: you are a human being and sometimes have strong emotions (like most humans!). Sometimes you act from those emotions and those actions, in retrospect, are not in alignment with who you want to be. ( I would want you to be specific here. I said "______", "I did ________ (action)"

T:?
F:?
A:?
R:?

When you imagine the person you are growing into being, does that person NEVER act from their big emotions?

How does that version of you meet themselves after doing something that, in retrospect, they wish they hadn't?

Is there anything MORE important than what a person does in the heat of the moment? If so what?

Let's keep digging!

Hi, this one has been rumbling around my head for a bit and I finally have a bit of space and time to get it down on paper. All of Tyra's coaching this cohort around "It shouldn't be this way" + revisiting emotional adulthood for the 124th time have helped nudge this submission into fruition. Thanks in advance.

C- I'm married. I'm a surgeon. I take call and have cases. We have two kids. I am not always home before 7PM. Some mornings I leave at 6AM. Husband has expressed several time that he feel trapped by me/my work schedule. Husband takes responsibility for groceries and cooking. Husband works from home and has a flexible job. I do not work from home. Husband has expressed overwhelm re: his responsibilities. Husband expresses blame towards me for "restricting his life," being the main source of his stress, wishing he had known that marrying me was "going to be like this," etc. Husband has used words like prisoner, slave, servant, on multiple occasions. Additional circumstances are that I am kind, I am not a slave owner, I am empathetic and compassionate, I care about my husband and my family.
T- This is not true, I am not enslaving you.
F- Misunderstood, indignant
A-
R-

Two or so weeks back I was talking with my therapist about how I just want/am almost desperate for him to take a 3-5 day trip every month-- to see friends, to do work trips, whatever he wants just to prove to himself that he is not shackled to the kitchen or the laundry room. That if he just went out of town THEN he would see that he CAN live his life, that I don't have a knife to his throat. The reason that I want this is because then when his perception changes then I can not feel misunderstood and indignant.

I'm looking for how to not feel misunderstood or indignant, even if the C doesn't change. This C and this F have been around for a while and I am really really over both being accused/viewed this way through his (distorted) lens. I'm gonna try an intentional model.

R- I feel seen and understood
A- ??
F- Seen and understood
T- ??
C- Husband expresses overwhelm re: his responsibilities and places blame on me when he is stressed.

OK ok, wow, that didn't go great. This is why I'm stuck.

I also have another thought/analogy that is somehow related to this so I'll put it here as well. When I was a resident and we were newly married, I was making more money than him and he felt emasculated. I remember having this biggish-moment sit down discussion with him where I pulled out a pen and paper and wrote out "Me: $XX -->. You: $YY -->". I'm putting 100% of my $XX dollars into our account and you are putting 100% of your $YY dollars into our account-- see? We are both contributing 100% of what we can. We are both contributing equally. ...So layered on the model above, I also have this thought which is something along the lines of When you had less than me, and we both gave 100% of what we could, I considered that equal and I gave you grace. Now, I can give a less quantity of time/effort to home responsibilities but I am still giving 100% of what I can and you are just blaming me. WHy am I not extended the same grace that I extended to you???? We are BOTH giving what we can. And, in fact, I give in *other* ways to support our family, i.e. financially etc which he views (in his stressed moments) as "useless" and "not really helping."

To close the loop, I am also aware that *he* feels unseen and misunderstood, but there seems to be nothing I can say or do to convince him that I appreciate him and his effort when he spirals into this space-- further leaving us more disconnected as the conversation anchors/pivots to the storied story that I'm the enemy. (Disclosure: we and I are also in therapy so I've got another space to process this as well). Thank you!!

ANSWER:
Hi Friend. Reading your reflections above I can tell how hard you are working on this and how constricted/restricted/trapped YOU feel here as well.

OK. What happens if we put this on your c line?
C: I am feeling misunderstood and indignant, and I long to feel seen and understood.
T:
F:
A:
R:

I see that you are stuck in your intentional model. You want to be able to think "He see's and understands me", but with the circumstances as they are, this is not available to you right now.

But let's zoom way out.
In what ways DOES he see and understand you?
In what ways do YOU see and understand him?

Keep working here.

PS. I love your framework about giving 100%. so powerful.

Wanted to say THANK you to whoever offered this coaching, mindblown and will do the work

Thank you

=================

Hooray! Love a mindblown moment, so worthy of celebration. Sharing your soul here is making your work count for SO MANY MORE PEOPLE, the ripple effect of this is huge (have shown this with qualitative and quantitative studied!)- so want to celebrate and thank you for that. <3

I hired someone to help cook at home. She is still learning the basics of our kitchen so I end up working next to her. She has a lot of questions while she's here. I tried working elsewhere and she had trouble finding what she needed or questions how something should be made. She's been here about 5-6 times now.

The nanny sees me and is excited to talk also. There is so much interruption, even if I wear headphones. Even if I say I have to get some work done.

I'm now questioning what's the point of hiring this support if they're actually distracting me from what I need to get done in a day?

Whenever I think of firing or replacing the support I feel so bad. They both need the money. I don’t want the effort of finding someone new. Feeling stuck a bit.

===============================
What an absolute perfect issue to dig into this month!

C: You have hired a cook and a nanny. The cook has been to your house 5-6 times and has questions while she's here. The nanny also has questions for you. These questions occur whether you are in the space or if you are working elsewhere with headphones on.

T: There's no point of hiring this support if they're actually distracting me from what I need to get done in a day!! But they both need the money.

F: Stuck

A: Vacillate between your own annoyance and trying to internalize their discomfort. Say the words "I have a lot of work to do" and expect them to interpret it with an unsaid request. Dread the effort of finding someone new. Engage in black and white thinking, instead of creative thinking to get your needs met.

R: Your brain continues to distract you even when your employees are not in the picture

Ok - this is a great place to practice setting a boundary. What you have done is made a request (and it's not clear that you even did that- telling people that you have a lot of work to do is not the same as asking them to not talk to you!).

A boundary is a request and a consequence about what YOU will do if/when the request is not honored. You can choose if you share the boundary with your cook and nanny or not, but it's important that you are clear on the boundary in your head so that you can get your needs met. It might sound like:

"If I am spoken to when I have work to get done, I will leave my house and work at a coffee shop"

I do advise getting specific, so that you can forecast all of the threats your brain or reality might offer you:
"When the cook and nanny arrive, I will politely tell them that I will be working from the office and can not talk, and to only text me questions that are urgent. Then enter office, lock the door, and do not answer texts unless I agree they are urgent."

A few questions on the ensuing "schmilt" that will come up (uncomfortable feeling of thinking you might disappoint someone):

-Do you believe that you need to talk to anyone excited to talk to you? Why? What happens if you don't?
-Will the decrease in efficiency for your cook to learn your kitchen without you, be worth the gained time to focus on work?
-Do you believe that you answering questions is the only or the best way for your cook and nanny to figure out how to get their work done?

Bring these questions (and whatever you come up with for a boundary) back here, so much good coaching to be done in this space for us ALLL.

i feel like this thought download will be therapeutic in and of itself so here we go. this situation just occurred

I was at a wellness conference, met someone who works as a prosperity coach, he offered "1 hour roadmap" calls to the first 17 people who asked and I scheduled one, his words: "this roadmap call will show you the way to your next 10k this year"

ok i joined the call, first thing I'm told is the call is 30 minutes not an hour. Okay I thought, I also understand this is his business, time is precious, he likely will market something to me etc I went in with those expectations. i answered questions honestly and openly when he asked about my business goals, money goals, what i currently make, how i see myself this time next year. the call was being recorded which he told me would last for 7 days only and he told me about this several minutes into the call, not getting consent prior or at the beginning of the call. As the call went on, i was starting to see this is not my kind of person, i don't see myself working with him, this feels like pressure, also misrepresentation compared to what was said at the conference, and icky sales vibe by the end

I come here for coaching because i feel uncomfortable, a little disgusted, and also worried - i feel that i was honest in answering my questions and the call didn't end well and it is also something recorded. he knows my speciality, my name, my contact info, i feel exposed. i know i will not be working with him in the future and he has all this information about me. i find myself wishing i didn't share details about myself in this way. trying to steer clear of self-blame "should've known better thoughts" but a little is there

===============================================
Hi there! So glad you brought this here. I'm really sorry this happened to you - unfortunately the field of coaching is still completely unregulated, and there are many folks out there who approach it from varying degrees of trustworthiness. 🙁

AND, I guarantee this is not unique to this situation, or the last time you'll get icky vibes from another human, so such a useful topic to unpack here!

Let's plug one of your thoughts into a model to see what your return on that thought is...

C: You signed up for a "1 hour roadmap" call with a prosperity coach. During the call you were told it was 30 mins. You answered questions honestly and openly. You were told the call was being recorded several minutes into the call, did not give consent prior. More words said by him.
T: This is not my kind of person, this feels like pressure, and a misrepresentation compared to what he said. He has icky sales vibe.
F: Disgusted
A: worry about things you can't control: spin about the fact that he knows you specialty, name, contact info, etc, imagine how this could be bad for you or go wrong. Wish you didn't share details, regret saying the things you said. Beat yourself up about this a little bit, (though bringing healthy awareness to this habit 🙂 ).
R: Your brain stays in an icky vibe.

Ok. Two things happened: 1) You had an expectation that was not met, and 2) you regret sharing information with a person.

I'm guessing you are not looking to "feel great" or even "feel better" about these two things, but the place to get some space around is what your brain is doing to you now that the event is over and out of your control. It looks like your brain is equating exposure to danger here, and it might be helpful to reality check this with some facts around your power, for instance: many business discovery calls are recorded routinely and doesn't give someone meaningful power over you. When your instincts told you this wasn't your kind of person, you listened. The information shared (name, specialty, goals) is typically public, and even if the interaction felt uncomfortable, you still retain some control (blocking contact, declining future communication, or requesting deletion). He does not have power over you, even though your nervous system is doing it's job and acting like he does.

We can see from the model that worry is not helping anything, and neither is regret. Can you think of any A-line items that would help? A result model might point you in the direction of a new thought for this event :

R: Your brain is the exact vibe you choose (???? what is this???)
A: ?????????? (process regret and disgust, practice self compassion (what does this look like for you?), have your own back, with no shaming or shoulding.... what else???)
F: ????
T: ????????
C: You signed up for a "1 hour roadmap" call with a prosperity coach. During the call you were told it was 30 mins. You answered questions honestly and openly. You were told the call was being recorded several minutes into the call, did not give consent prior. More words said by him.

Some questions to unlock a nice thought to try in your intentional model:

-What can you learn from this experience that you could translate to other areas of your life?

-How could this story highlight strengths in you that you are proud of, in addition to the things you regret? (I can easily see values on your part here of curiosity, honesty, and then... intuition and integrity!)

I’m dealing with a situation where there is diagnostic uncertainty around a possible treatment complication for a patient of mine. During an inpatient admission, one subspecialist felt there wasn’t enough evidence to support a treatment toxicity. Later, in outpatient follow‑up, a different subspecialist in the same division felt strongly that this was a treatment toxicity that had been missed.

The situation became difficult when the outpatient subspecialist called me without warning while in the exam room with the patient and their family, put me on speakerphone, and questioned why the issue hadn’t been treated. The family became understandably distressed. When they asked why there were differing opinions, the subspecialist emphasized their own experience and credentials rather than acknowledging uncertainty. After the visit, despite labs that I felt made the diagnosis less clear, the subspecialist messaged me stating they were assigning the diagnosis, that I needed to treat it, and that the patient had already been told this plan. They did not engage with my questions about follow‑up, uncertainty, or implications for future therapy. They also looped in another physician from my specialty without discussing it with me first.

Since then, I’ve been perseverating on the interaction. Partly I feel a sense of injustice for the patient, who was already scared and confused and then put in the middle of conflicting physician communication. I also feel disrespected, undermined, and shut out of what I would normally expect to be a collaborative discussion. I recognize that some level of upset makes sense given the situation, but I don’t like how much mental space this is taking up for me.

My Model
Circumstance:
A colleague believes a diagnosis is more likely than I do and communicates this to the patient without discussing it with me first, and while implicating that I and her colleague missed/didn't treat

Thought:
“This is unprofessional and bad patient care.”

Feeling:
Anger / rage.

Action:
I over‑document extensively, replay the interaction in my mind, and spend a lot of mental energy reviewing what felt wrong or unfair. I also talk to a bunch of people about the interaction to validate that I am right.

Result:
I provide what I believe is appropriate patient care, but I don’t feel settled or confident afterward, and I’m distracted from other work because I keep thinking about the interaction

ANSWER:
Oh boy- this sounds like a REALLY hard situation. Anyone would have felt steamrolled and thrown under the bus in that context. Wooooof.

Some I pick out in addition to yours.
C- Patient care, diagnostic uncertainty (you want the C line to be language that is as neutral as possible)
T- "It's not fair to the patient who was already scared"---> Sense of injustice
T2- "It was disrespectful to put the patient in the middle of the physician conversations"--> Undermined
T3- "This should have been a collaborative discussion"--> disrespected
T4- "This is bad patient care"--> Anger rage.

Each of those has their own A/R lines, and likely all of them have you ramping up the brain space you are giving this.

That's not WRONG, so to speak. It makes sense that things you care about: justice, respect, professionalism, collaboration, etc, feel like they've been attacked. Right?

But I hear you saying you don't want this taking up space for you. You want to feel settled and confident, and not let this distract you from your work.

Those models are available to you but might not feel accessible quite yet, and that's OK. Even if they don't feel reel, what might they look like:
C: Sequence of events around patient care, diagnostic uncertainty and communication with colleagues (neutral)
T:_______________
F: Settled
A: ______________
R:_______________

C: same
T: _______________
F: Confident
A: _______________
R:________________

Play a bit with filling those out and see if your brain throws any resistance to them your way. If so, what is that resistance?

I wonder what this model looks like:
C: I' experiencing rage, anger, undermined, disrespected, and other emotions in the wake of this event.
T: _______________________ (what comes up here? " is there resistance like "I shouldn't be?" or "It's not fair" or "It really sucks?" or something else?)
F:______________________
A: _____________________
R:_____________________

Keep going here 🙂

Looking forward to hearing what comes up

thanks so much for great feedback! my responses to the questions raised to me below:

What is it about this example that feels morally injurious to you? (I have a suspicion, but am curious about how you would put it into your own words). That might be like "I shouldn't have to _________", or "it's against my value of _____ to _______"

Put ONE of those into a model. What comes up?

My Response:

" it's again my value of women's empowerment through health to unnecessarily remove healthy organs rooted in fear and anxiety (unempowering"

A few things to chew on and bring back here for more (try not to censor yourself)

What do you make it mean about you as a surgeon or human when a patient doesn't receive your education and recommendations the way you think they should?

I think about where did i go wrong, how could i have delivered this better, how come they don't trust me, i wish they can see what its really like to have this surgery with long term outcomes to be truly informed

What do you make it mean about THEM when they don't receive your education and recommendations the way you think they should?

my research and also taking care of diverse and often very underserved populations, sometimes i think doesn't this patient know how lucky she is to be able to have the options and resources that she does ?why do they lack resilience? they're seeing too short term and not understanding long term and big picture

What are you obligated to do when a patient doesn't want to proceed with your recommendation?
as long as it is still within realm of expected reason, i have do it (i.e. perform mastectomy even if she's eligible for BCT),

What are you NOT obligated to do?
i could alwasy refer to another surgeon who would be willing to do it (in theory, not really in practice) , not obligated to be happy about decision

What do you WANT to think when a patient doesn't want to proceed with your recommendation?
i want to think that its ok, that in the end of the day i did my best and its ultimatley their decision and they have to live with consequences forever and hopefully they will be satisfied in long term

ANSWER:
Really great work here friend. I understand why this feels so charged for you. You care about women, you care about them being informed, you care about first doing no harm.

One thing I pick up in the questions/answers above is a lot of judgement. Judgement of yourself and judgement of the patients. This is normal, and I'm really glad you were open to bringing those reflections to the surface.

OK if we explore judgement and right/wrong a bit here?
In what ways has it served you in your life to have a strong sense of right/wrong?

Has that ever gotten in your way? If so, how?

Sometimes the decisions human beings make, are not ONLY informed by facts/data, but are informed by context, biases, emotions. This is normal. We are not robots. Why does it make sense for patients to be able to apply those other contexts to their medical decision making? (think about this outside the context of BCT here)- are there ever occasions where the patient centered decision is not the evidence based decision? When/Why?

In your last answer you said you want to think it's OK for patients to decide something different from your recommendation. How, even under those circumstances. can you trust yourself to have done your best?

You're doing important work here. Keep digging

I am working on how to set reasonable goals for myself and on allowing myself breaks/rest even if I feel like I don't "deserve" them. Usually, I feel like I don't deserve rest because I have not yet met the unattainable goals I've set or because I'm not struggling enough to truly *need* rest. This most often comes up during my admin time. I've structured my week so that I don't have any clinical duties on Tuesdays. I have a tendency to create long to do lists that have contain a mixture of non-clinical work admin tasks, inbox/clinic prep related tasks, home chores, and general life tasks that I always want to (and do) put off like look into my retirement options, figure out my student loan game plan etc. I am also trying to fit in appointments, exercise and social time during this day, and those do not go on my to do list because I don't want to turn them into tasks. I've noticed that I get a sense of accomplishment when I complete a task, but also a sense of inadequacy when I don't get as much done as I'd like, even though I know that my plan was totally unrealistic. I know this pattern doesn't serve me and I would like to adjust my thoughts/actions around it, but I am struggling on how to do so! I feel like if I don't write out all the things I need to do, then I will forget them and bad things will happen. Even though I also know that if the laundry doesn't get folded or an email doesn't get sent, everything will still be ok.

C: Tuesdays are my non-clinical day.
T: I need to get all my tasks done and also live a balanced happy life
F: frantic
A: wake up early when I don't need to, make long to do lists, prioritize the items that are quick so I can check as many boxes, structure my day in a non-feasible manner, beat myself up when I don't meet my goals, get frustrated if an unanticipated thing comes up that throws off my mental plan for the day, try to multi-task as much as possible, focus more on quantity of task completion rather than quality, don't allow myself breaks that I deem unproductive
R: my non-clinical day adds to my overall stress rather than helping alleviate it

C: I make long to do lists and expect to accomplish all/most tasks
T: If I don't get enough things done, I am not good enough and don't deserve rest
F: inadequate
A: same as above but with an emphasis on beating myself up
R: same as above

===================================
ANSWER
There is so much insight here already! You’ve mapped your pattern really clearly, and that’s going to make this work much more accessible. Let’s look together at the part about “deserving rest." The word “deserve” seems useful, but it actually creates a question your brain can never answer. Right now, your system is set up so that: rest is conditional, “enough” is undefined, and your brain stays activated, even on a day meant to restore you.

The entire framework of deserving and not deserving is subjectively, inherently flawed. We use it because we think it's going to make us feel more secure, more validated, more vindicated, but it doesn't (as you showed us above). The way it makes you think about yourself and your own life, is paralyzing, and leaves us with confusion, second guessing, doubt and shame. When your brain says: “I don’t deserve rest yet” it opens up this loop: "Have I done enough?" , "Was it the right kind of productivity?" , "Did I work hard enough to earn it?" And the problem is, there’s no objective answer to that, which keeps your brain trying to solve an unsolvable equation… and the emotional result is that frantic, never-enough feeling you described. The issue here then isn’t your productivity, but the rule that rest has to be earned.

Ok- so if we reject this idea of deserving and not deserving, then how do we decide when to do anything?

One idea that I like is to decide something because.....
YOU
WANT
IT.

That's it. Decide to rest, eat, breathe, work, think a certain way, dress a certain way, and everything else because you just want the experience you think it will bring you. Not from a place of avoidance or checking out, but from a place of intention, curiosity, and self-trust. That might sound like:

“I want to rest because I value feeling restored.”

“I want to complete this task because it matters to me.”

“I want a day that includes both contribution and care.”

This doesn't mean "taking it easy on yourself" or "letting yourself off the hook" - but deciding what you WANT from a place of inner wisdom, and sometimes from inner curiosity. Not because you’ve earned it,
but because you’re choosing the kind of experience you want to create.

Some questions to get you started on this journey:

-Where did you first learn that rest had to be earned?

-Do you apply that rule to all forms of rest (for example, nightly sleep? Or sitting down at work?)? Why or why not?

-If rest were accepted as a basic human need (like food, water, air), how do you want to include rest in how you live and work?

I'm a breast cancer surgeon who's speciality involves a lot of shared decision making. I actually mainly enjoy this part. For the treatment of early stage breast cancer when the patient meets criteria, breast conservation treatment (BCT) vs mastectomy lead to the same exact clinical outcomes (survival, recurrence) but have very different risk profiles, length of surgery, complications, cost, and patient reported outcomes in the long term. I'm super evidence based and to me this is one area that i wish insurance actually wouldn't even pay for one of these options with the exception of true medical necessity/ very high benefit to risk ratio. there are even multiple society level recommendations again contralateral prophylactic mastectomy due the evidence. In my group we even have a joke that i'm the BCT whisperer. Many patients understandably come in with a lot of fear, anxiety, and often misinformation or misunderstanding and say something along the lines of " cut them off, i don't need them anymore, i want to be done with this." I have a detailed patient education packet and spend up to 1 hour with a new cancer visit to thoroughly educate them about their disease. Majority of the time, most patients feel very grateful for all the education and reasoning and either make decision for BCT or need more time to think and process and later when we revisit at different time they bring excellent questions about surgical options and long term and short term outcomes and risks and either choose BCT or those that choose mastectomy are usually able to articulate reasons why they feel its best choice for them thats not rooted in the " just cut them off genre" However, sometimes i do have these patients (and i anecdotally notice a theme in their demographics) that are just dead set in their pre conceived notions and decisions and not take in any of the evidence and cousenleing i provided. This scenario for me is an example of moral injury. i'm trying the CFTAR below, and my question is how do i manage myself with these patients

C: My patient with early stage breast cancer is choosing to have bilateral mastectomy
T: Why haven't i been unable to get through to her? why do i have to practice non evidence based medicine which is my goal and gold standard? why are they choosing fears over facts? i'm a surgeon not a psychiatrist, we shouldn't treat anxiety with surgery.
F: anger, resentment, frustration
A: refer to plastic surgeon that is less patient friendly then others in demeanor/education (still great technical surgeon), put the case in lower scheduling priority, be less warm and compassionate with the patien than i normally am,
R: make it a less positive patient experience

ANSWER:
Hello friend.

Nice job on your reflections here and what a great thing to bring here for coaching.

A quick few notes on your model
1. whenever you ask a hypothetical question in your T line, the ANSWER to that question is the actual T
ex: "Why haven't I been able to get through to her" might be "I'm failing to get through"
"Why do I have to practice non-EBM which is my goal and gold standard"--> "I'm being forced to do something I disagree with".
"Why are they chasing fear over facts"--"they must not trust me"

These are just some guesses I have about the answers to those questions. What do you think your uncensored answers to those questions are.

2. Each model only has ONE thought and ONE feeling. So each of those questions has an answer, and each answer is a T line on a separate model, and each T has a F which are often a little different from each other. I know, it's pedantic but it's MUCH easier to look at them one at a time.

OK let's talk about the moral injury that you're experiencing here.
What is it about this example that feels morally injurious to you? (I have a suspicion, but am curious about how you would put it into your own words). That might be like "I shouldn't have to _________", or "it's against my value of _____ to _______"

Put ONE of those into a model. What comes up?

I have a sneaky suspicion that the salt in your moral injury wound here is that, when you are operating from these models, you are DISCONNECTING from the patient, de-prioritizing them, sending them to other surgeons who aren't as patient-centered as you. And this hurts even more because that's not the doctor and surgeon that you like to be, and THAT is an even worse injury- Feeling like you have no choice to be the kind of person you don't want to be.

All of this makes sense, and allllllll of us have been here.

A few things to chew on and bring back here for more (try not to censor yourself)

What do you make it mean about you as a surgeon or human when a patient doesn't receive your education and recommendations the way you think they should?

What do you make it mean about THEM when they don't receive your education and recommendations the way you think they should?

What are you obligated to do when a patient doesn't want to proceed with your recommendation?

What are you NOT obligated to do?

What do you WANT to think when a patient doesn't want to proceed with your recommendation?

Let's see what comes up. Bring it on back 🙂

I am a physician at an academic medical center with roles that are both clinical and in GME (50/50 split). I also have 3 children (8, 6, 2) and a husband who is also a physician. I love what I do, but I have not been happy because I feel like I am never in the driver seat an always playing catch up. Objectively I am a perfectionist to a fault. While it has helped me become thorough as a provider and successful at launching ideas, it has now turned into a huge fault when I need to balance the work load of all of the above. It takes me double the time to complete emails, close notes, or complete projects because I want it at a certain standard. I could keep up when it was just me, but not with a family. I also on top of this have a strong value of truly treating patients like family. I do use my nurse, however for bigger conversations I will always be the one to call. This also leads to lengthy conversations on the phone that eat into my academic time. My perfectionism and commitment to my patients is not sustainable. I have spent the past year blaming external factors-its too much work, we have 3 kids and of course its crazy, but even with help and appropriate amounts of time, I know deep down that my traits are really contributing. So the model which will need work:

C: I am a physician at an academic medical center taking care of complex patients. I have work that is both clinical and in GME. I am also a mom of 3 young children, married to a husband who is also a physician.

T: I am getting in my own way. The traits and values that got me to where I am and are all I know are taking away from the joy in my life. I don't know how to find the balance. The amount of work I have is doable when I map it out, but I am too slow and too much of a perfectionist to get through it. It is not the work, but my inability to efficiently complete tasks that is taking away from my family life and relationships. I cannot have it all when I am always behind, stressed, and catching up. I don't know that I can, know how, or want to change how I'm wired.

F: Frustrated and conflicted

A: I compare myself to my husband who is extremely efficient and become envious of his ability to still be efficient. I perseverate on finding solutions- I look up online programs on how to change charting methods/engage in dictation software. I also become paralyzed and overwhelmed when I see incomplete projects as a result of the above and there is a significant amount of inaction--if work piles up I dig out on a very surface level. Consider cutting back at work so the load is less

R: I get less done because I am perseverating on this. I am angry and envious of my partner-resulting in me feeling less connected. Patient charts remain open longer than needed which indirectly can result in worse patient care.

======================
ANSWER:
Hello! So glad you brought this here. I could jump in the pool with you (I've been you before! so many of the same details!), and agree with everything you said but that wouldn't help you move through this uncomfortable phase of life/career you're experiencing right now. So I'll keep my coach hat on, but know that you're not alone in how you feel right now.

Quick clean up on your model.
Perfect job on your C line. Great!
Only ONE thought and ONE Feeling per model.

See if you can break what you wrote in the T line above into individual models where each sentence is ONE model and goes with a separate F/A/R.

This just makes it much easier to look at each one on its own. to see what the investment in thinking that way brings back to you.

Here's what I"m picking up from your reflection:
A lot of things that served you in getting where you are, (perfectionism! being the most thorough! high standards!) now feel like heavy weights that are keeping you with barely your lips above water.

You care deeply about what you do, treating your patients like family, taking extra time, etc. I pick up on values of service, care, excellence, innovation, connection. What beautiful values to have.

It makes sense that the R line above hurts as much as it does. When you invest your time in those thoughts- "I'm in my own way", "I don't know how to find balance", "I'm too slow/perfectionistic", the sum of those thoughts being something like "I'm the problem here", you feel terrible about yourself, and when you feel terrible about yourself, the actions you take lead you AWAY from the connection, service, excellence that matter so much to you. A double whammy!

OK, I invite you to take a deep breath here, shake out your shoulders. You are not wrong or broken. You are not fixed in any ways that you don't want to be fixed in.

Let's zoom out a bit so we can get a wider view. Please take a few minutes to reflect on these questions and bring anything that comes up back here of more coaching.

1. When you think about "balance" what does that mean to you? How would you know you had it? When you "arrived" at balance would it take work to maintain? why or why not?

2. Where you are right now is where you are, and that's OK. I hear you beating yourself up pretty hard in that reflection above. Is there an upside to that approach? A downside? Do you find self-criticism to be motivational sometimes? always? never? why?

3. What is working for you right now and why? name 5 things.

4. What do you want your relationship with your patients and your work to look like?

Let's see what comes up in these reflections. I hope you bring it back!

Okay, I'm back to dig into my adopted belief: Anything less than 150% = personal deficiency.” What is it protecting you from? I.e.: in the environments where you learned the 150% rule, what happened to people who gave 100% (or less)?

---

One benefit of this, which I've been learning as I try to develop an exercise practice that coexists with parenting and full-time work, is that giving less than 150% requires intentionality and decision-making. In some ways, it's much easier to go go go until I crash entirely than it is to make conscientious, daily decisions about how much energy I have. This causes decision-fatigue. I'm trying to work on rules of thumb and heuristics to help guide my practices in these different domains, but I can feel very adrift. I don't have existing close role models for how to do moderation well. My parents, my husband, and many of my colleagues are examples of how NOT to do this!

At home growing up, giving less than your all meant wasting opportunity and privilege, a lack of grit, unfairly burdening others. In high school and college, I was expected to demonstrate excellence and serve others; anything less than that was wasting opportunity. In med school and training, it meant not caring enough--about your own success or about patient care. There was lip service, I guess, to "put your own oxygen mask on first," but, to belabor the metaphor, perhaps just enough oxygen (self-care) to get sats >88% in order to get back to giving your all. Rest and balance as a mechanism for excellence, success, and service, not an intrinsic good.

That definitely reflects how I feel and act now. Yeah, I work hard to get 8-8.5 hours of sleep (!!! I will say this is great and I highly recommend it !!! ), but getting enough sleep = better ability to perform, not grace and restoration. It's still in service of performance, on some level. These practices (sleep, exercise, church, time-blocking my work...) do make me feel better, and I do them for myself, not because of outer expectations, and they ARE worth doing and make me feel better... But they're also actions I'm taking in service of a thought model where if I don't do those things, I'm wasting opportunity and privilege, burdening others, demonstrating mediocrity, not serving others, not caring about my own success. I don't want those feelings to be the motivator for my "self-care." And those ARE the feelings I have when I don't do "self-care," i.e. when I shop online or veg out watching TV with a glass of wine (and yet I still do it). Like, self-care isn't working if it feels like a required obligation not to be a selfish burdensome mediocrity?

Thinking of activities that I do because they genuinely feel restorative but also don't trigger those feelings: gardening, playing outside with my son, calling or hanging out with a friend.

=====================================
ANSWER
Really great work here! This “150% rule” sounds like it once served an important purpose for you: it helped you succeed in environments that rewarded relentless effort and moralized productivity. That makes sense. And at the same time, you’re seeing the cost of continuing to treat that rule as truth:

C: Basic human care (sleep, exercise, church, considering how to spend your time)
T: If I do this wrong, I'm wasting opportunities and privilege, lack grit, and am unfairly burdening others.
F: Guilt
A: Consider all of your actions and time through this lens, and create a world where you need to make a choice in every moment - "how will this help me be excellent"?
Basic human care now becomes a high stakes choice to make on every level since you need to calculate your potential for excellence at each moment. You view rest and relaxing as good only if they are a mechanism to return to excellence, success, and service, not for the intrinsic experience or desire of it. Whenever you find yourself doing activities that are not in your manual above (TV and wine, "vegging" etc) - you beat yourself up, call yourself names ("mediocre" , "waste") for it and compound the guilt.
R: Decision fatigue, compounded suffering leave you "wasting" more of your time and drain any potential enjoyment of life right now.

Whew! I'm sure we can all agree that medical culture fully supports and even selects for this model (I wrote an article on this last year! Fainstad, T "Secret Part-Time, JAMA 2025). And now, you are having just enough awareness to the ill and ironically counterproductive effects this model creates long-term. Not only does it not drive excellence and success, but, if you stay here long enough, it actually ERODES them.

Ok. There is a moment for you, when you consider not doing the 150% thing. When you consider not giving your all, being perfect, doing it "right" all the time. A moment when you feel the tug towards rest, relaxing, doing something not on your manual for yourself. It appears that 99% of the time you turn away from that thing, and 1% of the time you indulge and then beat yourself up. Instead of searching for rules-of-thumb and heuristics to guide each decision about your future actions, let's look upstream of that for a rule-of-thumb when you reach a FEELING. For you, the feeling that comes up when you consider not showing up with 150%, is guilt.

Your work here is to become reallllly familiar (dare I say friendly even?) with this guilt. My guess is that this feeling is not the same GUILT that happens when you do something outside of your value code (like lie, gossip, hurt someone etc) - if you are anything like me, then this guilt, is a cousin of that GUILT. It's a bit more insidious. It's quieter, yet more omnipresent. I call mine "pseudo-guilt" (or a feeling when I have a thought that I could disappoint someone), and for me, this is what drives the action of trying to perfect everything for everyone and control how I am viewed. What's it like for you?
What does it feel like in your body?
What are the common triggers?

Once you have gotten familiar with it, the work is to gently unravel ITS rule of thumb (the "150% rule") so that you can view it as an old myth that isn't working anymore rather than truth to live by. The work isn’t to fight the feeling of guilt or replace the rule overnight, but to get curious about it when it appears and start gently questioning whether it still deserves to run the show. Some questions you might play with:

What evidence do you have that giving less than 150% actually harms people around you?
What would change in your life if “enough” were truly allowed?
What could become possible (emotionally, relationally, career-wise, or other) if rest didn’t have to justify itself through productivity?

Hi, hope you can help me think /feel about this in a different way

C: I am scheduled to lead a journal club for my division
T: I am going to do a terrible job and not understand some statistics question someone brings up, and everyone will think I am an idiot
F: Anxious/frenetic
A: Spending wayyyy too long preparing for this, reading lots of other sources to prepare me to field questions
R: I am not spending time on other things in my personal life and work life that are important and that I need to do. And in my down time have that anxious feeling.

==============================
ANSWER:
Well hello to your inner critic! It's done a phenomenal job of zeroing in on your biggest fear (understanding stats) around journal club and trying to sabotage you with it. What a great little IC you have, although not at all helpful.

First question is:
-Why is it a problem to not know every statistical detail that could come up? You gave the vague explanation that people will think you're an idiot if you don't, but you can't honestly believe that folks will think you are a true IDIOT, right? Is it that people will know about your weak spot in reading articles? If so, what about that is a problem?

Remember that literally every single human has a weak spot in any given area. We all do, since we all understand some things more deeply than others, we all have a non-uniform understanding of any article. Your brain is trying to tell you that it's a problem for yours to be known, but I want to question that very premise.
Imagine a journal club where everyone just wrote their weak spots on the white board when they walked in... so that we could craft a cool experience where we dig into each one a little. What could some be? Here are just some that I've coached people on before leading journal clubs (no you aren't the first by a long shot):
- "I'm worried I'll be asked to read out loud and I'm dyslexic so it's slow"
- "I hate coming up with questions for the group at the end"
- "I don't understand the MoA of the drug
- "I don't get different types of study designs"
-"I don't get why this is relevant to me"
-"I am a super slow reader"

Everyone will have a very slightly different one, but you can imagine that many folks share your focus. Ok, now, in our imaginary world of highly transparent and authentic journal clubs, you would also need to put your STRENGTHS down on the board. In addition to having a strength in the area of each deficit above, you could also consider:
-Group facilitation
-Icebreakers
-Bringing food
-Humor
-Finding interesting connections between papers
-Lifting up quiet voices
-Questioning everything
as strengths.

Where are yours? Your brain wants to only give air time to the one deficit right now, let's turn up the volume on the rest!

I feel trauma from a short reel I saw the other day - I did not click it myself but it auto played about someone in Florida going to jail because she was physically hitting children in daycare, dragging them across the playroom and things of that nature. I don't mean to be triggering, but I'm a new mom and the picture keeps playing in my head. I read some of the comments and there was a lot of comments about how this is the reason why people choose to be a stay at home mom, no salary can ever be OK at the expense of your baby safety, and a bunch of other what felt like gaslighting comments about women who choose to work or who have to work for whatever the reasons. no mention of stay at home dad btw. anyway these thoughts are spinning in my head, for our current situation being a stay at home mom is not something I could do and also I do like the independence and routine structure of having an outside job. Personally, I think motherhood is the hardest thing I've ever done and is harder than my Dr. job. I'm feeling some guilt after reading those comments about my choice to continue being a working mother and the thought that my child may be at harm in the future if I ever were to send him to an outside facility for caregiving (which may be possible in the next few months). Even if I do everything in my power to keep him safe, it's possible that he would get harmed in the outside world or even in my own home for that matter. I would appreciate some help working through this, thank you.

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

Yes, terrible things happen in the world. Yes, our phones feed videos of those horrors to us, and those images can be triggering and traumatic.

Those things can be true, but let's see if we can identify some of the twists your brain is taking here that are adding to the pain.

What do these models look like for you?

Circumstances- Some people in this world harm children.
(Saying this is a fact doesn't mean that I AGREE that it should happen. I wish it didn't happen, but it does happen).

T- Even if I do everything in my power to keep him safe, it's possible that [he could still get harmed inside or outside my home]
F1- _______________ (name ONE feeling)
A1- _______________(name what you do when you're feeling that way- VERBS)
R1- _______________ (this will be something like "I harm MYELF by imaging scenarios where my child is endangered or harmed).

Why do you think this model exists for you? Try to not to judge it at all, let's just ask, why does your brain offer you this thought? what's it trying to protect you from.

We make choices every day without being able to know what harms could happen on the other side of those choices?
What values or beliefs do you want to guide you as you face all of the choices and challenges that come up in parenting?

Keep pulling here.

I think the feeling is shame....

To answer your questions (copied below)...

- My negativity bias is protecting me from other people surprising me with or "discovering" my weaknesses and failures. I feel more in control if I am aware and choosing my weaknesses and failures. But then I focus and ruminate on them, and am at risk for overestimating them/focusing on the wrong ones/having blind spots.
- Turning toward other people's evaluations of me. On one level, no. I want to be responsible for setting my own expectations and competencies for myself, I don't want to put them in somebody else's hands, especially when I'm not sure that I trust or value their feedback/evaluation. But I also want to elicit helpful feedback, value the feedback of people I respect, and learn from others.
- I'm not sure I would phrase it as difficulty = personal deficiency. I'm okay with things being hard, and I've demonstrated that in my life and choices again and again. I think it's more "giving anything less than 150% = personal deficiency." That's a belief both my parents modeled growing up, for sure, and is a recipe for feeling shitty (either I'm giving less than 150% and feel personally deficient, or I'm giving 150% and feel deficient because I'm running on fumes).

Positivity Bias Model

C: I have institutional investment and protected time for research in an area that prompted me to pursue a career in medicine. I have been doing work in this area for 17 years with multiple abstracts presented across that duration. I have a mentor in my area of study who has an R01. I heard back this week that my manuscript received extremely minor revisions only. I submitted multiple abstracts to conferences this year. I am presenting a nationwide study protocol at a society conference this month after receiving society endorsement for the study for which I am PI. I have awaiting IRB approval, a request in for data extraction, and a plan for a scoping review. I am ready to submit a small grant proposal and in a writing class to create the materials for my K. I'm a good writer. My mentors gave me feedback from my LOI that said, "This looks really great," " I really like how this is evolving" and "Oooh this is good!"

T: My career trajectory demonstrates an unusual and impressive longitudinal interest that captures my commitment to this work more than any single publication ever could. My manuscript will get published if I keep working at it. I can turn my recent abstracts into publications. I am building a national reputation by presenting at this conference. I am moving forward research projects that would reasonably be anticipated to take time to complete and am learning the structure and resources of my new institution. Delays on projects have pushed me to expand my network to find opportunities, which will set me up for future projects and build my reputation. My small grant proposal is a relatively low-stakes opportunity to build my skills at writing and preparing a grant submission, and to refine my ideas. I have more time and thought to put into my K submission than many people do, setting me up for success. I can enjoy the writing process rather than seeing it as an albatross. My mentors are genuinely on board with my ideas and execution.

F: Hopeful

A: Do what is in my control to publish and submit an excellent grant, while basking in the time I have to do other things that aren't work instead of worrying about what is going wrong or could go wrong.

That sounds nice 🙂

===================================================
What incredible insight here! Your C line contains an enormous amount of evidence of competence, so interesting to see how your brain wa weighting the absence of publications as the only valid signal. I'm so inspired by you and your work here!

This nugget is pure gold: "I *feel* more in control if I am aware and choosing my weaknesses and failures. But then I focus and ruminate on them, and am at risk for overestimating them/focusing on the wrong ones/having blind spots."

That makes so much sense. Your brain learned that if you identify the weaknesses first, no one else can surprise you with them. In that way, your negativity bias is trying to protect you from the sting of shame or exposure. It’s an intelligent strategy. And at the same time, as you noticed in your model, the strategy has a cost. When your attention is consistently scanning for weakness, your brain starts treating those data points as the most important or most representative ones, even when the full picture is much larger and more balanced. So- while you feel in control, you actually are not (as the rest of the model shows).

Often, what we call “control” is really just predicting the worst-case scenario ahead of time so we don’t feel blindsided. But that prediction, if you don't direct your mind on purpose, can mean you end up living inside the worst-case scenario emotionally, even when the reality (as your C line shows) is much more promising.

The way through is to get comfortable with uncertainty, or "letting go of control" (I put quotes since you never actually had a grasp on it, only the illusion of one).
Your intentional (reframed) model illustrates this perfectly:
--> In practice, this means trusting that you can and will handle criticism if it came, instead of trying to pre-experience it now.

Finally, great job identifying your adopted belief that “Anything less than 150% = personal deficiency.”
That is a belief worth slowing down on, because it’s the real engine of the model. When life slows down for you or you feel motivated to dig here, it would be interesting to unpack this belief: What is it protecting you from? I.e.: in the environments where you learned the 150% rule, what happened to people who gave 100% (or less)?

I am a fresh out of fellowship surgical attending. My son who is six has complex medical needs requiring specialized care 24-7 and while he is mobile, verbal and often healthy he has chronic lung disease and will often be hospitalized for what would otherwise probably be relatively minor respiratory illnesses. My husband and I used to travel, love international travel and used to love doing outdoor activities, camping, hiking in remote areas and this has pretty much felt inaccessible since my son was born. I am overall really happy with my current job and my partners but we are stretched very thin and very busy clinically right now. With a move to a new area it has been really challenging to find caregivers or nurses for my son and so a lot of that falls on my husband. My son ideally should have someone awake overnight with him, but we have had to resort to having him sleep in our room and taking turns waking up for alarms and checking on him hourly on nights when we don't have that. We have wonderful neighbors who will sometimes help us out on weekends when I am on call and can come hang out with our son for a bit so my husband can take a nap or do other work, but we live far from family and we basically don't have anyone local who we can leave him alone with except his school nurse on days when he has school. So there is basically no redundancy - recently my husband had a peri-tonsillar abscess and came into the ED and they wanted to admit him overnight for antibiotics, and it was eye opening since I am the only person who can fill in if my husband isn't available, It's not like we can just ask someone without extensive training and prep to drive him to school or babysit. So we have had this idea of wanting to travel internationally as a family and that just feels impossible. We do some travel to see family and we have even flown when we used to live far from family. Right now my parents are traveling internationally and sending pictures and it is really hard. Also, my partners at work have international travel planned for the next few months.

This is very rambling but I have tried to work it into a model:
C: My son has complex medical needs, we don't have nurses or other childcare to consistently watch him at night, or to help during the day time. My husband and I are the only people who are currently trained on his medical care who live locally. We have a nanny who helps us with nighttime care ~3 nights per week. We have travelled including short plane flights in the past. Other people travel internationally.
T: International travel is impossible. Not just that, it's frivolous and not really something we should be doing because we can't even keep up with the more critical issues of trying to hire or find more people to help us with his care right now. Also, if our son was to get sick when we were somewhere without good reliable medical care he could have a complication or bad outcome. We would have to bring someone with us, pay for their travel and for them to take care of our son, and so it also can't be a vacation with just the three of us. Even if we do something pre-planned like a resort experience usually our son can't participate in some of the activities and one of us would have to be with him, so it wouldn't be fun. We can't even make arrangements for much more necessary things like tonsillectomy that my husband needs, so I really should be taking my vacation time for things like that. If we are sick we just have to work through it. Traveling is a luxury we don't have and is for other people.
F: Resentment, jealousy. Hopelessness. Sadness, because it brings up a lot of thoughts about experiences it feels like my son can't and might never have.
A: Basically put this dream in a "can't have it" category. Resent and not take actions to make this happen. Also rule out possibilities for things that aren't this big goal, but might actually be more feasible, like possible ways to have a date night or even a weekend travel someplace more locally, because it just doesn't feel like it will be worth it.
R: Don't travel internationally, also miss opportunities to travel places more accessible as a family. I have a lot more free weekends than I did as a trainee including long weekends and even though we talk about going places out of town more often than not we don't actually do this.

ANSWER:
Hello friend! So glad to have you back <3

Great work here. let's dig in.

A few reminders about the model.
- we want to have the C line be as emotionally neutral as possible. Sometimes it's helpful to have it just be "life" or "Life with a 6 year old kid". Could have "life with 6 year old medically complex kid who requires 24h care" if that feels neutral
- Each model should have only ONE thought and ONE feeling. so your model above is probably like 5 or 6 different separate models.

For example
C- life
T1- international travel is impossible
F1- resentment?
A1- ???
R- ???

C- life
T2- Travel is frivolous, and a luxury we we don't have.
F2- jealousy?
A2?
R2?

C- ife
T3- We can't even keep up with finding reliable help at home.
F3?
A3?
R3?

breaking it down like this just helps us look at each model like a facet of a gemstone, different ways of looking at something.

OK zooming out a bit. A lot has changed over the past few years- new job, new city(?), kiddo getting older not in training any more (!), attending money (!), more flexible schedule/hours than training (!!!). A number of things haven't changed as much- kid has medical needs, you and your husband are the primary do-ers of the care, among other things.

I hear some things breaking through here following this transition out of training. Travel, something that has felt entirely out of reach during training, now is something you can imagine, and long for. It's a part of something you and your husband miss. The idea and logistics of travel are very different for you than they were during other phases of your life.

What is the primary emotion (choose one) that comes up when you think about these changes and constants in your life?

Why do you feel that way? (one sentence, this is your T)

In what ways does it make sense to feel that way? In what ways is it taking care of you/yours to be in this model?

In what ways does it not make sense?

Let's keep pulling on this thread (or any other that feels OK to pull on right now).

Hi, I am early-career faculty (instructor) and have the privilege of being 65% research/35% clinical for 2 years while I submit my K. I feel good about my application and mentorship team but have no first author publications despite a good number of abstracts. I know this is a weakness and have one paper re-submitted and under review so I'm hopeful about that but feel like I need more to successfully get funded. But my efforts to get other things in the work keep getting delayed by institutional barriers (getting through the IRB, getting EHR data pulled, completing DUAs, getting a librarian to help with a scoping review...) I feel like every time I come up with a way to get data that seems like it should be easier (retrospective, review, from my mentor, etc.) I still encounter roadblocks and feel like I'm running out of time. I start spiraling about how I should have used residency and fellowship more effectively, but also recognized I was stretched to my limit with clinical obligations, the pandemic, pregnancy/baby... but then I think, those are weak excuses because other people experienced those same things and got publications. I must just not have what it takes to be a successful researcher. I try and remind myself that's not true because otherwise, why would my institution give me protected time and start-up funds (that other institutions laughed in my face about giving me) if they didn't believe it was possible? But I'm scared I'm blowing my opportunity.

C: I have 65% protected research time and start-up funds for two years. I don't have any first-author publications, but I do have one under review and multiple abstracts. I have initiated processes for multiple study ideas.
T: My lack of publications is a weakness. F: inferior A --> Don't bother working on more publications. --> R : Stuck in a spiral, back where I started
T: Moving these projects forward is out of my hands. --> F: hopeless --> A: Don't follow up, don't try to push things through, don't come up with new ideas --> R: lack of progress becomes self-fulfilling
T: My excuses for not having publications are weak since they didn't slow other people down. --> F: alone --> A: Don't try to connect with others --> R: isolated
T: I must just not have what it takes to be a successful researcher. --> F: scared --> A: paralyzed, thinking about the future instead of intellectual work --> R: no progress made
T But maybe I do because this institution is investing in me. --> F: valued --> A: working on the things that are in my control --> R: make progress, can defend how my time is used even if I don't have a deliverable
T: Also fuck that department head who told me to go into private practice and that nobody would consider funding me to do research! F -> indignant --> A: rant about how academic medicine acts confused about why women don't stay when this is how it treats us --> R: feel stuck in a shitty system AND F -> determined A -> find creative solutions R -> make progress on my research because I want to prove [LONG ASS LIST OF PEOPLE] wrong

=========================================
ANSWER:
Ok my friend, this is incredible awareness work here! I could title your pattern here in allllll of these models "looking at my life through a negativity lens" - and create one meta-model:

C: protected research time + start-up funds, no first-author publications currently. Initiated processes for multiple study ideas.
T: Everything about my past, present and future is a weakness. It's not fair, not my fault (but omg it might be).
F: (what's the core feeling here??? shame?)
A: mostly inaction. Don't bother working on more publications, don't follow up, don't push things forward, don't act on or create new ideas, spiral downward, catastrophize, Isolate myself, avoid connection, avoid showing up authentically, rant about how academic medicine exploits us and stew in justified indignation. Tell yourself a story that "this should be easier" - create a world where it's unfair if it feels hard and unfair for your to get the data, instead of expecting difficulty. Call institutional processes "barriers" and perceive them as road-blocks instead of what they are intended to do. Perceive a "no" answer as "laughing in my face". Regret your past, create a narrative about how you did it wrong. Compare yourself to others, and come up short. Call yourself weak and unsuccessful at every chance, and create chances to do this when there are none.
R: lack of progress becomes self-fulfilling, you blow your opportunity to truly support yourself here.

I see that you do have one reframed T available: "But maybe I do because this institution is investing in me" - My guess is that it might feel true, though pale in comparison to the others up there. And watch out for that "determined" one at the end.... Does proving them wrong move you toward your long-term vision… or keep you tied to them?

Ok- DEEP BREATH.

Reminder here that this reaction you are having is completely normal, and also completely COMMON to all of us. This is the literal, EXACT state that both Tyra and Adrienne were in for most of the time during the creation and pilot of this very program - SERIOUSLY. In fact, I would go as far as to postulate, that this very painful, very stressful, very existential questioning of your being.... could be a necessary ingredient to success. IF. If you can open to it instead of resist it.

Answer me this:
-What is your deeply entrenched negativity bias doing for you here? What is it protecting you from?
-Are you willing to turn towards the very thing it's trying to protect you from? Why or why not?
-When did you first learn or adopt the belief that difficulty = personal deficiency?

Next steps:
Once you sit in and with the pain of this unintentional model - I want you to "play" with a different version. Can you please rewrite your past, present and future with a positivity bias, just to see what that might be like? Don't change any facts at all (here are some actual facts: Your institution invested in you. You secured protected time. You generated ideas. You submitted a manuscript. You are still here.) but I want you to only document the good things about the decisions you have made, the benefits of your exact stage right now, how having no publications yet could end up feeding a superpower, what previously invisible good things could exist. What skills are you building right now that fast success would never teach you?
How is this all for you? What would someone who expects difficulty, bureaucracy, and struggle as normal, and not evidence of inadequacy do differently?

This is likely to be very disjointed but here goes. After fellowship we moved closer to our respective families, since then I have had a second child and my parents moved from PA to CT and now live 20 min away. My mom and husband wanted to manage childcare on their own, and although I had my doubts I went along with the plan. My son is now 9 months old and still not in daycare. My mother "retired" but still essentially works full time, my husband works full time from home and I am 1.0 FTE clinical and still have other responsibilities when I am not on clinical service (don't we all). There are a few issues that come up for me, I'll put them in the models below

C- my mother is doing the majority of our infant childcare
T- I can't disagree with her or have my own rules because she does this for free, and she is my mother
F- frustration
A - getting into small arguments with her that blow up, our last argument started with me asking her to use different bread and ended with her not speaking to me for a week
R - resentment, and more frustration and spiraling

C- my mother is our childcare
T- she doesn't understand that my meetings are equally important as hers
F - frustration
A- looking for daycare, then ending up in an argument with my mother about said daycare
R - nothing happens and we are all annoyed

UGHHHH. I think the ideal situation would have been to get daycare from the beginning, but now we are stuck struggling to find a place which will take our son.
====================
Hi there!! Wow is this a perfect example to dive into this month's work with! For this purpose, let's really dive into your first model, which you've written perfectly. This is an iconic example of how crossing our own boundaries (for whatever reason) is a fast train to resentment.

The work here is alllll in the T line. There are the obvious questions to ask (gently) here
-Why can't you have rules for unpaid work? (can you come up with examples of other unpaid work where there are still rules of behavior? (like, for instance, volunteering organizations often have a lot of rules.... there are rules for kids at school even when the kids aren't being paid to be there....what else?)
-Why can't you disagree with your mom? (Can you come up with examples of when you have been aligned with yourself disagreeing with her and it was "ok" before? When?)

And then maybe some deeper questions getting at core beliefs running these thoughts here:
-What does it mean if you disagree with your mom?
-What is at risk if you speak authentically to your mom?
-What do you believe about what you do or don't deserve for child care?

Re- the second model (just to get you going):
You have a "manual" in your head for your mom, that you may have shared with her or not (I'm guessing not since the first model shows us that you think you aren't allowed to communicate your rules out loud). I'd encourage you to write out allllllll of the things that your brain tells you your mom "should" do in this role (let your brain go wild here! Unsavory thoughts welcome on the page). Documenting your manual is just good data to have about what kinds of expectations your brain is subconsciously making for your mom, and then you can ask yourself if you want to continue to have that expectation. Likely, some will be yes (like keeping your kid safe), and some may be no (like "should never ever cancel"). The problem comes up when you put your mom fulfilling your manual in charge of your feelings (other people being in charge of "doing it right" is just never going to work out for us, I wish it was possible! But I promise it's not). The good news is that if you can start this work on yourself now, it will benefit you so greatly in every single relationship you have for the rest of your life.

Ok- NOW, the work is in communicating the requests to your mom, with a consequence of what you will do if not met to get your needs met.

I am at a conference that I go to annually where most of the people in my field also attend. I have a tendency to get insecure and feel bad about myself at this conference from comparing myself to others, and I was hoping that this year would be different because I have been feeling aligned with my purpose at work recently and things have been going well in many ways. Also I'm generally a confident person! But literally within minutes of being at the hotel and seeing people in the lobby, I have started to feel badly again. Like- I didn't get invited to this working group meeting today and feel like I'm being excluded intentionally, or I ran into someone who we were supposed to touch base about a talk we are giving in April and she acted like she wasn't sure why I was talking to her about it and then got immediately distracted when people ran up to give her a hug, including one person who turned to me in what felt like a dismissive way and said "sorry, I don't know you, but I just had to say Hi to so and so" Here is my attempt at putting together a model, although I feel like I'm having a hard time pinpointing exactly whats underlying why I'm feeling this way.

Circumstance: I am attending an annual conference where the majority of my relatively small field is
Thoughts: I don't belong here, I'm never going to be part of the group of people who are leaders or decision makers in the field, People don't want me around.
Feelings: Sad, lonely, insecure
Action: Avoid putting myself out there
Result: Reinforces that I don't belong and don't give people the chance to interact with me

And honestly even writing that makes me feel pathetic (hi self-critic!) because I feel like I can acknowledge that these thoughts aren't helpful or even particularly logical but am having a hard time getting out of it.

ANSWer:
Hello! Great work here.

For what it's worth, (my coach hat is off), I feel the exact same way at conferences. Turns out this is a big social anxiety thing for me (and I have learned), a lot of other people too.Just wanted to say you're not alone in having this particular spiral. I'm right there with ya.

OK coach hat back on.

A few tiny notes on your model.
- I can tell your C line isn't really neutral to you 😉 we try and get this as factual and objective as possible. something like "Annual conference"
- on your T line- YES these are all Ts nice job. Each of these is a separate model. with a different F/A/R. I know I'm being nitpick but it really helps us to look at just ONE at a time.
T1- I don't belong here
T2- I'm never going to be part of leaders or decision makers in this field.
T3- People don't want me around.
- One FEELING/Emotion per thought (per model)/
- Make the A lines SUPER juicy, LOTS of verbs. "I don't submit my work" "I don't sign up for committees", "I compare myself to others, I hide in my room", whatever you are doing or not doing goes here. It should be the biggest part of the model.
- R- you are correct that probably the end result of each of these models is that you don't give yourself (or your colleagues" a chance to see your contributions.

OK now we don't need to use this information to beat you up. This is just one sliver of what is happening in your head.

You also have other models going on. one was
T- I'm feeling aligned with my purpose and things are going well
F- Confident
A- Arrange to go the the conference, think about who you want to connect with etc.
R- You put yourself out there a bit beyond your comfort zone.

So, A LOT of different models happening at the same time, of course. and none of them are "good" or "bad" we are just bringing awareness to them.

As humans, we get to feel sad, lonely, and insecure sometimes. You've noticed that these feelings tend to come up at conferences. And you wish they didn't.

Why does it make sense that these emotions come up sometimes?

Do you judge yourself for feeling these things? Why or why not?

What would it look like to allow these emotions instead of resisting or avoiding them?

Bring it back, friend!

Thank you! I have been reflecting on your response for a few weeks and here are my thoughts:

New model:
C: I am in my 2nd year of being an attending. I am a human being. I will get things wrong sometimes. When I miss things, have a different management style than a colleague, am slow or have a complication, my inner critic automatically offers me the thought that "colleagues will think I am a bad doctor" which naturally triggers anxiety.
T: I don’t like feeling this way, but I know it is normal, happens because I care about being a good doctor and is a feeling that I can handle.
F: acceptance (or at least partial acceptance)
A: try to allow the anxiety to be present, process situations that turn up my inner critic’s volume either with colleagues/loved ones or with myself through journaling and reflection, remind myself of clear examples of when I was a “good doctor”, practice meditation skills
R: hopefully with time have more self confidence and an inner critic that is still present but less dominating

Attempt at a result based model:

R: Show up as a doctor committed to service, connection and growth who learns from mistakes rather than being bogged down by the fear of others’ judgement
A: (I still had some trouble with this, but here is what I have come up with so far)
- Remind myself of my core values before a work day
- Visualize how I want to show up on my drive to work
- After each day, reflect on how my core values guided my patient care
- Speak to trusted colleagues about mistakes/different management styles
- Be open about gaps in knowledge
- Invite different perspectives, demonstrating that there are many ways of doing things and that one person’s potential judgement may not even be correct
- Acknowledge when fear of judgement arises and allow that feeling rather than try to suppress it
F: confident
T: I know this journey won’t be easy, but I have evidence to show that I am a good doctor and am capable of navigating a loud inner critic and the ensuing anxiety.
C: I am in my 2nd year of being an attending. I am a human being. I will get things wrong sometimes. When I miss things, am slow or have a complication, my inner critic automatically offers me the thought that "colleagues will think I am a bad doctor" which naturally triggers anxiety.
==============================
ANSWER
This is incredible work!! I really love the radical acceptance in your intentional model thoughts "I know this won't be easy" - that's exactly the place to dig in this week. If you are up to play in this thought-line, then would be interesting to explore areas that you are actually grateful for the "hardness" of this work... in the spirit of welcoming uncomfortable emotions since we know they are the very cost of growth - can you turn towards the "this won't be easy" with a mindset of gratitude or even love?
What other hard things have ended up benefitting you greatly?
Can you find ease in surprising places in this journey? Where might it show up that you didn't expect?
Food for thought.

Let us know how this thought goes for you in the wild!

I’m having discomfort about how a meeting went yesterday where a pregnant NP shared her grievances about her part-time schedule, not being approved by our department. I am one of the leaders in our department.

Although I’m not the one who officially made the decision that she can’t be part time, I was involved in the leadership conversations

I found it very hard to stay neutral and wanting to be her friend during the conversation. I’m just disappointed because when she asked me for who made the decision I gave her the name and I feel like I shouldn’t have done that. I want to be able to lead conversations and situations where I’m “managing down“ without trying to be friends with a person in front of me. Instead, I want to focus on the overall message as a department and present things as neutral and as firm as I can.

I think I approached the conversation trying to be understanding, trying to be her friend, trying to validate. Some of those things like validating her is fine, but I just have a regret of having name dropped and also making it seem like it’s not my fault and it’s someone else’s when really I was involved in the decision discussions as well.

ANSWER:

Great thing to bring for coaching!

OK. You said something you regret. You have an idea of how you want to be/act as a leader, this conversation went a certain way, and you wish you had done something different. This happens sometimes. You are human.

Humans feel regret sometimes.

What is the problem with feeling regret around how this conversation went?

Part of what I'm seeing you do is rehash/review the conversation over and over. Is this helpful? In what ways? In what ways is it not helpful?

Bring it on back!

Just wanted to share that this was supposed to be conversational coaching via Slack that’s why I was expecting a response because that’s how it’s been going so far

ANSWER:
Roger that. See my previous answer below.

Sometimes Clints answer written coaching, sometimes they won't.

What things might influence whether or not a client responds in Slack? make a list of at least 10 things.

I am working to certify in coaching right now. I did my first peer to peer coaching, and the conversation was written and the client stopped responding.

I did a second peer to peer written coaching, and found myself a little consumed and losing sleep over it. Again, this was written coaching.

I have noticed that I tend to ask a lot of questions, I’m not sure what the best or good question is and perhaps a client gets overwhelmed?

Once I noticed that I made it just one question on purpose and I STILL didn’t get a response on the written coaching from the client

It’s a little defeating/deflating. It makes me think Maybe I’m not good at this and also thoughts about maybe I made their situation worse rather than help them.

ANSWER:
Hello! So cool that you are getting certified as a coach- we are biased, but it's a great investment in yourself.

Learning how to coach is a PERFECT time to practice coaching yourself. 😉

Right now, you are making what the client does or doesn't do mean something about you.

C- In coach certification. Written peer coaching. Client no response for x days.
T- Maybe I'm not good at this
F- Defeated
A- ____________(what do you do or not do when you are feeling defeated?
R- You second guess and undermine your growth by looking to your client to prove your potential/value

What is your job as a coach?

What are YOU responsible for?

let's keep digging here!

Hello! Thank you for responding.

I will try to observe my mind with curiosity.

1. "Is this a rational response that a person might have to [working in] a broken system?" Why and why not?

-I think some people might choose to say the system is broken and leave it. Some justify it as “the way it is” based on what I see, and stay because they are doing some good inside the system, even if maybe it’s not exactly what they expected. I think many people stay for financial ties or other reasons. I do see colleagues who see a dysfunctional system and want to fix it/feel they can fix it, so clearly this is also a reasonable response (even if I observe minimal success in actually fixing it.)

2. How might a person know if they are escaping into a fantasy? What signs would there be? What signs would there be that a person were being practical/pragmatic or honest if they were doing the same things?

Signs of escaping into a fantasy: untethered from reality, grandiose delusions, no practical stuff behind it.

Practical planning: it works? It has math/rationality/a real workable plan behind it. The person has thought about what it looks like on the other side and is ok with that (I don’t meet the last one.)

Let's look at your model.
We want to keep the C line NEUTRAL. I can tell your C line is not neutral for you.
C- You are a hospitalist. You work at X hospital. You are 4 years out of training. You have a financial portfolio/plan.
T- This [job] is temporary, I have an escape plan.
F- In control
A- When I feel in control I feel that all the crap around me matters less. Like, I am less likely to tell my boss, no I really need to be 0.8-0.9 FTE if you want me to be here longitudinally, because I know I don’t have to be here longitudinally. I sometimes pick up shifts but honestly I don’t have to anymore. I do obsess over eating-out food bills which is not healthy. But mostly, I feel that I am stable and lucky and in control.
R- Your thoughts give you a sense of agency and control over your future.

You have another model somewhere that might be something like this
C- same
T- what If I'm running away from something and I never let myself "arrive”? OK: HERE IT IS: I am afraid that I will retire and then realize it was a mistake, that I have no purpose, that nobody respects me and I belong nowhere. I don’t like being dictated patient loads and RVU/LOS. I LOVE working with residents/students/hanging with the nurses and gossiping. I help the nurses with their personal stuff and write occasional antibiotics and they take care of me and bring me tea on bad days. Someone just brought me a basket of avocados!! If I leave the hospital IDK where I will feel belonging and team-ness like this. My family (who know me better than anyone!) say I’m too go-go-go to retire and I’m wondering if they are right. My worry that this is a fantasy is bc I have no plan of what “retirement” eg leaving hospital medicine DOES look like. I only know what it DOESNT look like - that nobody will give me an RVU target and a “discharge by noon” goal.”
F: unsettled, aimless, restless, unsure
A- I still pinch the occasional penny becuase having some way out seems better than 0 ways out. Even if I don’t actually have a concept of that “out” means?? It still DOES allow me to be less stressed (like when they were laying off MD faculty in summer 2025 I basically was like, ok worst case scenario I get to spend all the time I wanted with my family and traveling anyway and then eventually I’ll find another job.) But it’s hard to commit to a solid exit plan if I don't know what the AFTER looks like or if I want that.
R- you are correct. Many things HAVE gone right. I am early career but still past the point where I have to worry about normal money things that people at my stage do. I do feel a bit adrift and that I need a plan for post retirement. And I question if this is a realistic plan because it has not been fleshed out in the way that I am used to life plans being fleshed out (you do college > med school > residency> etc in a really mapped out sequence - but maybe also having a life map is not realistic??)

I think you are correct that autonomy/control/independence are really important to me and most of my financial planning has been in service of these. I just DO value meaning in work and feeling respected as part of a community also, and I feel like leaving medicine would take these away from me. I am not sure how to square this out (where medicine is by far the biggest stressor in my life but also probably one of the biggest contributors of “a place in the world” and "meaning.” Which I also value. How do I even think about this??

ANSWER:
Really nice job here, friend.

Your 2nd model up here is so revealing about what's going on underneath the surface. Each of the Ts are different models you could look at

C- career
T1- I'll retire and realize it was a mistake
F1- FEAR

T2- I have no Purpose
F2- Aimless?

T3- Nobody respects me
F3-?

T4- I belong nowhere
F4- Unsettled?

Each of those will be slightly different feelings/actions/results, but none of them, I'd imagine lead you into trust, purpose, belonging, or security with yourself.

The really good news is that you're doing this work now and this work is how you set yourself up for a smooth landing on the other side. you've done a LOT of the physical work (working, saving), and now you're doing the emotional work. Don't stop.

You said "medicine is by far the biggest stressor in my life but also one of the biggest contributors of [belonging] and meaning"

You seem to think that it shouldn't be this way? that you shouldn't have to feel the stress.

Do you think you shouldn't feel stress? or that it's something to be avoided/suppressed/escaped? Why?

In what ways is experiencing stress part of human life?

Do you imagine work should be stress free?

Should retirement be stress free?

Let's keep digging here.

Bring it back.