I'm working on the impossible goal worksheet, and it seems focused on a goal that we haven't pursued yet- but my impossible goal is something that I am pursuing but haven't achieved yet (/have not gotten even after attempting). What would be an alternative thought model to work on (i.e. instead of 'whats the main reason you haven't pursued your goal yet'). I have thoughts around 'maybe I will never get the thing' so I suppose that could be a place to start even though I do feel like I'm putting myself out there?

ANSWER:
HELLO!

Gongrats on being persistent in your impossible goal!

YES! Let's explore this thought and see what it's delivering back to you:

C- the goal
T- Maybe I will never get the thing
F- ? (ONE feeling)
A- ? (list ALLLLL the things you do or avoid doing when you're feeling that way)
R- _______________

You're putting yourself out here right now, but you're doing that as a brave thing because you WANT this goal. Let's get curious here. We are right alongside you 🙂

I did the thought download that you recommended around time with family. Just to clarify, really what I am referring to are weekend trips or weekend stays with my parents and siblings (outside of day-to-day life). My husband is very supportive of my marathon training and I have found it easier to fit runs and workouts into our weekly routine together. Where I get stuck is when I am visiting home and I want to maximize time with my loved ones who I don't get to see as regularly. So here is my thought download:

Main examples of when I have fallen "short" of my ill-defined quality time with family:
- when I spend 1/2 day of a 2-day weekend at home doing a long run instead of getting breakfast or coffee with my sister
- not being able to relax or "go with the flow" because I need to get my run or workout in, but my family has no routine and in general is very chaotic so I never know exactly when I will be able to get my workout in without missing out on some fun, family activity
- I think I've just learned over the years that it's easiest and most enjoyable to be with my family when I can put everything else aside, be 100% present, and have no agenda or expectations for how the time will go (because inevitably it never goes to plan). However, this just doesn't feel possible when I need to get a certain # of miles or runs in that week.

How does keeping my commitments to myself serve my relationships?
- My sense of pride in my hard work makes me feel at peace and calm, which in turn allows me to be more present with family
- Conversely, when I don't keep commitments to myself, I feel anxious and less present with family

I think knowing that this is a temporary problem and prioritizing my personal goals over spending every minute with my family is ok for now. I won't be training for a marathon forever and I can adjust my training schedule ahead of time to maximize time spent with them when I am on vacation, etc.

Throughout this thought download, I also realized that I am not training for the marathon to satisfy my ego. Sure, my ego might benefit, but I don't need to run a marathon to feel good about myself. I think my main motivation is just to see how I transform during the process. How will my mindset and organizational skills change to accommodate a rigorous training schedule while continuing to work full time? What new skills or new level of discipline will I discover? How much stronger can I become physically? I love feeling strong.

I think my motivation is similar when it comes to my second impossible goal of one day running for office. I think that deep down I know that I have unique gifts that could be honed and transformed into agents for important socio-political change. I think the reason why my brain keeps coming back to this dream is because it doesn't want me to let my talents go wasted. This doesn't feel bad or ego-centric. It feels grateful. Almost spiritual.

===============
ANSWER
Love this ego work!! Step into your power here!
On the time prioritization, let's look at a model:
C: You are training for a marathon. You have a mileage plan. Your family weekends are spontaneous and unstructured. Sometimes you spend ½ day on a long run and miss activities.
T: I have fallen "short" of my ill-defined quality time with family, I should be able to relax or "go with the flow" since it's easiest/most enjoyable when I can put everything else aside, be 100% present, and have no agenda or expectations for how the time will go.
F: ???? (guilt? Pressure? Obligation? Schmilt?) **schmilt is a new feeling I'm working on coining.... see below!
A: ruminate, question your choices, when you don't keep running commitments, feel anxious and less present with family
R: You get stuck, and fall short in both areas

**I'm questioning the feeling of guilt (which comes from a thought that you've acted out of alignment with your values) vs. schmilt (the discomfort of violating someone else’s unspoken expectations) because if we are dealing with schmilt here - then the actions make sense. When we’re out of alignment with our own values, guilt is clean and often corrective, even if uncomfortable. But when we’re out of alignment with an imagined expectation, the result is usually trying to "fix" their feelings with oscillation: we overcommit, then resent, then question ourselves, then try to compensate, occasionally cross our own boundaries or needs at the expense of others, and then end up resenting them more (in the long term if this continues).

The way forward is to allow others to experience disappointment (or yourself!) and not try to fix it for them.

The question becomes: Is 100% unstructured presence actually the highest form of love?
Right now your brain is equating: “No agenda = best connection.” But that may simply be the most comfortable version of connection.

As you point out, this is a temporary chapter. And you’re allowed to be in a chapter where discipline and structure coexist with family chaos. So what if you are not choosing between family and running, but instead choosing how you want to show up while honoring both?

I am feeling dysphoric after constructive critical feedback. Context is that I am applying for a young investigator award/grant that I have already applied for three times and been rejected each time, so this will be my fourth try- the deadline is normally end of April, but we found out in January they were moving it to end of February, so timeline was shortened. I'm excited about my project and feel like it is my strongest proposal so far, and I tried to strategically put together a team of mentors outside of my own institution that would be helpful for the grant and helpful because they are "in the club" with the organization. I sought out feedback from a senior person at another institution after he had offered to read my grant when I met him at a conference a few months ago. He called me this morning and said that he thinks it won't get funded because where we are in the clinical trial process is too early and reviewers won't think it is feasible. And then he said that for my two translational aims based on the trial correlatives that they lacked specificity/sophistication and right now sound like a resident could have written them. So I actually do appreciate the constructive feedback because it is hard to come by, but it feels too late to drastically change the grant proposal (its due in a week) and the comment about it being written by a resident stung, and played into this loop I have in my head about how I'm never going to "make it" as a clinician scientist, I'm not at the right institution, I don't have the right mentors/sponsors, I don't have the right skillset, etc. And I think this brings up shame and disappointment and exposure fear, and I try to sit with those feeings but they aren't just "passing through" and I wonder if maybe at some point if you get rejected enough it means it actually is true that you shouldn't be doing this?

C: Senior expert provided constructive but critical feedback on a proposal that means a lot to me
T: This is evidence that I can't be taken seriously, I'm not good enough to be a clinician scientist, I put myself out there and now he knows that I don't know what I'm doing, Everyone else who still has to give me feedback on the proposal is also going to see that I'm not sophisticated in my thinking
F: Shame, guilt, grief/disappointment, embarrassment
A: Withdraw, not think about how I can use pieces of the feedback to help refine my proposal
R: No forward progress, potentially backward progress?

==================================
Answer:
Ohhh I've been there! Feedback, no matter how growth-minded one is, is such a common trigger for dysphoria in the exact way you are describing. But the dysphoria is not a negative thing, necessarily, until we react to it with techniques that get in our way.....
When looking at your scenario in a model, let's stay *even* more neutral in your C line. Can you fill in the blanks?
C: Applying for an award for the 4th time, senior expert said the words "______________________" about it.
T: This is constructive, critical feedback on a proposal that means a lot to me, so I can't be taken seriously.
F: (Pick the ONE most predominant F here: ______ is it shame??)
A: Withdraw, spiral into "I'm not good enough" circular thinking imagine that the expert now "knows" that you don't know what you're doing, imagine that everyone else is judging your lack of sophistication, and block out anything helpful in the feedback. Try to “process” feelings in order to make them go away. Get frustrated when they don't seem to be just "passing through" and then question if proposal rejection actually means you don't belong where you are (rather than the stated meaning of "the selected people on this committee think a different proposal should get this money this time").
R: You don't take yourself seriously. (lol or yes "backward progress")

Ok- so interestingly here, you also have access to a plethora of thoughts that range from excitement about your project, and gratitude for this senior expert's candor- yet for some reason, this one about you not being right for this career is the sticky one.
Why do you think that is? What does this thought pretend to do for you? What type of protection does it offer? It's clear that despite your inner critic here, you are still experiencing shame, disappointment, embarrassment, etc - so what else could it be trying to protect you from? Is it relief in the form of "If I conclude I don’t belong, I can stop trying."? (a type of certainty over vulnerability?)

But here’s the deeper truth: You don’t need protection from shame. You need trust in your ability to survive it....and you already have evidence that you can! You’ve applied four times. You sought feedback. You got on the phone with someone who could sting you. You’re still revising. That is not someone who collapses under shame. That is someone who feels it and continues.

Interestingly, the way I am reading this reflection made me think that this senior expert takes you very seriously! This type of critical feedback is usually not given out with free time - my brain offered me the thought "wow- this person's proposal really made this senior person sit down, take time out of their day and put together reflections" - (i.e. "they are taking them so seriously!"). Now, there were some, perhaps unnecessary parts of the feedback that you get to decide if you take or leave. Nothing makes this person an expert on your proposal, only you hold that title. So if they give you a piece of feedback that feels frankly unhelpful (like calling you a name or rank that you don't have, for instance)- then you are allowed to DROP THAT PART OF THE FEEDBACK IN THE TRASH. Simply because it doesn't help. (yes, even if it's true!).

PS: A note on processing feelings - while it's true that doing this practice of sitting with them, allowing them (even inviting them in) does decrease the frequency and intensity, it does NOT mean they won't come again. Over an over again. You are obligated to experience some amount of shame, embarrassment, disappointment etc with some proportion of your life because you are human, and your time for these is now. And, ironically and tragically, the more we WANT these feelings to pass through us, the more they will stick around. If you have an agenda in your feelings processing of getting the feelings to go away - you are missing the point (you are not alone, even us seasoned coaches want unpleasant feelings to go away! If we could get them to though, I promise I'd tell you how!).
What if instead of even working to decrease the intensity or frequency with this work you had a different goal? Could it be to learn from the shame? To ask it what it wants to say? What else? What else?

What if nothing worse is waiting for you on the other side of shame? What if the thing your fear is warning you about… is just the feeling itself?

Shame says: “If this is true, you will be annihilated.” But what actually happens when shame is allowed?
Your chest tightens? face gets hot? mind loops? feel exposed? What else? And… you are still here.

The fear is not protecting you from professional extinction, it’s trying to protect you from feeling shame.
But you are already feeling shame. So what is it doing now?

Frustrated that I cannot lie in bed too long. How do I Instead allow the day pass .(accept the red tape of life).
I work a full time job. I am trying to use my 10 days of bereavement intermittently (law in in my state ) but can not grieve as have to deal with processing mistakes or I need to submit documentation for my 10 days of bereavement .
For example I did not get half my pay check as HR used the wrong code to notate leave of absence ( not just PTO) . I had to spend my day off calling and writing to HR..
I wish I could just have a day off work/paperwork to grieve.\

ANSWER:
Hello Friend. Thanks for bringing this here. I"m so sorry to hear about your mom's passing.
All these feelings are coming up. Frustration, grief, I'd bet also overwhelm, anger, resentment, sadness, and exhaustion.

Your to-do list has a million things on it. Work administration is hard to work within.

You are a human being who is doing her best at navigating all of this while driving the loss of a parent.

When these feelings come up, what do you see yourself doing?

Do you think you're resisting feeling them?

What happens when you resist them? do they get bigger? Do they prickle your throat?

I want to invite you to close your eyes and take a deep breath and ask "What am I feeling now".

Can you name the emotion?

Where is it in your body?

Does it have a weight, a shape, a color, a size?

How does it change as you envision it within you?

Can you sit with it for a minute? maybe more?

What happens?

We are here with you as you navigate this time, friend. Bring back anything that feels important to bring to light.

<3

Hmm, these are tough questions...

I would agree that the resistance you are hearing in my 'should' is probably my perfectionist coming through. On a practical level, I know that everyone struggles through things and that it is OK. I am working on telling myself that this is OK for me too, but some days I still get frustrated, like I should be able to rise above it. But I'm working on it!!

What does it mean to you about your relationship that you process things differently? We have always had very different personalities so I am not sure that it means anything special to me that we process things differently. However I do think that it DOES mean that we should spend more time talking things through so we can understand each other better and not get misled into thinking, for example that we don't care about each other.

C- you are a human and you notice you prefer processing life through talking, commiserating, and connecting with people. He is a human and has his ways or processing life.

T- We should talk to each other more so that we still feel connected, but why can't he talk to me??
F- Frustrated, worried, alone
A- Oscillating between silence and pressuring him to have conversations when it's not a good time for him.
R- Still disconnected and continued frustration and worry.

In your mind, what does communication look like in a "healthy relationship"? Regular (maybe even just once a week) deep communication about things that matter, not just the day to day tasks that need to be done.

What evidence do you have that people can cope in different ways and that's OK? I can think of couples who cope like this (like my own parents), but I don't think they are flourishing and I want to have a flourishing loving relationship.

Is it possible to process life in a different way from someone else and still feel connection with them? How? I think so, but I think we need to find a common hobby or some other way of connecting (if it is not talking)

What does "connection" feel like in your body? What are you thinking about (your partner, your baby, your family, your friends) when you feel it? be as detailed as you can. When I feel connected to someone, I feel a deep sense of joy. My tummy is warm and my heart is full, my face, brain and whole body is relaxed and I feel content for time to stop. I feel like I can open up about anything and there is a lightness in the surrounding.

ANSWER:
Welcome back. You're doing such good (and important) work here. I know it's a bit tender to dig into this kind of work, so well done.

OK Whenever we ask ourselves a question on the T line, the underlying thought is the ANSWER to that hypothetical question.

C- Relationship. you are humans.

T- He can't talk to me because __________________

F- ________________ (ONE feeling)

A- ___________________ (this is the juiciest section. as many verbs as you can here. list alllllllllll the things you do or don't do when that feeling is driving the bus)

R- _____________________ this is the result/return FOR YOU of the sum of those actions.
I suspect that the result for you here is that you DISCONNECT from him by wishing he were different.

Can you fill out that model?

I really love your exploration of how "connection" feels in your body. I can tell that right now, you think he has to do something different, or he has to change for you to feel connected to him. -->
" If he would have deep conversations with me then I could feel connected with him"

You want him to show up differently on your C line, so you can feel differently. CONNECTED goes on the F line of your model. Think back to a time where you felt connection in your relationship. What beliefs/thoughts/narratives contributed to that?

C- Relationship. You are humans.

T- ?

C- CONNECTED

A- _____________________ what would YOU be doing differently if you felt connected?

R- ____________________ ?

What might that model look like?

OK. Listen, all of us, from time to time, wish people would be different so we could feel better. It's not a problem necessarily, except for when that wish brings you AWAY from what's important to you. How is that happening here?

As an exercise of radical curiousity and perspective taking.... I want to invite you to imagine what a model of his might look like. If you can, do this from a place of as much generosity and curiosity as possible. What thoughts/feelings do you think are driving him? We will never know if this is actually what is going on for him, but it can be powerful sometimes to imagine what it might be like for them.

C- relationship. humans.

T- _________

F- _________

A___________

R___________

What comes up for you here?

This is REALLY important work you are doing, and I commend you for it. I'm here as you keep working through this.

Keep it coming, friend.

On the last coaching call a very lovely surgeon talked about making it to an attending position and then dreading work and feeling "is this all there is for the rest of my life?" And discussed that when you are in med school or residency, that there is some sense of "I just have to get through X and then it will be better" but then once you get to being an attending you realize you got there and....now this is the rest of your life. I had a mini crisis listening to her and now I have a lot of questions about my life

Some part of me has been burned out since med school. I vividly remember visiting family and then having to leave and go back to school alone. I sat in the airport and cried, and thought, I never want to sit in an airport and cry again bc I don't want to leave my family. This (somehow) led me to early retirement blogs and the FIRE movement back in 2013. Long story short, I got really good at finances, lived frugally, took side jobs and saved a lot of money even during med/grad school and residency, and invested successfully. I've been an attending for 4 years now and I'm set to retire at 45 (in 7 years) and the math works (the financial guy confirmed this.) My family all know about this but I've kept it really quiet otherwise because obviously it's professional suicide to say any of this out loud. I must be hiding it OK because I got a bonus and was asked to be APD of the residency program recently.

Having this as a secret escape plan in my pocket all along has made every stage of my life, including attending-hood, so different. Residency sucks? That's why I'm saving money to escape! The hospital is squeezing me to make more RVUs? yeah that's corporate medicine but I have a plan to get out! My boss denies my request to go down to 0.9FTE from 1 due to burnout? Welp of COURSE the job only cares about getting the work done, this is why I'm GTFO'ing and then I won't have to answer to anyone. The ability to not really care much about this stuff is great (whereas if I thought I was going to deal with it for the next 30 years that would suck.) But the bigger question that flashed through my head on that call was, oh no, did I just make attendinghood another "residency" stage where I keep telling myself, i just have to work for X years and then it will be better bc I'll retire?? Am I not having the crisis that this other person had re: attending life frequently sucking because I've already conceptualized this part of my life as a stage I ALSO have to get through and then it will be OK? I don’t even really have a plan for how I would spend my time in early retirement. It’s just….this fantasy land that doesn’t have any of the current elements of suckage that work carries. It probably has its own pitfalls and all of those are just new to me so IDK what they are yet. (I imagine lack of meaning/belonging and respect would be a big one.) I’ve saved/worked for this for so long that I think I’m actually making it happen but now that it’s getting a bit closer there’s a voice in the back of my head that’s like…….are you really going to do this?

Is this a rational response to a broken medical system where I feel (as a hospitalist) that 10-20% of what I do is connecting with patients and taking care of them and 80-90% of it is optimizing hospital throughput and improving LOS and documenting correctly so that patients can move through the hospital faster and we can bill more RVU’s with the same number of beds bc the hospital is in the red? How do I decide out if I’m just escaping into a fantasy of retirement/leaving medicine, or if I should try to find the kind of job I wouldn’t mind doing long term? If/when I leave medicine am I going to have the same crisis that this other caller had, and suddenly realize that “early retirement” is now “the rest of my life” that I’ve fantasized about as the promised land and realize that it doesn’t measure up?

I don’t even know how to fit this into the model. I just felt myself so vividly in that other caller (and I’m so thankful to her for her courage in sharing) so wanted to put this out there and maybe ask for some direction.

Here’s my best shot

C: challenging job focused on productivity
T: this is temporary
F: feel like I’m in control bc I have a secret escape hatch
A: less likely to change things that I think should be changed (unclear if I have the power to do this?), sometimes I do think I get a bit more neurotic about money because it’s such a lever of control to me
R: work chugs along but I am not as deeply invested? Still got promoted so apparently it’s going ok…Presumably I eventually leave for reals.

I feel like the alternative “ideal” thought model would involve me working to change a dysfunctional environment and investing more in it to make it better but please believe me when I say, I cannot give work more of my life than it already has, and I firmly feel that within a hospital system I cannot change the profit model. Maybe I could if I hung out a shingle and didn’t have to make a living doing it and this is one of my intermittent “retirement” fantasies but I get that something has to keep the lights on and apparently its RVU’s. Sorry if I’m rambling.

ANSWER:
Hello! This is a great thought download.

Take a deep breath, this does not need to be a crisis. I want to invite you into to observe yourself and your mind with curiosity. Is that available to you right now?

Nothing has necessarily gone wrong here. From an outside perspective, some may think a lot has gone RIGHT! You have been proactive in taking care of yourself financially, you have worked hard professionally and are experiencing the products of all of that hard work (a secure retirement plan, professional opportunities, for example).

Then, You observed someone be coached, and you are making this mean that you can't trust the reasons you have done all of this, or trust yourself to be OK on the other side. That maybe you won't let yourself relax even in retirement. Is that right?

You asked a few hypothetical questions. I invite you to zoom out a bit and try to answer them from a place of curiosity. It might feel hard to answer them as yourself so let's move them to a 3rd person.

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

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?

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 Y years out of training. You have a financial portfolio/plan.

T- This [job] is temporary, I have an escape plan.

F- In control

A- (this section is all verbs. What do you do when you feel in control. Do you sign up for shifts, save money, learn about investments? what else?)

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"

F- (fear? worry? what is the feeling here?)

A- ?

R- ?

There is no such thing as an "ideal" model. There are just thoughts and feelings in your head and the model helps us see them.

Some of the values that seem important to you based on all of this is
- agency
- autonomy
- control
- independence

You have been working very hard for many years to honor and live in alignment with those values.

There are some other ones that I think are a little less tangible or clear to you but are still there, and these are what you're trying to reconcile here.
- meaning in work, and meaning after you've left this career
- ability to be present
- ability to allow yourself to be satisfied and at peace with where you are, even if where you are is't perfect or always comfortable.

What comes up for you here?

Hi BT, I’m working on week 1 and my “impossible goal” is having a life outside of work. For this exercise, I’m focusing on wanting to host friends more often. It feels impossible because I usually only see friends when they suggest plans. It feels easier to be passive than active in my relationships outside of work.

I’ve done a CTFAR and would love your guidance. As always, thanks for your help!

C – Circumstance:
My free time is usually filled with work-related tasks (Epic in-basket, pharma consulting) or passive relaxation (Netflix). I rarely plan social activities myself and usually go along with what others suggest. I host or initiate social plans only 1–2 times a year.

T – Thought:
“I’m too tired after work to plan or host anything.”
“It’s too late to start planning dinner or inviting friends; I don’t have time—even though I only see patients 3 days a week.”
“I might get rejected if I suggest plans.”
“It’s easier to do low-effort, comfortable things than create social plans.”

F – Feeling:
Tired, anxious, frustrated with myself; sometimes lonely or regretful when I look back.

A – Action:
Watch Netflix instead of planning social activities, let others dictate my free time, delay hosting friends or planning events, work extra hours or do low-effort tasks instead of personal projects or hobbies.

R – Result:
I feel like I have no life outside of work, regret not spending more time with friends, and experience a sparse, passive social life. I feel like others are making decisions for me and reinforce the idea that work-life balance is impossible.

==================
Hello there, I love this goal! Especially since it really feels impossible for you. However, I'm going to push you to get more specific about the goal- in particular, when will you know if you have achieved it? What number of times do you want to host friends at your house? How frequently? What kind of gatherings? By when? Visualizing yourself doing the goal, with DETAILS, is a really important preparatory step, because what you are doing here even more than taking the steps to host your friends is BECOMING A HOST version of yourself.

Now, let's get specific with your unintentional model. Be careful to get really neutral with your "C" line, no adjectives or impressions here. Also, I want you to pick the one predominant thought and one feeling (I'll choose one for you below, but please correct me!)

C – Currently, I do XX hours of work-related tasks and XX hours or passive relaxation (Netflix) in my non-working hours. In the past year, I have planned/hosted 1-2 social activities myself, and attended XX number of social activities planned by others. I have a goal of hosting XX number of friend events per month by XX (date).

T – This goal is going to be hard, make me feel tired, and has the potential for social rejection.

F – Anxious

A – Watch Netflix instead of planning social activities, let others dictate my free time, allow others to make the decisions, delay hosting friends or planning events, work extra hours or do low-effort tasks instead of personal projects or hobbies. Then regret choices. Theme = seek easy, comfortable, dopaminergic activities, at the cost of your goal.

R – Your thoughts about your work and life have reinforced the idea that work-life balance is impossible.

Ok. This is a beautiful and critical place to be in- because the work here is to get really honest with yourself. Do you really believe that the way you are thinking about your life is creating this result for you, or are you secretly hanging on to a belief that because you are a busy clinician or there is some flaw about you that is creating this result for you? It's not until you fully see that your thoughts are driving this train that change is possible.

Aaaaandddd.... I want to be really clear, your current thought (the one I summarized) - could be absolutely true! If you try to grit your way though an action line of a result model (i.e. if you tell yourself what you need to do without doing deeper thought work) like "make dinner reservations on Monday, then call 5 friends and invite them on Tuesday, then send reminder texts, then when Friday rolls around make sure you are home in time to change and get ready, etc. etc." or whatever your action line looks like.... that probably will feel hard, scary and energy consuming.

However, it doesn't *have* to. Even if you are the most introverted of introverts, it seems that you do believe there is something to gain in social interaction, that there would be something fulfilling in the connection for you to counterbalance the energy it would take to coordinate. So knowing this value exists inside you, how else can you look at this circumstance? What we want to build is evidence that you can create your social life, and that work-life balance becomes something you create, not something that happens to you.

C –My free time is usually filled with work-related tasks (Epic in-basket, pharma consulting) or passive relaxation (Netflix). I rarely plan social activities myself and usually go along with what others suggest. I host or initiate social plans only 1–2 times a year.
T
F
A
R

(Fill this in and bring it back with whatever comes up!)

Here are a few bridge thoughts to get you going:
"Planning something small is uncomfortable, but discomfort isn’t danger.”
“Netflix is easy in the moment, connection is nourishing over time.”
“Even one invitation per month is a completely different identity.”
“Energy follows meaning more than it follows comfort.”
“I am building social muscle, not throwing the perfect dinner party.”
“Avoiding anxiety has cost me more than risking it.”

And here are a few questions to ask yourself as you shift your mindset:

-What identity are you protecting by staying passive?

-Right now, your brain believes that Netflix restores you, but I'd like you to get curious about this: can you document how you feel the morning after connection vs the morning after avoidance? (What if social planning and connection creates more energy than watching netflix?? Let's find out!)

-Sometimes we mislabel the discomfort of growth as exhaustion. Let's find out if you are actually tired or if you are inexperienced at tolerating social vulnerability... and if it's the latter, that's great news since you've taken an amazing step simply by showing up here to explore this in BT! (tolerating social vulnerability is something most people are afraid of, you are not alone!)

Thanks for the encouraged reflection

How would you rank these values? - so I did add one value at the end (higher scores better)
- Stability 6
- Clinical competence (or excellence?) 4
- Research Competence (or excellence?) 7
- Leadership in your field 6
- Novelty 6
- Accomplishment 8
- Family happiness 9

deeper dive on these questions

Then for each of those values. ...
a) In what ways is applying to Chair position aligned with that value?
b) In what ways does applying feel in conflict with that core value?
c) What is the downside of applying?

Family happiness – I like my spouse and the work goes well when we have low stress, has helped me extensively as a colleague to write papers, grants, discouraging wasted time and effort. Kids also like where we are, even though they are away in college
a- chair is not aligned at all, although we have great friends in that area
b- Spouse has great job (its not the primary revenue source for us though) and will not want to move, but looking at this makes me realize, I might be asked to be chair somewhere in our current city somewhere one day, so might as well start prepping
c- wasted time from my current research and local division initiatives, mentoring my current partners; might accidentally decide to take this job if offered in another city and force us to move. Engaging OB would make me pretty grouchy, it’s quite a stressful part of our discipline.

Accomplishment – I don’t like to be bored, its satisfying to get meaningful stuff accomplished, you get positive feedback from people, and its better than just holding the status quo only doing the same task again and again each day like on a gerbil wheel, I associate having good finances with always making progress-- hard to fire or leave someone in a lousy work spot who is constantly succeeding and innovating.
a- chair is certainly a fresh accomplishment
b- it is quite coherent with that value, and gives me the department pursestrings
c- it could limit other avenues for accomplishment that I specifically care about, especially having to deal with the OB side

ANSWER:
Really great reflections here. Let's keep going.

I'd like to play a game called "Is it true?".

In this game I'm going to pull a few lines from your reflection above that you think are facts ;). For each, I invite you to ask yourself "Is it true?". See if you can find at least ONE piece of evidence for each that might prove the statement is NOT true.

You game?

IS IT TRUE? (imagine a groovy theme song here)
1. [time spent pursuing chair position is] wasted time from current research and local initiatives.
2. [I could end up] accidentally deciding to take this job in another city forcing us to move
3. Engaging OB would make me pretty grouchy
4. OB is a stressful part of our discipline
5. [ pursuing chair position] could limit other avenues for accomplishment.

OK and this line
"Engaging in OB would make me pretty grouchy..." that goes in a model like this
C- OB exists
T- ?
F- Grouchy
A-
R-

I am pointing out that it's not OB in and of itself that makes you grouchy, but your thoughts/opinions/beliefs/perspective on OB that makes you feel grouchy.

You can fill out the rest of the model to see what that delivers back to you.on the Result/Return line...

Keep it coming, friend!

A goal I have that feels impossible is to let go of my fear that others will judge me and find me lacking. This goal seems less tangible than some of the examples of impossible goals, so I am not sure if it works with this exercise. But it’s something that has been affecting how I feel and how I show up in the work setting recently, so I would love some coaching!

Thought download:
I’m in my 2nd year of being an attending. I know that I will miss things, make mistakes and have procedural complications because I am a human and not a robot. I am trying to give myself grace and practice self compassion when these things do happen. But I often find myself stuck on the thought “what if my colleagues think I am a bad doctor”. This thought makes me feel anxious and inadequate. When an OR case takes longer than anticipated because I am still learning the procedure (but everyone is safe with no complications), I find myself spiraling that the other surgeons will be mad at their cases are delayed, that the OR staff are gossiping about what a bad, slow surgeon I am, that my colleagues will be upset that they have to spend time training me. I start apologizing to people and fantasize about not doing this component of my job (which is something I worked hard to be able to incorporate into my current role). After having a case discussed in peer review, I find myself anxiously overdocumenting to make sure I’ve clearly explained my thought process/recommendations, which makes note writing more arduous. I think my result is that I am not present as my favorite self at work – rather than focusing on the things that bring me joy and help me connect to my core values of service, connection and growth, I am approaching work from an anxious, CYA standpoint. And it makes me not like my work as much.

When I take a step back, I can recognize that I know I am often actually a good doctor – I care deeply about my patients and strive to listen to them/care for them with empathy, I try to stay up to date on the evidence, I am humble and willing to ask for help and learn from mistakes. But feeling that I constantly need to prove this to other people (and myself in my anxious/inadequate moments) is exhausting. I’d like to not worry about others’ potential judgements so much because I will never be able to actually know or control what they think and I don’t think it is serving me in any positive way to spend so much energy on it.

C: I am in my 2nd year of being an attending. I am a human being. I will get things wrong sometimes.
T: When I miss things, am slow or have a complication, my colleagues will think I am a bad doctor
F: anxiously inadequate
A: catastrophize, imagine all the critical thoughts someone could be thinking about me, overdocument, beat myself up for any potential mistake or thing I could have done better, apologize for perceived issues, fantasize about a different job, spend time and emotional energy outside of work worrying about things I may have missed or missed documenting
R: don’t show up as my favorite self at work, disconnect from my core values, have difficulty accessing self compassion

Result I want: To 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

I don't know how to approach the actions in the reverse model that will get me there!

================================== ANSWER
Hello there, thanks for bringing this here! I love this aim, which is essentially to change the volume of your inner critic. It's your inner critic, or "negative-self-talk center" in your brain that is offering you all of these thoughts about how critically you may be perceived by others. This is VERY NORMAL inner critic stuff, we all have it, though we all have different volumes, frequencies, and strength of belief of our inner critic.

The way you phrase it, it sounds like you'd like to put your inner critic on MUTE, or abolish it all together, which I am going to say is not a great impossible goal, since from what we know about neuroscience and physiology, this is *truly* impossible, something you don't actually have control over. We use the term "impossible" a bit facetiously here - we don't actually want to try to do something impossible (like throwing a ball 1000 feet, or becoming a professional football player at age 80), but something our brain tells us is impossible but is actually theoretically possible.
I have fantasized about the perfect stroke that would abolish the negative self talk center in the amygdala, but I don't think the circulation actually works that way - and also, if it did, that stroke would probably leave the person pretty strange!!

Ok- so if we can't get RID of the inner critic, then the question becomes how can you relate to it in a way that moves you towards the result you want? Knowing this, I would suggest moving your inner critic's thoughts to the C line:

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

If you want to try a result model, let's put your beautiful R at the top and work our way down. I recommend only filling in the very next step (i.e. don't think about the thought yet, focus only on your A line first. You could even ask yourself what would SOMEONE do to get this result, even if it weren't me? What could I imagine needs to be done or not done to get this result:

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: ????? (what goes here for you in this C? get really juicy here, what are all the things you need to do and not do in THIS circumstance to get your result? what things does your favorite self do differently than your anxious self?)

F: ????? (what feeling would you need to cultivate to do these things?? Pretend all feelings are possible here, which would you choose?)

T: ??? (here's the money shot: what T can you think, about this C, on purpose that you believe and creates this F?)

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.

Some Qs to ponder as you do this work:
-If the inner critic is a natural and neutral part of the circumstance rather than the problem, what does that change about how you relate to it? What do you notice feels different when you expect it to show up?
-If you believed your colleagues also expect you to still be learning, how would you show up differently?

Here are some bridge thoughts to get your creative juices going:

"Ah yes, my inner critic is looking out for judgement again, sigh. I will need to be extra kind to myself today to take care of us both and show up how I want to."

"Ohhhh, right, hello inner critic, thanks for trying to protect me from embarrassment or failure, you are really looking out for me! But, unfortunately, you got your tactics wrong, and you are creating more suffering for me, not less so I'm going to take the reigns right now."

"Huh, how interesting, I remember that when I take a step back, I can recognize that I know I am actually a good doctor – I care deeply about my patients and strive to listen to them/care for them with empathy, I try to stay up to date on the evidence, I am humble and willing to ask for help and learn from mistakes. Maybe nothing has gone wrong here, and me taking extra time in the OR has actually led to these qualities that I love about myself."

"This is what my brain does when I’m learning in public, but right now my job is service and safety, not speed."

First guided thought
C- Work, research/clinical components, change will always be a part of our systems.
T1- It's important to not get complacent.
F1- I don’t like to get caught unprepared so I should pursue this national chair opening, and I want to have a career that I dictate terms to work until I finish, not the other way around (what feeling does this bring up in you? can you name the emotion? – that would be ANXIETY)
A1- This drives me to pursue a job that seems like a promotion, even though it takes me away from a trajectory of relentlessly building skills as a surgeon and researcher that I have worked on for decades, while the administrative stuff is more stuff I’ve casually picked up by necessity during those times. It also seems reactive to avoid changes that I cannot even envision, but that will be happening, as we tighten budgets and potentially research funding gets tighter (what does that feeling/emotion drive you to do or not do?
R1- The return is like the cost of buying insurance, it’s not investing in what is important to me, but maybe limits the risk of a lot of what I currently have (what is the return on these actions for you? does it bring you closer or further away from what's important to you?)

Ok, that's an outline for a model of your first thought there.
See if you can fill out the F, A, R lines and see what comes up.

Second thought
Does one of those other thoughts (T2-T5) feel louder or more pressing? Which one? Why?
Can you build a model out of that?

C: If I take on a chair role, I will be overseeing obstetrics in a department
T: T2- I don't want to manage an L&D that is a core responsibility of any Chair position
F: I am annoyed that I would have to lose sleep and invest time from other objectives to help manage an inherently flawed philosophy of care in American L&Ds.
A: This drives me to avoid seeking this chair promotion, which might also reduce my access to being able to build many interesting domains elsewhere in the department, and continue to allow career advancement/security
R: I can stay where I am, and just build on my current interests, while leaving me vulnerable to the plans of other more senior leaders.

ANSWER:
Hi there. Great work here and thanks for bring it back.

Quick feedback on your models your F line is only ONE word and it's a feeling/emotion. In both of these models you have extra Ts. No problem, but to keep it clean we just look at ONE thought and it's corresponding feeling at a time.

In your first model you name the emotion of Anxiety
T- It's important to not get complacent
F- Anxiety
A- (VERBS)- pursue a job you're not REALLY interested in
- focus moves away from surgical and research skills
- spin in circles arguing one thing and the other
- imagine worst case scenarios
R- You are moving around in circles, but without identifying what is truly important to you.

To move through this, let's see if we can get in touch with some of your core values.
In your reflections above, a few things jump out at me as ideas that are important to you

How would you rank these?
- Stability
- Clinical competence (or excellence?)
- Research Competence (or excellence?)
- Leadership in your field
- Novelty
- Accomplishment

Are there core values that you hold that I haven't picked up on here?

After you've ranked them, I invite you to take the top 2 and write for a few minutes about each one. Why is this value important to you? How has it gotten you to where you are now?

Then for each of those values. ...

In what ways is applying to Chair positionsaligned with that value?

In what ways does applying feel in conflict with that core value?

What is the downside of applying?

Would love to keep digging here with you. Please bring back anything that comes up for you in these reflections.

Thanks for the clarification-- the model is a bit rusty! I do have to say was helpful in turning off the ruminating thoughts and being more present for my family.
yes, I care a ton-- not that much about research but about creating that support structure for the residents to get their projects done. I care that I'm supporting them to meet their requirements and supporting an overall environment of clinical curiosity and improvement for our patients.

1. being someone who ruminates... I think that diffuses a lot of self judgement already--so what, you're right. I think what I'd like is to be able to control when I'm spending time and energy in non-productive ways. I think it means that I'm deeply invested and care a lot. It means I want to analyze situations and improve things. I also means I'm sensitive to the feelings/thoughts of others. None of which are as negative as my self-judgment on them makes the out to be (though I do still desire more control on who/when I feel so sensitive). I think that sensitivity can help me be attuned to things but it also contributes to negative thoughts about myself.

2. Yeah brain goes quickly in that thought cycle, My husband notices quicker than I do though I notice changes in how I feel pretty immediately. It's like a broken nail where that jagged edge just grabs your attention and it can pop up suddenly. I am not as aware of the off-ramp. Like with this I noticed but kept going back to it, composing the reply email, debating the tone, texting the PD to discuss the hard vs flexible boundaries, planning out what that might look like for other residents. I think this one I really had trouble letting it go which is what prompted me to seek the coaching. the process of organizing those quick and interconnected thoughts into the CFTAR model helped quite a bit and then it was dinner time and so that transition helped. Venting helped. In general, I schedule things to help with day-to-day "running my list" -- maybe an EM metaphor but thinking through what all I need to do -- if I schedule time to do it I can put it in a better container and worry about it when it's time to do that task rather than keep using my current thoughts about it. I think there's always some background noise or thinking about things I need to do (birthday present for nephew still needs tissue paper, this kid needs pants, this one needs to pee, we have 30 minutes until we need to go so I can only work for another 10 minutes) or, on shift (this one's waiting on labs, this one needs to go to CT, I need to check this one's resp status after that breathing treatment but they just started so I'm going to finish this note first then breathing treatment and talk to nurse on the way etc etc) So I don't find those too bothersome but it is like it's always going.

3. Success to me=connection and support

============================
ANSWER:
Wow, great reflections here! Fantastic description of your rumination signs/signals.

I notice the word "control" pop up a few times in here.

What do you think about that?

How does the idea pf "control" show up in your life and work? For better and for worse?

I love your definition of success= connection and support. In what ways can you offer those things to yourself right now?

C: new role offered to me
T8 - I don't know what I really want.
F: wishy washy, not confident
A: creating lots of scenarios, asking for more but also considering role as is., worry that i wont grow
R: confused and still dont know what i want

How would you know you'd done enough to advocate for yourself here? I think i have done enough here, this was my last attempt
What would the offer have to be for you to say yes, and trust your yes? reduced rvu
What would the offer have to be for you to say no, and trust your no? current offer or less

ANSWER:
Good to know all of this. Of course feeling "wishy washy" doesn't help you move forward with confidence or clarity. That makes sense. In the end of this model you said "I still don't know what I want". So let's see if we can get clarity on that.

If you didn't have to censor yourself, if you could be honest with yourself and everyone around you and not be judged.... What would you want?

Be as granular and specific as possible. If your brain says "I DON"T KNOW", sorry but that's not an allowable answer 😉

If you DID know.... what would it be?

Keep it coming, friend.

Thanks for the support and interesting questions!

Yes, I think it is totally normal for humans to experience exhaustion, disconnection, overwhelm and frustration. Therefore, these feelings should be OK for me and my husband too. Perhaps more root to the problem is that when I experience these things, I like to talk them out and commiserate with close friends and family. Whereas for him, I think he is at the state where he just wants to shut out the feelings, do the things, then move on with his hobbies/personal time. When this happens, I have also been retreating back to my defaults of scrolling or watching TV, or frankly, taking a nap! But I don't think this is healthy for our relationship long term... Or maybe that's just my "old way" of thinking and that it could be OK during this phase of life? Maybe if I can convince myself that it is OK for us to cope in different ways, then I will find clues of our closeness in other ways in our day-to-day?

I think I'd love some guidance on how to work the model backwards to reach a result of feeling connected to my husband during this trying time. Thanks!

ANSWER:
Welcome back! I know you want to move into a better feeling model here.

You said "these feelings Should be OK for me and my husband too".
I sense the tiniest bit of resistance here, like "they SHOULD be OK, (but they really AREN'T OK, at least not for me"). Am I off base here? Let me know?

You mentioned that you know some things about yourself and how you process things- talking them out, commiserating with friends and family.

He is a different person, so his approach will probably be different. our coaching here won't be changing what he does or doesn't do. We are here to look at you and what you think and feel and do, OK?

What does it mean to you about your relationship that you process things differently?

C- you are a human and you notice you prefer processing life through talking, commiserating, and connecting with people. He is a human and has his ways or processing life.

T- ? (what does it mean that you process life differently?)
F- ?
A- ?
R?

In your mind, what does communication look like in a "healthy relationship"?

What evidence do you have that people can cope in different ways and that's OK?

Is it possible to process life in a different way from someone else and still feel connection with them? How?

What does "connection" feel like in your body? What are you thinking about (your partner, your baby, your family, your friends) when you feel it? be as detailed as you can.

Let's see what comes up here!

Thank you guys!
I am core faculty and have been research director for a couple years now for our program. I re-vamped the research rotation which had previously been a vacation with another name. July 2024 I reestablished handbook guidelines which were previously not enforced but would be from that point on. July 2025 we changed the timeline requiring them to *complete* the project before their 3rd year research rotation or else have M-F 9-5 schedule expectation during that roation. (this was in response to two seniors requiring extensive faculty support to get theirs done at the last minute). This was faculty approved and distributed to the residents in July. This particular resident pushed back at the time, so I know he was present when it was presented in July. I touched base with him in August and in Sept. Now he sends a huge chat gpt generated email about how he was not given any written notice of this, he won't be able to change his moonlighting (though that's explicitly written into the rotation requirements that you have to check in before scheduling any) and that he will likely not be able to complete his research in the provided time (a bold assertion in this context). I feel ok setting boundaries and also very supportive of residents in general. I am even ok working with him around the moonlighting IF he can still get substantial work done. My PD is supportive and commiserating offline which has been helpful to me.
I would like some help in how to not let this get to me so much. Like, it feels like rejection and thoughts include he doesn't like me, the residents don't like me, to even he's actively gaslighting me because I have had multiple conversations with him by email and text as well as in person. I want to balance making accommodations and being supportive with not undermining the clear guidelines other residents have been able to follow at this point too.
Biggest thing is working on separating professional requirements/boundaries with the rumination primarily seems to be around wondering how/if I should have been more clear and probably just wanting people to like me lol

C- resident didn't complete the requirements,
F- I’m a failure
T- I should/could have done more
A- rumination
R- distracted time with family, not working on lectures I should be prepping, hours spent re-reading communications instead of more productive things.

C- same
F- obligation
T- It's my job to facilitate research
A/R 1- I could do too much and the R is residents expect me to carry largest load of their projects and I have less time for my family and my own professional work, other option is
A/R 2- I just re-communicate the expectations and allow him to fail or succeed on his own (with support as asked for) R2- he may fail or succeed, residents understand culture of professional accountability and I'm not drawn into additional work I didn't choose for myself (I prefer that one😊)

C- claims he didn't know about them
F- frustration
T- I don't know how to communicate more clearly
A- more rumination! thinking about this when I could be engaged with my kids in bath time, school drop off, and now when I have other lectures to do haha
R- haven't yet but I'm worried this may make me more overbearing in communication in the future, probably helpful- all my communication with him is going to be in writing going forward so things are documented

C- same
F- sad/rejected
T- he doesn’t like me, residents don’t like me, he/they don’t listen or respect me (I know not one thing but all so related)
A- ok, I swear I do more than ruminate but that’s why I’m here now because that’s the main thing I’m doing about this. I could also overcompensate and “try harder” to be liked (sounds lame to write that out but I digress)
R- act insecure by “trying” harder to be liked (likely to backfire)
A2- somehow put this in a better brain compartment so it’s not taking so much time/energy, R2 – accomplish more connection with family and progress on lectures
a3- withdrawal
r3- less engaged with the residents and not do my job as well.

Alright, thanks for your perspective on this! Really appreciate you guys T-> F->
"It's my job"-->obligation
"I could have done more--> failure.
"I don't know how to communicate clearly"--> frustration
"He, and therefore maybe other residents, don't like me"--> rejection
3. Everything on the A lines should be Verbs that are driven by the feeling on the F line. and this section is the JUCIEST
- ruiminate
- disconnect from family
- judge myself
- judge the resident
- look for evidence I'm doing a bad job
- look for evidence they are lying
- verbs verbs verbs.
4. The result is the return or result FOR YOU of all of those actions.

Make sense?

OK

Nice job identifying rejection as a core emotion in your experience of this whole thing. Also so good to see how you make this person's actions/inactions around this assignment mean something about YOU.

It's clear to me that one of the reasons this bothers you so much is because you CARE, right? You care about the residents, you care that you do a good job in your role, you care that you communicate your curriculum clearly, you care that you model what you want from them (professionalism, accountability, what else?). You also care about how you show up outside of work, connecting with family

What comes through to me in your models above, is that when you get in your rumination cycle, it actually takes you AWAY from those things you care about.

A few questions for you to reflect on and bring back here for more.
1. You're a human being who ruminates sometimes. So what? What does that mean about you?

2. Some of these models probably happen in your brain very quickly, maybe before you're even conscious of them. I'm thinking of: T"He doesn't like me"--> F rejection--> A rumination. About how long does it take for you to notice that you're in it? Once you can identify the on-ramp of the thought habit (or similar ones), can you diagram your usual off-ramp? (I presume you stop ruminating eventually, right? what is THAT model?)
3. If you could zoom out to a 30k foot view, how do you define "success" in your role as an APD? Use as few words as possible 😉

Ok bring it on back for more!

Hi there Adrienne and Tyra! First to say that I loved the BT program and am so psyched for BT2, thank you so much for all the time, energy and love you pour into this program every day!!

The main problem I have been struggling with these past few months is balancing work/baby and the complete lack of 'life', which I think I have been handling OK because I love my job, but it has been really hard on my husband and our relationship. I became a mum to a beautiful baby girl 9 months ago. Both my husband and I work full time (our schedules are somewhat flexible), we do not have any family in the US, and she currently goes to daycare parttime. Unfortunately since we both restarted full-time work, we have been going through illness after illness, sleep regressions, clingy baby... I am sure all parents can relate. This has led to minimal time to ourselves and no time for our relationship- Weeknights, we are dead tired and just want to go to bed at 8pm, and weekends are consumed by cleaning and resetting the house, shopping and meal prepping for the week ahead, catch up work etc. I keep telling us that this is only a phase and that we will survive. We do make a good team in splitting the nights and pickup duties etc. But it's been really straining on our relationship, especially for my husband who needs time alone to recharge. I feel frustrated and sad that we are not more thankful and enjoying this new life with our adorable and healthy baby. I am quite an action-driven person so it's been particularly frustrating for me and am at a loss as to what to what I can do to improve our situation so thought I would bring it to coaching!

C- We have a 9 month old baby. We do not have any family or support system near us. Baby has been getting sick and waking up frequently at nights. Both my husband and I have full-time jobs.
T- The pile of laundry, the list of to-do's and the work never ends. We are all exhausted and our relationship is suffering. I don't know what I can do about it.
F- I feel frustrated that I don't see a solution except to push through. I feel a bit sorrowful that we are not enjoying parenthood as I thought we would (and know that we will probably look back one day and regret how negative we feel about everything right now instead of enjoying every detail of her smallness). I am worried about my relationship with my husband deteriorating further.
A- Because of these overwhelming feelings, I've just tried to shut them out and buckle down to get more tasks done. The few heart-to-heart conversations we have had have not been helpful as we are both so tired, down and negative.
R- We continue to provide the best care we can for our baby, but cannot find ways to increase closeness and improve our relationship.

ANSWER:
Hello friend! Thank you so much for your kind words about BT. We are so glad to have you here!

Oh man, you are in the thick of it right now. I can relate viscerally to your thought download, and have felt so much of what you describe here before! But for the purposes of our coaching here, I'm going to "stay out of the pool", and try and throw you a life preserver, OK?

Ok let's work to clean up your model a bit just so we can see one thing at a time.
Some pointers:

--- try and keep the language in your c line as neutral and objective as possible. ---
C- You have a 9 month old. You do not have family in the US. You have a partner. You both work outside the home.

--- T line is ONE sentence---F line is ONE Feeling--- Each T is it's own model with a F/A/R--

T1- The pile of laundry, and to-do list never ends
F2- Exhausted
A- (what do you do when you're exhausted?_ disconnect? scroll? bare minimum connection?
R-?

Another model might be
C- same as above
T2- I don't see a solution except to push through
F2- Frustrated
A- look for the negative, don't extend much grace or patience to your partner or yourself, shut down
R- Focus locks in on the hard stuff and drives you away from connection and closeness

I am not going to try and offer a positive spin on this at all. It won't work to try and convince yourself that "I'm going to miss this!" or " all I have to do is X, Y, X to fix this problem".

What you are doing, raising an infant human being and being in partnership with another adult is hard work. And it is around the clock. We can acknowledge that.

I want to do an experiment where we add the fact that you are human to the C line. We can also add to the C line that human beings feel exhaustion, fatigue, disconnection, overwhelm, frustration, and sorrow sometimes. They also feel fulfillment, love, closeness, joy, satisfaction, intimacy, and a million other feelings.

What would it look like, instead of shutting down those feelings, to acknowledge them?

What might connection or closeness look like during this phase of life?
- with yourself?
- with your partner?
- is it OK that that might look different now than it did before? than it will in 10 years?

What comes up for you here?

Bring it back, friend.

I'm a fairly busy hospitalist and I am actually on site/working for 11-12 hours per day. Sometimes I will get off with 10. It's a demanding patient population in an academic hospitalist group that somehow still has ever increasing RVU targets yearly. When I come home I am exhausted. Like actually "exhausted" in the original meaning of the word, like I have been used up and there is nothing left of me. I try to care less and skate through but I just don't seem to be able to. Some neurotic part of me won't allow it. I do have times/things in the job that I really enjoy, including some patient encounters, the nursing staff, my hospitalist group, and working with/teaching med students and residents! It's not all bad. I just wish I could somehow do this job and also come home and be able to do anything but lie on the couch and watch trash TV? A large chunk of my off weeks is spent recovering from the on weeks.

There isn't a huge "academic" culture in my group despite it being a university program. People will do a case report here or there or maybe a small QI project but there is no requirement to do any academic work and no incentive or protected time to do it. It comes from my off weeks. I want to do this. I finally decided I was going to, and my director and I met to discuss a small single-center paper on transitions of care and readmissions given we just hired a coordinator so have before/after for this. That was months ago. I skimmed some papers on TOC. I haven't written a word. it's just always in the back of my head as yet another hanging chad that I'm supposed to do but I'm either on, or recovering from being on. It is important to me to do academic work - I think we should do this stuff, and also I was asked to be the APD of our residency program and if I don't do this stuff, how am I going to mentor residents in it?? I just don't know how or when to do it. And even at the end of my off weeks when I feel somewhat reconstituted I STILL haven't done anything?? Its just like there's some block there. And then I feel terrible and lazy and like something is hanging over me and now the off weeks aren't nearly as relaxing because now I'm supposed to be doing something. Then its a vicious cycle because I am not relaxed bc there's something hanging over me and then Im just even more irritable.

I tried to model this
C: I was asked to write something on transitions of care. I have a supportive boss who gave me this project.
T: aaa im tired when do I do this I already work so hard but also I want to do this
F: stressed out, not rested, irritable, trouble relaxing
A: I don't do anything? (IDK? is this why I'm not doing it?)
R: Nothing gets better and I keep not doing anything.

Potential alternative model
C: same
T I have an opportunity to do something that will help me mentor residents in the future and also contribute to the literature.
F: maybe i feel more curious/excited about the opportunity?
A: Maybe I do something and occasionally write a few sentences?
R: I do an academic thing and feel better about myself and also once I do it, it won't be hanging over me!

I don't know how to get from point A to point B. After reviewing the manual/intro I tried telling myself "THIS IS AN OPPORTUNITY YAYYY" but it doesn't change the fact that I am TIRED. How do people find time/bandwidth to do these things? How can I set myself up better for success? I've even tried working on my diet to stress eat less junk so that maybe I will physically feel better and have some energy to do other stuff? I feel so stuck. This is such a small thing that's not even leadership material but its been wrecking me for months. (if context helps I have always been garbage at academic type work without a fixed deadline which frankly is why hospitalist work is perfect for me - 1 day deadline, every day, take care of these people to the absolute best of your ability, teach some learners, and then go home, done.) Sorry if I sound like a frustrated lunatic. It should be SO SIMPLE to just do the thing but I just don't seem to be able to??

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Answer:
Hello my friend, thank you for sharing this incredibly collective, relatable thought download around physical and emotional exhaustion. I see you *trying* very, very hard here. Your brain is using all sorts of techniques to TRY TRY TRY to get you to activate. What I want you to do this week, is stop trying. The emotions you are trying to force: curiosity and excitement are activating emotions... and you are already over-activated. Let's drop the rope. Let's really explore this unintentional model and see what it might be trying to say, since your attempt to drown out it's voice with yelling "THIS IS AN OPPORTUNITY YAYYY" is not working.
I'm going to back the model up one step and look at your mindset towards your job as a whole right now:

C: academic hospitalist, when on, you often work 11-12 hours per day.
T: I have been used up and there is nothing left of me.
F: emotional exhaustion
A: Try to care less and skate through work, though the part of yourself that enjoys and values parts of the job prevents this in totality. When you get home, you lie on the couch and watch trash TV. When off service, you narrate your rest time as "recovering from the on weeks" and resent the on weeks. Don't do any academic work despite having a genuine desire/value for this, narrate this task as "another hanging Chad that I'm supposed to do" As a result of this self-flagellation, your off weeks aren't nearly as relaxing. And then beat yourself up for not doing things by calling yourself names (terrible and lazy). Recognize there is a "block"- but refuse to pay any attention to it.
R: Vicious cycle commences (not relaxed b/c you create the sense of work hanging over you and then beat yourself up, --> even more not relaxed).... could we even say, "You use yourself up until there is nothing left"?.

Ok - let's get really curious here. This thought, "I have been used up and there is nothing left of me" is of course fueling your feelings and actions below. But that doesn't mean it's a "bad" or inappropriate thought that needs to change, which is the cycle that you are stuck in now. When we are in a hurry to change a thought, you can miss a lot of good self-learning.
To me, it sounds like this thought is a really valid response to being stretched too thin. Now, unfortunately, the thought doesn't serve you in that is actually spurs MORE stretching, but the thought inherently is just a normal reaction to your sensing that something is off.

-What do you think this thought and feeling want for you? Get specific here (how *much* rest? How often? What does true relaxation really look like in your life? How would you know when it's enough). If we treat this exhaustion as useful data rather than a command, what might it be informing?
---> Notice when your brain wants to turn your "rest time" into "secret labor time"
Right now, your “rest” has conditions:
“I should be doing the paper”
“I should be using this time better”
“I should be relaxing better!"
Your brain is just constantly surveilling you, and you are feeling that. You're always on the hook.

-What happens when you stop narrating weeks off as “recovery”? (i.e. what happens when you allow yourself to start experiencing it as is? As neutral living?)

PS: Exploring your thoughts about this academic project is step two- would love to see you flesh out those and bring them back here! For instance, what rule do you seem to be operating under about how academic work has to be done? Where did you learn that rule? Who benefits from you continuing to believe that? What kind of APD do you want to be modeling (academic perfection, or sustainability)?

I'm in the final stages of negotiating a Medical Director contract. i FEEL this role is a strategic career move to open more doors for me although tbh the actual role isn't the most desirable one (creating an inpatient service line for my specialty from scratch - it will be a lot of work with more risk than my current comfortable situation). I want to keep my career trajectory upwards and do feel a but of stagnation after returning from 6 months maternity leave and thinking that i dont have much to leverage for other negotiations since i haven't produced much rvu wise in the last year. i've created somewhat of a rule that i need to negotiate for an increase in salary each year one way or another - maybe there is a problem with this "rule"

The negotiation was stalled because the administration did not want to lower my clinical target. i dont want to accept this role just with a leadership stipend - i also want a clinical target reduction in rvu for at least the first year while this program ramps up

I've emailed my director expressing concerns and asking again for a target reduction. Received lots of what sounds like excuses in terms of why they can't do it. He says he will try one last time for me.

I am now waiting for the final decision. I've done all I can. or have i?

What I could use coaching on

1. Preparing for Both Outcomes:: mentally and strategically prepare for both a "yes" and a final "no" how to not ruminate over what the outcome could be and just wait until i hear back
2. Handling Rejection: If the answer is still no, like it has been 2 times already - how do I process that and decide my next career move without letting it impact my self-worth or fears that my career is stagnated now with no leg to stand on for negotiation or growth both salary and role wise

ANSWER:
Hello there. Congrats on the new addition to your family, and also for this new professional opportunity!

OK- your brain is braining and you have a lot of ideas about this opportunity. The upsides, the risks, etc. All normal.

Here are the circumstances
- You have applied for medical director position
- You took 6 months of maternity leave.
- Your RVUs are X.
- You have exchanged Y number of emails
- difference of opinion about RVU reduction

Here are just a few of the thoughts swimming in your head that I've pulled out
T1- This is a strategic career decision that will open doors
T2- The ACTUAL role isn't that desireable
T3- IT will be a lot of work with more risk
T4- I don't have much leverage
T5- I want to negotiate my salary every year

We could look at each of these.

Those are the background Ts. Here are some that I suspect are a layer or two below your consciousness
T6- I haven't done all I could
T7- I don't know how to handle rejection
T8- I don't know what I really want.

I want to challenge you to take one of these Ts (Pick a T any T!) and put it into a model to bring back here. Let's see what's going on under there.

After that I have a few questions:
How would you know you'd done enough to advocate for yourself here?
What would the offer have to be for you to say yes, and trust your yes?
What would the offer have to be for you to say no, and trust your no?

Bring it back here for more, let's keep digging!

Something I've been thinking about a lot recently is WHY I choose my big goals. I want to make sure that I like my reasons for choosing them.

For example, one big goal this year has been to run a marathon. However, I worry that my reason for doing this is the sense of pride and satisfaction I will feel after I complete it. Shouldn't I be able to create those feelings for myself without completing the marathon? I mean I do feel proud of myself right now just for putting in the hard work to train for it... but I still am really looking forward to the satisfaction I will feel when I cross that finish line. The other issue with this goal is that it sort of comes in conflict with one of my deep values which is to spend quality time with loved ones. Unfortunately, training hours per week for a marathon often comes at the expense of spending time with my friends and family. Sometimes when I choose to go on a 2 hour run by myself instead of hang out with loved ones, if feels like I am choosing my ego over one of my deeper, more honorable values.

Another HUGE pipe dream that has been floating around in the back of my mind is to enter politics. Like run for the state legislature. I don't think I would do this anytime soon since we don't currently live in the area where we ultimately want to end up, but my brain still brings this wild dream up A LOT. I'd like to think this is driven by my desire to make real change and see how much positive impact I can have on the world. However, I also worry that a big part of why my brain keeps bringing this up is my ego. Like, I can still make a huge impact by quietly getting involved in local advocacy or community organizing. Why do I want the spotlight of being a politician? Maybe because I think I am uniquely equipped to deal with that spotlight and bring people together? Or maybe I just want the prestige and recognition?? The quote that always gets me here is what Plato said whenever he was alive: "Only those who do not seek power are qualified to hold it." So what does it say about me that I want to seek power??

A lot to unpack here I know. Thanks in advance!

Answer =====================

What a perfect thought download to bring on month 1 week 1! Making sure your like your reasons for doing anything is KEY in the outcome. And yes! You are right, that you absolutely CAN create those thoughts that cultivate pride and satisfaction before you run a marathon. In fact, I would argue, that doing this will make running the thing way easier. If you adopt the thoughts of a person that has run a marathon, the completion of it is almost inevitable.

Where you are turning against yourself is not with cultivating good thoughts in training though, what I'm seeing you do here is applying a moral "goodness" code to your own values, and then using it to beat yourself up. Why are the *extra* hit (yes, in addition to the pride you are creating now) of pride and satisfaction that come with completion not good reasons to run? Let's see what this self-created moral code gets you in a model:

C: Goal to complete a marathon
T: I want this for a sense of pride and satisfaction, and I "should" be able to create those feelings for myself without completing the marathon
F: ???
A: should all over yourself, block yourself from accessing the pride you already do feel for even starting the process. Make up a moral code about what desires are good for you right now.
R: You use the code against yourself and your progress

Expanding this theme for your next "huge" goal....

C: goal to enter politics at some point in career
T: I should do this because of a desire to make real change and positive impact, but I've got this ego that wants the spotlight.
F: ??? (guilt? Shame? What is it?).
A: Expand your made up moral code where you are less "good" of a person if you become a public figure than you would be if you stayed "quietly involved." Shush the voice that notes your unique ability to deal with the spotlight and bring people together (because this voice doesn't support your code). Shame yourself for wanting the very common human desires of prestige and recognition. Use a random Plato quote to quiet any flame around politics that exists, rather than fueling it with the 1000s of other ones available around the nobility of politics and public change.
R: make other's opinions of you more important than your own.

Ok. Real talk- you didn't make this code up out of thin air, it was likely curated for you by your culture, family, and our world. But, that doesn't mean it's valid, and certainly doesn't mean it's supporting you. I want you to allow yourself to enter a realm where no set of values has any moral value over another. In this world, wanting influence and recognition is just as morally good as wanting to help. If that were the case, what else could be possible for a person that has ambition towards being a famous politician? What if recognition doesn’t disqualify you, but prepares you?

In both of your examples, wanting pride, satisfaction, impact, recognition, or influence doesn’t have to cancel out your values. It gives you information about what matters to you. The work isn’t to "purify your motives" or eliminate ego; it’s to decide how you want to relate to it.

-If you trusted yourself to hold ambition and integrity at the same time, what choices would you make about how you train, how you connect?
-How would you let these bigger dreams live in your mind for now?
Let your reasons be human.

PS:
I'm glad you brought up the issue of perceived value opposition (quality time with loved ones vs. the hours per week for a marathon). Homework is to do a separate thought download on this - specifically around how you are defining success in the "quality time with loved ones".
-What does that quality time have to entail to "count"? Is there a number of minutes per day? Week? And how long do you have to keep that up to be successful at the end of your kids' childhood?
Often times, we create vague (almost unattainable) bars of success for metrics like "be a good enough parent" that will always leave us feeling short. The way through is to bring that bar down into sight and define what success looks like in your shoes, your life, your family.
How does keeping commitments to yourself serve your relationships, even indirectly?

I am happy in my current job, but its important not to get complacent and our system is undergoing radical change potentially.

How do I prepare for an interview to be a department chair when I a) do not want to manage one of the clinical units that is a core part of that role and is a lightning rod for lawsuits, , b) I don't like to fundraise c) I am perfectly content doing a mix of research and clinical work already, but I realize our system is evolving and who knows what is down the road for my current job responsibilities.

I just started the program so won't put it into CTFAR yet. I see the other few dozen follow this framework so I can consider that later...

ANSWER:
Hello and welcome! We are glad you are here.

Let's take a look at what you wrote above and then we can put it into a CTFAR to see what's going on.

Here are some of the Circumstances
- You have a job
- You have a mix of clinical and research work (you could get more specific here, but we will leave it here for now
- Healthcare systems are ever changing and evolving (not technically neutral language, but I"ll allow it here)

Here are some of the thoughts/evaluations/judgements/perspectives you have about those circumstances
T1- It's important not to get complacent
T2- I don't want to manage the clinical unit that is a core of the Chair position
T3- It's a lightening rod for lawsuits
T4- I don't like to fundraise
T5- I'm content doing a mix of research and clinical work already, but things change

The next step is to take ONE of those thoughts to look at in a CTFAR model. Each of them has their own model running in your brain at the same time, but we just use this tool to look at them 1 at a time.

C- Work, research/clinical components, change will always be a part of our systems.
T1- It's important to not get complacent.
F1- _________________ (what feeling does this bring up in you? can you name the emotion?)
A1- _____________________(what does that feeling/emotion drive you to do or not do?
R1- ______________________(what is the return on these actions for you? does it bring you closer or further away from what's important to you?)

Ok, that's an outline for a model of your first thought there.
See if you can fill out the F, A, R lines and see what comes up.

Does one of those other thoughts (T2-T5) feel louder or more pressing? Which one? Why?
Can you build a model out of that?

This exercise is simply to see how your thoughts about your work are leading you towards or away from what is important to you. These aren't inherently good/bad, or right/wrong, just shining a light on things that might be happening below your consciousness.

Bring it back here and we will see what we learn!

First thank you for this program- it has been a lifesaver in my work, my patient care, my self worth and my relationships.

Circumstance: I am 37 yo. I have a 2.5 yo (conceived naturally). I didn't try to start having kids until after I finished fellowship. We have been trying to have a 2nd kid, but have been unsuccessful. Saw REI and long story short, things do not look promising/possible to be able to have a kid through IVF (without a donor egg).

Thought: I should have frozen my eggs when I was younger. I was too rigid about finishing training and I should have not delayed having kids (waited until after chief year, fellowship)

Feelings: Adrift with total loss of control of the situation; guilt at having made the "wrong" choices; sadness (the sadness feels okay to me, like feels appropriate)

Actions: Ruminating- not present with my beautiful child when I hang with her, not present with my husband, not fully present during sessions I teach or with my patients

Result: Not fully immersing myself in the relationships and work that are most important to me...without actually changing my circumstance (which I have no control over)

I feel stuck in the guilt and paralyzed by the loss of control, while realizing they aren't helping me. I don't know how to move forward or ladder away from these.

ANSWER:
Hello, friend. Thank you so much for your kind words. We are so glad to have you here with us.

As a person who has been through infertility treatment, I can fully empathize with what you're going through. I'm going to stay in my "coach hat", here but please know that I know the weight of this kind of news. I feel you, friend.

OK. Let's take a look at your model. Nice job! Just a few things to help apply this tool (the model) a little more neutrally.

C- On this line, try to use language that is as neutral as possible. Sometimes we might even say
"fertility doctor said words" if "things do not look promising/possible", doesn't reach a neutral for you. " I'm 37, and have a 2.5 year old conceived naturally", are neutral. "Donor egg" is an option might also be added here if it feels neutral for you.

T- On this line, try to look at just ONE sentence at a time. One I pull out is
"I was too rigid about finishing training and should not have delayed having kids".

F- Adrift is a really great word. Is that the feeling here? Or does that sentence bring up another feeling emotion? Is it guilt? No right or wrong answer here, just choose ONE.

A- Great awareness of your action line. I wonder if other things that go here are avoiding making a decision, arguing with yourself about what to do next, what else?

R- This is always proof of the initial T and the summ of the As. In this case, you're right, you double down on your guilt by withdrawing from relationships and work that you DO want to nurture, and you are being rigid in resisting the reality of what is.

OK. This model you've made is a tool. It is agnostic. This model is not good or bad. Your thoughts in and of themselves are not good or bad. right or wrong. We are using this tool to bring awareness to what comes from judging and blaming a past version of yourself who made choices.

In this case, judging your past self, leads to more pain.

I know you want to move from this model to something that feels better. You can, and we will. But stay in this one with me for a minute.

On today's BT2 welcome call, I shared a quote from the late poet Andrea Gibson. They wrote:
" Everything you are feeling, name it love".

When you read through that model above, what is it trying to teach you, or ask you, about love? Where is love hiding in this model? Where is it missing?

A few things to ask yourself if that last one feels a little out there. 😉
- what are the reasons (if any) for holding on to guilt here?
- What are the reasons (if any) for releasing it?

Please bring anything that comes up here back for more coaching friend.

<3

I ended the year and the BT course on much improved footing! I felt great 3 months into my new position, accepting and working with FFTs, healing my mind, body, and thoughts from prior burnout, and feeling like I was setting myself up for success!

CONTEXT:
Yesterday was my first day back after a 10 day holiday reset, pumped to start the new year afresh.
Then clinic happened. My clinical role includes several multi- or interdisciplinary teams in a subspecialty pediatric setting. This was my first time in one of the interdisciplinary teams clinics. I've been looking forward to it. But the clinic triage and flow is new to the whole team in recent months and there are a lot of kinks. It's made it confusing to existing team members and families. It's very confusing to me, but I'm taking a FFT mindset. I should have prepped the patients in advance since they can be pretty complicated, but I was on vacation and trying to actually take vacation for once. I got in to work 2 hours early to prep. Then, last minute an intern was added to shadow me all day. That's three hits -- not prepared, learner, chaotic clinic.

Circumstance: I'm a behavioral subspecialist mostly dealing with fairly subjective behavioral profiles for diagnosis, but sometimes clear medical entities also come to light and must be deal with.
1st patient: I'm clear on diagnostic impression, but my teammate comes away with completely different diagnosis that I had felt I confidently ruled out. The patient walks away with my Dx because I'm the MD.
2nd patient: Same deal.
3rd patient: Considering medical differential diagnosis as a contributor and now my intern second guesses me.
4th patient: Teammate had a different impression; I'm certain in mine, but I go ahead and tell the patient the other diagnosis because now I'm doubting myself. Intern asks more good questions and I can't really justify myself at this point.
Throughout the day, the intern is asking (reasonable) questions about the point of the subspecialty, reason for the interdisciplinary structure and multi-day format, etc etc. All things I find myself questioning during times of burnout when I think of leaving the field altogether. Despite the fact that I sought this new position BECAUSE I was working 100% solo in my prior position and value the traditional interdisciplinary format, especially for complex patients as these are.

F: self-doubt

T: What the hell am I doing in this specialty? Commence impostersism and then burn-out automatic negative thought cascade that I thought I had overcome.

A: come back home without charts done and feel like a miserable failure. Cry about life, the universe, and everything at my husband. Go to bed late for my new earlier exercise routine for the new year. So now it's a mental and a physical cascade.

R: continue feeling worthless and spiraling the next morning; procrastinating the work and not making forward progress while giving in to very toxic thoughts.

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reframe:

C: same as above
F: self-doubt (and un-prepared)
T: I know what I am doing, and I do this well, but when I am unprepared and get overwhelmed, I doubt myself and spiral and this does not benefit myself, the patient/family, or the learner. this is a reinforcing moment that my specialty is cerebral and requires adequate preparation (chart review CANNOT be done same day to be done well, despite charting efficiency training) and a pause outside the room to reconsider all the evidence before completing the diagnostic conclusion. Many other centers for our specialty provide the feedback on a separate day rather than the moment of history and physical precisely because it can take time to formulate the accurate and precise diagnosis/diagnoses. The differential diagnosis is complex, especially when the straightforward diagnosis (usually the referral Q) is clearly not the answer.
A: Resolve to plan for and schedule time to adequately review the charts during the administrative time provided, so that I don't have to do it during PTO or weekends for Monday clinics.
Resolve and plan to STEP OUT of the room to collect my thoughts, material, and AVS to aid discussion with the family. It's also a good moment for interns or other learner's to ask pertinent questions before diagnostic conclusion and help give some of the desired autonomy.
R: Immediately feel better completing this thought exercise. This plan will help me be more prepared, give myself the necessary cerebral time, and convey competence to families, trainees, and myself.

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ANSWER:
I mean, just wow - this is such high level self coaching. Your intentional model is beautiful, and what strikes me is that I think none of this would have been possible if you hadn't had to endure the "three hits" day in the exact way it went down. Sometimes, the pain itself is the best teacher, and this is such a great example. I wish it didn't have to involve emotional and physical discomfort to get there, but it does, every time. Knowing this, do you think there is a way you can prepare for the next "painful" day? You did great work here to prevent this perfect storm again (with the time to pre-chart, etc), but there will certainly be more that you can't predict.

So the next step is to explore how you want to react to your pain and your toxic thoughts which will surely precipitate again. Is there opportunity to sit WITH the pain, self doubt, second guessing etc without wishing it wasn't there? Can you become familiar with the physical signs and symptoms of these feelings and instead of trying to solve them away, remember that they are often your best teachers (as you beautifully showed above)?

Zooming out, I see this more meta-model in your first reaction:
C: first day back after a 10 day break. Clinical role includes several multi- or interdisciplinary teams in a subspecialty pediatric setting, and
1) this was first time in one of the interdisciplinary teams clinics
2) The clinic triage and flow is new to the whole team with some kinks in recent months- existing team members are confused.
3) intern was added to shadow all day and asks a lot of questions about your subspecialty

T: Those are “hits” to me.

F: Doubt

A: interpret intern or other teammates differing opinion as undermining yours, then ultimately start to doubt yourself. When you can’t answer an intern’s question, you lose your prior grounded footing and start to question everything, including your own subspecialty. Slippery slope. Commence imposterism and then burn-out automatic negative thought cascade that you thought you had overcome. Make this mean you are a failure, and cascade into venting about the rest of life, the universe, and everything at husband. Go to bed late, miss your exercise routine.

R: Slide towards burnout by taking “toxic” thoughts seriously.

I want to first offer that your nervous system did exactly what human nervous systems do under cognitive + evaluative threat: it looked for meaning and found an old, well-worn story. It's normal to want to prevent pain from this space, but instead of *just* doing this, I want you to add another layer of exploring how you relate to pain as well.

So thinking about how to approach the emotional pain inherent to being human - is there a different way to think about it other than a "hit" to be dealt with? What if it was the beginning of what you knew to be a beautiful opening into your mind, soul and self? Can you think of an intentional thought to support this?

Thank you so much for your response. I had so been planning to join the live coaching call last Friday but I got stuck in the operating room and wasn't able to make it; am just getting around to responding.

I ABSOLUTELY LOVE that the C you suggested was "you and your husband are humans and sometimes humans engage in emotional childhood. Sometimes there are patterns where this happens in your marriage." You're right, that's so true. My thought about that is "yeah, duh" I can also see all the ways that I reach for finding disconnection to 'prove my point' instead of seeking out ways where I might *actually* be able to connect with him while meeting his needs. #brains;ugh

I think this might actually be boundary work in a sense. My mind will be much more at ease if I know that after I give him 90 minutes during the workday that I will be given that 90 minutes "back" in the evening to get what I need to get done done. I think my anxiety spirals when I spend time/devote time to him and still have to get all the things done but now in less amount of time. Perhaps this isn't true 'boundary' work but I'm thinking of it along the lines of "If you need a 45 minute mid-day phone call with me four days a week then I need to work on my computer after the kids go to sleep one night a week." I don't want to get into this being "tit for tat" with him; but I also really do need to get my work done and if he feels like he needs my time during the day then perhaps I need to better articulate what I need to make that work.

I think that if I had a plan/boundary for figuring out the logistics, my mind wouldn't race into anxiety/irritation and perhaps I would be better able to focus on having a positive experience spending time with him because I am reassured that my need (to get my work done) will be accommodated without judgement.*

*In general I try not to work at home unless I'm abnormal overwhelmed or have a grant deadline etc. This is, in part, because I know that it's really important to him that I don't "work all the time." so I have a high bar for keeping work at work. OK, let me try a new intention model:

C- My husband has expressed that he “needs more of me.” I value him and want to strengthen our marriage.
T: Of course, Happy to meet your needs. In order to meet your needs I will also need some time to accomplish my other tasks so I can focus on being present with you.
F: Empowered; in control
A: I vocalize that I will need to spend X additional amount of time outside working hours to accomplish Y amount of things that I will be unable to attend to while I am offering him my focused attention; I make plans for meeting my own needs from a neutral/factual space instead of an angry/irritated/judgemental space
R: My mind is free from worrying about getting the things done because I know that I have time set aside later, and also because of that I am more able to foster connection with my husband when it works best for him; fostering connection with him is what I also want/need so then I set myself up to have my needs met by acknowledging/respecting my own needs?

What do you think?

ANSWER:
I LOVE this reflection.
So helpful to see how when you're committed to proving your point, you look for more evidence to disconnect. The opposite of what you want, of course!

A few things you might want to continue to pick through.

How do you feel when you read through this model?

Say more about "in control". in your map of feelings, does this land nearer or further from "connection" you are looking for

I LOVE the A line of meeting your own needs. So good.

What happens if you give 90 mins and you don't get 90 mins back? what would that mean?

Keep working here!

Hello! First I want to say I have enjoyed this program so much and am grateful for all of the good work happening here. I am asking for coaching around feeling wistful for practicing medicine during pre-Covid times. I have been an attending for 15 years and have really loved my job (and still do love it), but find myself comparing my job to 5-10 years ago and missing "the old days." Covid seemed to accelerate long wait times for patients and understaffing. Compared to even 5 years ago, I find that patients are distrusting of medicine and turning to social media. Battling misinformation on these platforms and distrust of my profession, one patient at a time, is starting to feel exhausting.

C - I have been an attending for 15 years. My daily work feels harder since Covid due to long wait times and distrust of the medical establishment. Patients call and are increasingly upset about their medical care.
T - the system is broken, I miss how I practiced medicine 10 years ago
F - disappointment and frustration with current state of medicine, wistful for pre-Covid times
A - alternate between apologizing for systems issues like understaffing and getting defensive when patients are upset with their medical care
R - emotional exhaustion, not fully focusing on what I can do for the patient right now

Trying some other thoughts:
T - I'm doing the best that I can in a system that is broken
F - some self-compassion (but some days it doesn't feel like it's enough!)
A - take care of the patient in front of me
R - provide good care, but still sometimes ruminate about how things used to be

T - This patient is seeking out my advice in clinic today, not social media
F - eager for the opportunity
A - partner with the patient to come up with an acceptable treatment plan
R - evidence-based care

I think something I'm struggling with is having patients be angry or distrustful of me right from the start of a visit. My rational brain knows not to take it personally, a lot of it has to do with circumstances unrelated to me, but I'm realizing this is a skill I haven't needed to develop until recently. I know I'm resisting reality when I get wistful for medicine in pre-Covid times, but I haven't landed on a thought that makes me eager to care for patients who are angry or distrustful of me. Thanks for helping me think through this!

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ANSWER
Hello, friend! Thank you for posting this incredibly relevant thought download. That “F” of WISTFUL is so interesting, and so relatable. I think it often signals that we’re resisting reality in the exact ways you insightfully named. And just to normalize: humans have always resisted reality, and we will continue to do so. It’s not inherently bad. In fact, it’s part of how we evolved: wanting things to be different is what pushes our species to improve our world. Feeling wistful or frustrated is not a flaw; it’s actually a beautiful part of you. I really love your intentional models. You did such thoughtful work here. But you brought this to us for a reason, so I’m guessing these thoughts still don’t feel quite right for some reason. Let’s try a small shift that often unlocks things: move your intentional T to the C line. Here’s an example using your first intentional model:

C - I have been an attending for 15 years. The system is broken. I miss how I practiced medicine 10 years ago (when I perceived shorter wait times, less distrust, and fewer angry patients).

T: NOW WHAT???

What do you want to think about the fact that you work in a broken system? Right now your brain is holding tightly to a story that "then was good, now is bad." And of course it is; brains love a clean narrative. But part of this work is gently challenging those stories while not gaslighting yourself, (i.e. not pretending the system is great, but stretching your thinking just enough to give yourself some breathing room).

For instance, you’ve attributed the shift in patient behavior to Covid. But what if the explanation is more complex, or even more interesting. Could some of what you’re noticing come not from patients directly but from your own professional maturity and how attuned you are now? Could patients be more aware of the realities of corporate medicine and starting to push back in ways that might eventually benefit all of us?
Could you be in a phase of painful-but-powerful professional growth that precedes becoming an even more grounded version of yourself?

Here are a few more questions to play with:

-Are you sure working in a broken system is inherently bad? What might be good, funny, compelling, energizing, or meaningful about it?

-Is there any system that isn’t broken, or are there just moments where we haven’t yet noticed what’s cracked?

-What kind of physician do you become when the environment gets challenging?

-What parts of your identity, strength, or leadership would never have developed without this challenging era of medicine?

You also mentioned wanting a thought that makes you feel eager to care for patients who come in angry or distrustful. That is such an honest and important desire. You’re right: your rational brain knows it’s not personal. But the emotional skill of holding steady in the face of distrust is a new and uncomfortable one for many of us, and it’s okay that you’re still learning it. Your wistfulness makes sense. Your frustration makes sense. Your brain is mourning a version of medicine that felt safe and familiar. And at the same time, there is room for a thought that connects you back to your purpose, and your agency.

You’re doing the work beautifully. Keep going, we are here with you!

Backstory: Husband and I have been doing off and on couples counseling since April and I'm figuring a few things out. Husband works from home and does a lot of the home things like cooking, cleaning, laundry etc. He has and continues to express that he needs more of me. The asks are a bit vague and seem to shift; oftentimes they are conflicting. At times, he expresses that he needs me to be present and help more with the kids, but then when I help it's not the way he wants it done, or he'll convey that really what he wants is for me to be there and not actually help etc. Sometimes he needs/wants my undivided attention and other times if I work at home to be around it seems to make things worse because I'm not present to fulfill his needs immediately if he has them (for example he'll ask me to fold the laundry or talk about something I think is non-urgent just because I'm there). Sometimes me just being "around" (i.e. working from home) fills his cup. I have tried asking him to try to clarify/think about/figure out what it is that he actually needs and that is hard for him to do.

Recent Progress: With this as a backdrop, I've now layered in the info that this time/presence, even if not well defined, is what he says he needs to feel centered/grounded/anchored/supported/less anxious/less mind-spiraling/calmed. Me. He needs me; more of me. I've simultaneously realized that nearly all of my re-centering activities are solo. I listen to certain mantra playlists/songs in the car; when I'm over stimulated or stressed I focus inward, I regulate my breathing to calm down, sometimes I step away to take a shower.

The Conflict/Problem/Conundrum: He says that he needs me to feel calmed; I feel increased stress around him because his emotions are more volatile/unpredictable, I can't seem to get things right most time, I don't often find it "enjoyable" or relaxing to be around him. What calms him stresses me. To compound it, my to do list increases when I'm spending time with him and not doing the things on my list of things that need to get done. This stresses me out even further.

Attempt at a Model(s):
C: Husband has expressed that he “needs more of me.” I often feel more drained after spending time with him because of 1) his unpredictability and 2) because I am not accomplishing other tasks/taking care of other responsibilities during this time
T: Meeting his needs is contributing to/adding to my list of things to do
F: More stressed, more irritated
A: I do more additional deep breathing and mantra listening to calm my own self down
R: Feel more disconnected from him by meeting his needs

C: Husband has expressed that he “needs more of me” and I have made changes to meet these needs which have been successful from his perspective but I’m feeling irritated
T: Why can’t he take care of his own needs without me?; why can’t he work towards emotional adulthood?; ugggghhhhhhh
F: Resentment
A: In this model I lose curiosity, breed additional disconnection, shove my own needs and emotions further down, question how to solve this issue
R: Feel more disconnected from him by meeting his needs

I’ve done this before when I’ve been coached about my marriage, and now after writing this out I can see that I’ve done it again-- I’ve slipped into emotional childhood here myself-- I’m blaming my irritation on him. Yikes/uggggh/sigh. This is still so hard.

OK ok, so is this what’s happening?...

C: I spend time with him at a time of day that is convenient for him and inconvenient for me (during work hours during the work week) because he has expressed that this is what he requires to feel connected to me. I meet his needs then I feel irritated.
T: If you hadn’t asked me to do this I would be able to be doing what I want and if I was doing what I wanted then I wouldn’t be feeling this way therefore you are making me feel this way.
T: You/your ask is making me feel this way.

Ugggghhhhh.

I’m blaming him for being in emotional childhood and I’m doing the same thing. Help!

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ANSWER:
Thanks so much for bringing this here. Great reflections. I can tell how hard you are working on this. Nice job picking up on how emotional childhood is showing up here.

A few questions for you <3

you said "I can't seem to get things right". What would it look like to "get things right:?

I'm picking up on a tension here... tell me if this feels right... an underlying idea of "meeting his needs disconnects me from him, and meeting MY needs disconnects me from him".
In what ways is that not true?
Where do you find yourself in connection with him?

What might this model look like:
C: you and your husband are humans and sometimes humans engage in emotional childhood. Sometimes there are patterns where this happens in your marriage.
T: (so what? now what?)
F:
A:
R:

Keep working here!

Like many of us, my body has been changing as I get older - my metabolism is slower, my old pants are snugger, my grey hairs more prominent. Sometimes I am able to embrace this as part of the natural aging process, and other times I look in the mirror and feel like I am getting old, ugly and fat. This negative self talk has recently been compounded by the fact that I have been trying, and failing, to get pregnant. Yesterday, I had realized I should probably go up a scrub size, which is what my pregnant colleague just told me she is having to do. This set off a series of negative thoughts and feelings.

C: I need a new scrub size. I am not pregnant and would like to be. I looked in the mirror.
T: I'm getting old, fat and ugly and I'm not even pregnant or a mom.
F: something like self-disgust? also with a hefty sprinkle of shame and inadequacy
A: avoid mirrors, put myself down, compare to others, compare to my younger self, think about eating less dessert but not actually do it, tell my husband how I'm feeling but dismiss him when he says I'm beautiful
R: continue to feel bad about myself, disconnect from my husband

ANSWER:
Hi Friend. Oh man, I appreciate you for bringing this here. Thank you, I know it's tender.

Your model is spot on. When you inner critic spews this hate at you, it ends up taking you AWAY from loving your husband and yourself.

Let's get a little meta here and see what we can learn. You in?
When your inner critic is uncomfortable, they get judgy and mean. What is it you think that part of you is afraid or unwilling to feel?

You are currently dealing with a reality that has not gone how you hoped it would. You wish things were different right now.

What do you think you really need right now?

What would you offer to someone you loved, if they were facing this same pain?

<3