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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

ANSWER:
Hello! So glad you brought this here.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

OK. I'm gonna try it.

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

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

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

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

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

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

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

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

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

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

Please bring this back, this is such valuable work!

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

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

Answer:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Coaching opens on 9/2! Bring it on, friends!

i am a radiologist and registered for this program.
how and where do i sign up to schedule 4 one on one scheduled personal coaching session?

ANSWER:
Hi there! Glad you're here!
You can sign up by copying this link into your browser: https://faculty.bettertogetherphysiciancoaching.com/1-1-coaching/

Or, when you're logged into this website, go to the top right corner dashboard and hover over the word "COACHING" and select "1:1 COACHING" from the drop down list.

From that page, if you click "Schedule a 1:1 Session", this will take you to a scheduling page that shows all of our coaches availability and you can select the time that works best for you! You'll be scheduled with whatever coach has availability at the time of your choosing.

If you are more flexible in your schedule and want to choose a specific coach, scroll down and click on the coach who you're hoping to schedule with and that will take you to their individual booking page. Their availability will not be as flexible as the option above.

Let us know if you have any trouble!

I have gained 30 lbs in past year.
my thought is that I am failing at being healthy.
My feeling is that I am tired, I have migratory pain, I am perimenopausal and I am allergic to estrogen patch.
My actions: I eat brussel sprouts, salmon, broccolli and get gasey lol without losing anything.
I work out and I am strong but my weight and size does not budge.
result: I am exhausted and want to give up.

my husband is overweight and likes to eat sugar. I try to encourage him to choose wisely for all of the health and family reasons. I think he has some underlying depression issues and avoids that topic. help 🙂

ANSWER:

I'm going to put some of your F line up in the C, since it's factual:

C: Age 50, gained 30 lbs in the last year, newly married, have migratory pain, perimenopausal and am allergic to estrogen patch.
T: I'm failing at being healthy
F: Exhausted
A: "Try" to lose weight (by eating "healthy" foods that make me gasey, working out)
R: No weight loss, and you don't see yourself as healthy.

Ok- this thought probably feels very true, but it's NOT, and also it's not helping you achieve your goal of health (or weight loss if that is a current goal). Also, listen, even if it WERE true (like if there were some blood test for the "health" that you were in control of and yours was massively deficient) - you thinking about it is not getting you closer to your goal, so I suggest not thinking it in either case!
The first place to start here is questioning the thought, trying to make your brain come around to the idea of a different one:

-Is it true that you are not healthy?
-Are there areas where you ARE healthy? If so, what are they?
-Is "being healthy" something that is totally under your control?
-Are there examples of people you know who are not healthy, but also it is not their fault (i.e. not a failure?)?
-In what areas with your body and health are you a success?

I have alot of irritation and anxiety about providers not including a clinical indication in the orders they are placing for imaging. Traditionally radiologists are taught that if an appropriate indication is not listed by ordering provider - we could not get paid - usually by insurance. I have been in practice 20 years and the listing of appropriate indications provided to me continues to decline. I feel I need a good history to give a better interpretation and give appropriate next step suggestions.

My thought is that not taking time to explain why you are ordering a study-defining a purpose for the order - then I feel disrespected, as a human, as a doctor and a clinician. We (rads) read 80-150 studies a day and we do not open there charts as part of a work flow.

My actions vary depending on what I see on the study. Sometimes I reach out to the provider via epic which takes alot of extra time. I do teach our NP students 3 hours during their school about how to order and why. I do smile when I see a order from them in the ER and it is sooooo helpful.
I have emailed CICU practioners that state the "post op" indication is in their order set and not filling it out as in what surgery, any lost items, something not going well, lines and tubes - this has lead to a few bad misses by me and other rads because they know something we dont.

I want to feel not angry and not like a "lesser" doctor as a radiologist. We dont refer patients to ortho and cicu and just say "guess"

Result - no change.

ANSWER:
I'm so glad you brought this here, especially since you also have insight into how you WANT to feel/think and act, and how this is different from your current state. After I clarify your current model, let's work on a "reverse model" (starting with the R line you want) and work our way up:

CURRENT (unintentional) model:

C: I am a radiologist. Some of the time (XX% of the time? XX times per day?) I get an imaging request without any clinical indication or context. Having a patient's history helps to give a better interpretation and suggestions (I'm going to put this in the C line, since I bet there is good evidence to support this as fact!)
T: These ordering clinicians are not taking time to explain why they are ordering a study!
F: disrespected
A: Defend yourself (think about how you read 80-150 studies a day and don't have time to open each chart)
Sometimes send EPIC messages or emails to providers on why this is wrong, sometimes do nothing, worry about bad misses, fume, blame the "others" ("We don't refer patients to ortho and cicu and just say "guess"")
R: You double down on the story you have created that links the clinical indication to respect for you as a human.

Ok. You identified here (insightfully!) that you don't want to be feeling angry (which I'm guessing is your larger umbrella for the "disrespected" feeling) and you also don't want to be thinking that you are "lesser" than the other doctors.

I'm guessing that it doesn't feel like an option to you to stop thinking this, and there is probably some part of your brain that is committed to the story you are holding onto as fact, it feels certain that these other clinicians disrespect you.

However, I want to give you permission to gently pull this story apart with some questions. You'll need to get into a curious space (rather than an angry space) when you do this work, so if you are still feeling anger in your body, I suggest going back to Month 1, week 2 to process that, maybe many times first! Then:

-Think about the ordering providers: are you positive that the (in)action of not writing an indication on the request comes from a feeling of disrespect for you? Could there be any other feelings that lead to this action? What are they? Get really creative here, imagine all of the possibilities
-Let's pretend that we are able to know for certain that the ordering providers are "good" people who respect radiologists and whave good intentions toward both you and pt care (just pretend for a moment!) - what else would then have to be true for them to not place an indication in the order?
-How do you want to feel when this happens again?

Let's try a Result model (fill it in and bring it back!)

R: Change your story (so that you don't feel disrespected)

A:??? (what would you do if you didn't feel disrespected here? What would you not do?)

F: ??? (what would you need to feel to do these things?)

T: ??? (what is a thought that you can believe now that cultivates this feeling?)

C: Some of the time ordering providers do not place an indication for a radiology study request

I want to spend some time reflecting on my relationship with "sick days". As a surgical resident, I was taught that sick days were simply not used unless you were close to dying (or some other equally absurd hyperbole). We showed up no matter what. I can recall my chief getting fluids during rounds and even once my chief was admitted to the hospital as a patient and we conducted our pre rounds in his hospital room! I don't resent them for imparting that belief on me. I was proud to be in that club! I was a badge wearing member of the "show up no matter what" team. I can even remember a day when I had a fever so high that I was having hallucinations while scrubbed in (my attending actually did end of sending me home and I used to boast that it was the only day I left early). I still believe there is honor in being able to preserve even if you don't feel great; but, like many of us, that belief was turned on its head during COVID, when instead of being something to be proud of, it was almost shameful to expose your fellow colleagues to your illness. For me, that sudden and unexpected change was really hard for me to deeply grasp, like at a fundamental level, I couldn't process this new world, This was also the time when Wellness became very important. I drank that Kool-Aid; I was on our hospital's Wellness Committee and I still do believe that Wellness is highly important to Physicians and trainees. But I also I still identify as someone who can push through; that grit is a skill that must be practiced. To add another layer to this --in addition to the massive change in group thinking we had during COVID, I am also dealing with the fact that I have two kids (aka germ factories) and I seem to be sick every few month; and not just a little sick, but really knock me on my butt sick (norovirus twice this year! The flu, COVID and most recently bronchitis). I am not coping well. I have taken sick days, truly out of necessity and for the safety of my patients, but I am not happy about it! I know I am worthy of sick days, I know its important for my well being and I know that my staff/patients don't want to be around me when I am sick...BUT I truly hate taking sick days. That's my thought download. I'll try a model.

C: I have been sick several this year
T: Taking a sick day is a sign of weakness
F: disappointed/embarrassed
A: I take the sick day but I wallow in self pity that I needed to take it and think about the other sick days I had to take this year, I imagine what other people might be saying about me (she is always sick, she isn't a strong part of the team, she allows herself to take sick days) I over explain myself when I get back to work
R: I continue to have an unhealthy relationship with sick days

Thanks 🙂

ANSWER
Hi there, I'm so happy you brought this here! Let's first start with the fact that you mention that you are proud of your thought ("sick day = sign of weakness") and also disappointed and embarrassed. These are actually three different models - let's explore what each one gets you

C: Sick days
T: sick day is a sign of weakness
F: proud
A:????
R: ???

C: Sick days
T: sick day is a sign of weakness
F: disappointed
A:????
R: ???

C: Sick days
T: sick day is a sign of weakness
F: embarrassed
A:????
R: ???

I'm struck by two themes in your download
1) You have drank a lot of kool-aid (i.e. adopted group-think as your own belief system)
2) You seem to have an underlying belief that "wellness" = "not pushing through" and/or that "wellness" does not include "grit". ("I still do believe that Wellness is highly important to Physicians and trainees. But I also I still identify as someone who can push through; that grit is a skill that must be practiced.")

I invite you to explore both of these. #1 will require some imagination... I want you to pretend there are NO preconceived notions around sick days. For instance, pretend you are going to Mars, to set up a medical practice with some Martian doctors who have never set anything like this up before. You get to decide what the culture is and explain it to them - they have no idea yet. Let's say other than the culture, the rest of the environment and logistics is the same (you have kids, viruses are contagious and dangerous for patients, there are a limited number of doctors to take care of pts etc. etc). In this imaginary Martian-hospital, how do you want your Martian colleagues to think about sick days? Try not to judge yourself here - just free write on how you might set up the *ideal* sick day culture if you got to decide.
The point is to drain the Kool-Aid out of you and see what you actually think.... i.e. make your own Kool-Aid (or maybe lemonade? Kombucha?? 😉 ).

Ok - now that you know what you actually think about how sick days "should" be thought of:

-How does "grit" show up within "wellness" or "being well"?
-Is it ok to "push through" and also "be well"? How does that look, specifically? How often, what are the boundaries, etc.
-How do you want to show up for yourself, your patients and your family when you feel sick?

I saw a patient last week who was due for an infusion this week; I noticed his renal dysfunction and I know we routinely dose reduce this medicine when given for another indication for patients with renal dysfunction. I asked my pharmacist if we do the same for this infusion and she said yes so I modified the plan to have a reduced dose. This morning I I got added on to a secure chat where the infusion pharmacist told my pharmacist that this medicine doesn't get dose reduced for this indication and asked my pharmacist to 'educate' me and mentioned they had submitted this to the patient safety reporting system. My pharmacist said she hadn't realized when I had asked her that I had been talking about the medicine for this specific indication. I found myself immediately getting defensive- like why is my pharmacist throwing me under the bus, I told her what the indication was, and also why is someone being told to 'educate' me, why is this being reported, etc etc. And then also feeling this embarrassment of I made a mistake and now its going to be reviewed by the patient safety system etc. Result of this was I was a little bit snarky in my chat reply back, which didn't make me feel great. The rationale side of me acknowledges that this was a mistake and mistakes happen, I don't often order this medicine for this indication so I learned something, there was no harm (and actually I had considered his renal dysfunction and thought I was behaving safely- which I would rather err on that side than overdosing a med), but I still keep perseverating for an unnecessarily and unhelpfully long time on this. Do I have to just sit with the embarrassment and let it go away on its own? Would it be helpful to try to change my thoughts on this?

ANSWER:
Wow- I just want to commend you here big time on NOTICING YOUR "F" line of this model! So often, we never bring any awareness to our "patterns" and stay lost and victimized in what we think the circumstance is. Let's look at your model (the irrational one, since I know the rational one is there, but it's not the louder one right now I bet!)

C: You renally dose a med based on one pharmacist's recommendation, later to learn you didn't have to and a second pharmacist secure chats: "this medicine doesn't get dose reduced for this indication, pharmacist #1 should 'educate' you and I have submitted a patient safety report."

T: I made a mistake and now its going to be reviewed by the patient safety system, (and this pharmacist is mean/wrong/awful? ).

F: embarrassed

A: defend, defend, blame, stew. Argue in your heard about fault, who's getting thrown under the bus, etc. Snarky in reply

R: Don't show up how you want to as a physician, and waste a lot of energy trying to pin blame away from yourself.

Ok- I want to look at the second half of that T because I'm guessing it's the second part that drives the actions you aren't proud of. I want you to ask some questions around your beliefs of this second pharmacist:
-What do you want this pharmacist to think of you? Why? How would you feel if you could believe what you wanted about them and their judgments?
-Are you certain that you made a mistake? (It sounds like you are "defending" yourself against this thought, probably with things like "I was just doing what I was told!" or "It's not my job to know how to renally dose every med" or whatever, and if you are doing this, then why are you also continuing to believe you made a mistake?
-If you do believe it was a mistake, what are you making that mean about you?

Finally, this is a crazy idea in our field: but what if there is NO ONE TO BLAME HERE? This is a hard pill to swallow, because even in the most collaborative M&M conferences or patient safety root cause analyses, blame is almost always front and center of everyone's mind. And more importantly, avoiding blame, since it feels so awful to be "at fault."

But what if that whole premise is wrong? What if it's just true that even the very best of human brains are liable to make an error some percent of the time (just like cars or computers or calculators or whatever), and sometimes this happens and can not be prevented?
I know. Crazy because all we live/breathe/think about is preventing mistakes, and I'm not saying we should stop, I do think this is beneficial, but, I know that it's ALSO true that we can not actually prevent all of the mistakes because humans are imperfect.

So why hold anyone up to perfection?

I am a gastroenterologist. 9 months ago I accepted a new position and moved with my family across the country. Past two months it has become known that the institution has severe financial difficulties. As a result, we were given new RVU requirements, and administration just took away the 4 hr of administrative time given to me as the center director. The administration is also expecting me to be at RVU target which I haven't been able to as a new faculty who is still building the practice. Beginning of this week I was told that I would have to do additional clinic and endoscopy to hit that target when I will be doing a total of 8 sessions. I want to go to HR to complain about the violation of my contractual violation but a colleague (not a physician) warned about possible retaliation from the administration which would make it difficult to work. I don't want to move as my kid just started school, he was very upset about the move, and struggling with fitting into the new environment.

ANSWER:
Thanks for sharing this here <3. I can only imagine how this feels for you.
Your download has a LOT of circumstances (which is so great!) - but I am curious what your exact thought is about them? I imagine you might have slightly different thoughts about each circumstance, but what if I summarize your situation like this:

C: I am a gastroenterologist. I moved with my family across the country 9 months ago under the assumption that my job would have __hours of admin time and __ RVU targets. In the last two months I was given new RVU requirements of __, 1 extra clinic session, 1 extra endoscopy session, and 1 session of administrative time was removed. My child is settling into school now after moving.

T: ______________________? ("this isn't fair?" , "how dare they!" , "I can't do this" , "I can't see a way out")?? Which is *the* primary thought about this C?

F: ____________? (angry? trapped? what else? see if you can come up with the main F for the T).

A: Fume, stew, worry, vent to colleagues, consider complaining to HR, but ultimately don't out of fear for retaliation. Consider moving again, but don't.
What else are you doing? How are you showing up at work, to staff, to your family and to yourself right now? What are you NOT doing when you are in this particular F?

R: ??? What's the result for YOU from these actions? (my gut says it's along the lines of moral injury.... or perhaps early burnout, but I'm curious!)

Bring this model back so we can start unpacking it for you - there's SO MUCH good work in here! Some questions to consider:

-Where do you have control?
-Where do you have power?
-What are your deal-breaker boundaries? (get specific)

Great questions. I actually don't really believe in deserving, though I guess I do believe that people do deserve kindness and respect. I think in my model I meant more along the lines of "they haven't earned it" or "I want to give them grace, but what if I shouldn't/what if offering grace will somehow result in harm."

I think I'm afraid that offering grace (both because I want to and because I'm trying to influence how I am perceived amongst the residents) will result in harm to patient or a preventable negative outcome that wouldn't have happened if I was meaner/stricter/scarier [though I don't really believe that this is true]. I'm worried that if I give the residents passes for not following things up or not thinking about next steps or not having a broader differential etc that there will be negative consequences.

As I'm writing this I am will to acknowledge that maybe I can trust myself to figure out how to give them feedback gracefully. Though then I get back to my first model where even though I was trying to do that the resident was getting defensive/not taking my initially grace-filled feedback well. So then maybe the core truths are

1) I can trust myself to figure out how to give residents feedback with grace
2) When residents get defensive I can practice staying centered in grace
3) I can trust that I am looking out for the patients even if the residents aren't-- (though this seems like a bit of a slippery thought)
4) Me being approachable is way more important for patient safety than any single 'small' detail-- (I want to think this is true, but is it?)

Thoughts???

ANSWER:
This is such a cool exploration!

What does it mean to you to offer grace? Specifically, how is this different from "a pass" (paragraph 2)?
How is this different from offering graduated autonomy?
How do expectations of performance fit in?

Let's get really specific about your core truths. For each of them, I invite you to explain with a sentence like "This means that when _________, I will______________". "If I need to adjust, I'll try_________" Get in the weeds here, super detailed.

Keep it coming!

Thank you so much for the initial feedback on this. I had a chance to read it (but not respond) once it was posted and then was able to make a call mid last week. Am going to share some reflection models as I pull this together and tie in some of the coaching I got from Tyra. 

As a refresher, my UNintentional Model: 
C- Residents act in ways that flabbergast me sometimes
T- I want to give them grace, but what if they don't deserve it? It can't be right to give them grace if they are *actually* messing up/making errors
F- Irritated
A- Talk to others= attendings in and out of my department- about the "behavior" of the residents that I find challenging to work with; split residents into good and bad in my head, go back and forth about purportedly wanting to give them grace but throwing my hands up that I can't "with this behavior/issue." End up really not wanting to blame the residents but resort to blaming them for their actions/inactions ANYWAYS. 
R- I'm out of alignment with my values despite awareness of them in my attempt to sort out who does and doesn't deserve grace and how I know if they do or don't. 

Behold, my first iNtentional Model (after coaching from Tyra):
C-  Residents act in ways that flabbergast me sometimes
T- I can give grace to the residents, even if they might not deserve it, JUST BECAUSE I WANT TO
F- Relief
A- No more rumination about who does and doesn't deserve grace, no more worry that somehow giving them grace is bad or harmful, recognition that in the worst case scenario I'd rather still just offer grace and be wrong than not offer grace and be wrong. 
R- Functioning in alignment with my values

I also present my second INtentional model (also after coaching from Tyra):
C- Sometimes residents can be untrustworthy, and they don't owe it to me to trust me. 
T- Yep. Fact. 
F- Yep. 
A- No more rumination about why and how the residents are untrustworthy, whether or not they are or are not able to be trusted, or blaming them/finding reasons to blame them for moments that I perceive them to be untrustworthy. No more being irritated when/if they show signs of questioning me. 
R- Saving energy, more brain space for worrying about actual things worth worrying about. 

Woohoo!  Happy for feedback. Thank you ladies!

ANSWER:
Hello! Welcome back.

I love to read these reflections, especially love to see you identifying and aligning with your values on this.

Want to pull on another thread?

What does it mean to you to be "deserving" of something?
How do you know if you are or you aren't?
How do you know if someone else is or isn't?
What are the rules? What is it contingent on?

<3

I work with many different colleagues who send patients to me as a subspecialist. Because of how our fields overlap, there are many patients that are seen by this specific colleague who end up needing to see me instead. the colleague has expressed many times that they are unhappy with the wait time on getting in to see me. they have said that they want to keep sending patients to me but "the current system isn't working" implying that they will send all of the patients elsewhere if I do not accommodate their patients in a timely manner which they have said is within 1 week. their team walks patients over to my clinical staff and ask them to "work them in" when my staff is busy in clinic. my thought, it is not feasible to accommodate their request in our current practice structure. i feel threatened, bullied, disrespected. i express my dissatisfaction with clinic leadership. the end result is i don't talk to him in person, instead talking to other people about the problem. and the other result is that he keeps bringing this situation up over and over again.

ANSWER:
Hello! Thanks so much for bringing this here.

Sounds like a tricky situation! and it sounds like you agree that the current system isn't working.

Here's how I'd look at this with different models for each T and F.
It's possible that the actions you're taking of avoiding talking to him, talking ABOUT him to other people, and bringing this up with your leadership could come from any of those models.

C- Colleague says "the current system isn't working", and expresses expectation that his patients be seen within 1 week

T1- He's threatening to send patients away
F1- threatened
A1s- What do you do/not do when feeling threatened?

T2- He has unreasonable expectations of me and my staff
F2-bullied
A2s- What do you do/not do when feeling bullied?

T3- It's not feasible to accommodate their request in our current sturcture
F3- disrespected
A3s- What do you do or not do when you're feeling disrespected

Intuiting a bit about this, I"m guessing that the end result FOR YOU of these models is leading you AWAY from your values of respect, collaborative relationship building.

Does that resonate with you? What other values do you feel are not aligned here?

OK, let's do a thinking exercise. Assume for now that we can't change his expectations (be they reasonable or unreasonable) or his approach to solving the problem. We don't have to approve of him or his approach, but let's see if we can get into curiosity about it.

If you had to guess, what do you think is HIS model about this problem?

If nothing changes about his expectations or his approach to solving the problem, what does success look like FOR YOU in regards to this problem?

Write as much as you can about that, and bring it back here.

I'm a new attending and am navigating the dynamic between myself and the senior residents. I have two separate but likely related issues that I wanted coaching on and I think I'll put them in one submission for simplicity sake. The first is around my experience working with a senior resident who, in my view, is getting easily/quickly defensive when I ask her questions about the patients (which are extremely passively and nicely worded because I'm me) or disagree with something that she has said or does (again, collegially and with an explanation about why I'm asking xyz or making a specific request/inquiry). Her defensive response comes off sassy and then I get just a little bit irritated and the more it happens the more the irritation has built up.

The second but related situation is that I am the absolute biggest resident advocate, truly the biggest resident advocate that I know. My purpose in life and especially at work is to create psychologically safe places for people to bring their whole selves, to be seen, heard, and understood. I promised myself that when I became an attending I would remember what it was like to manage the patients for four attendings at the same time, be in the OR and be expected to be updated about the floor etc. And I have not lost this, I still have this, and I am offering grace in all the places that grace deserves to be offered and more, but something is still missing in the actions/ behavior/ follow through of the residents at my new institution. I find myself thinking something along the lines of "I am giving you all the grace in the world right now but/and I still need you to care about this patient/these labs/this case/ following through/communicating with me well etc. Me thinking negative thoughts about the resident behavior is not the thought I want to be thinking, but they are making it really hard LOL. Let me try to put these in a model.

Model A:
C- I was coordinating a direct admit for my partner who is traveling internationally right now. My partner called me early AM and we reached out to the resident via text to help with the direct admit. She wrote back "The only way I can take care of her is physically here. I understand she is sick.".. followed by reasons/excuses [I'm calling it an excuse here and acknowledging that this is a thought] about why she felt that helping to coordinate the direct admit was not her job.
T- OMFG, this response is SO sassy. Can she not see that helping this patient get the care they need is indeed apart of her job????
F- Irritated
A- My partner (currently in Africa) and I coordinate the whole direct admit ourselves with the help of the clinic nurses. I messaged her "Thanks. We can take if from here." after I got the sense that she didn't want/wasn't able/didn't care enough to help.
R- The patient got the care they needed, I coordinated it, I'm still irritated that the resident didn't see this as a part of her job and spoke to me in the way that she did. I acknowledge that she was managing a full list of patients and I totally understand that she didn't want this to be her problem early in the morning but also COME ON.

Model B:
C- The resident (same as above) asks for an instrument in the OR and proceeds to try to do something that I perceive as unsafe. I take the instrument out of her hand and hand it back to the scrub tech saying something like, "no, we are not going to do that right now." She gets subtly defensive/aggressive/irritated with me [this isn't quite a perfect circumstance but for the sake of the model I'm putting it here to outline the rest of my TFAR].
T- You have no clue what you are doing, I am not criticizing you in any way but I can't let you do that, why are you getting defensive; jfc.
F- Irritated
A- I just keep moving along with the case and if anything am over compensating being "nice" and "chill" since I know that what I did irritated her.
R- I'm irritated that she got defensive, I try to offer her grace and am decently successful but also like-- really? I then proceed to have more thoughts about why her defensiveness is unhelpful and unwarranted while also I'm glad that she feels safe enough to express her displeasure with me, but then am also still irritated, haha.

Model C: (different chief resident)
C- I have a complication with my own post-operative patient that is identified on POD7 on the floor. I have communicated with the intern and the consultant throughout the afternoon because the chief isn't responding. She messages around 5PM " Oh bummer" and then I don't hear from her again. I know from looking at the schedule that she is not in another case since she was in my case in the morning and my case is done. Now it's after 9PM and I've decided to bypass the chief altogether and am texting the night intern myself to followup on the results of the CT scan. While on the phone with a friend I also mention how I'm low-key appalled that the chief hasn't followed up on the imaging herself.
T- I know that these residents are managing a lot, but this is important and it's not OK that I haven't heard from her after several hours. This is a critical scan to followup on and she should be telling me about it.
F- Irritated
A- Vent with my close friend and confidante about the behavior of the resident, hate myself for doing that and not offering unlimited grace, struggle with my own annoyance and my deep desire to acknowledge that the resident is probably doing the best that she can and might be tied up with something else even though I'm certain that she is not.
R- Worry that I'm becoming an attending I don't want to be though this isn't quite true because with this resident in particular I have achieved psychological safety and we have a good relationship. I later learned that she did scrub with another attending to help with something and she did text me at 9:30PM when she got out of the OR with the results of the scan. Then I was even more irritated with myself that I hadn't offered enough grace. In this model I think another result here is that I'm feeling like I can't trust the residents, which I know is a super normal feeling, but me not trusting them to follow up/care etc is leading to me thinking poorly of them, which is not in line with my values/purpose.

This was a pile-on of a thought download and I'm sure some of it came out jumbled. Hopefully I'll be able to join a call and may be able to discuss more in depth but my schedule just hasn't worked out over the last two weeks. Thank you in advance for reading this and offering your insight/guidance. leads to the result of YOU being sassy.

In Model B
Your thought "She's so defensive"---> YOU get defensive

In Model C
Your thought (I'm summarizing here) "Her behavior is inappropriate"---> YOU take actions that I suspect you'd call "inappropriate" because they are outside of your values (venting about your friend, being critical of both her and yourself) with the end result that you judge YOURSELF for not being the attending (or maybe the human) you want to be both to your trainees and to yourself.

I wonder if irritation isn't the emotion here, but is a surrogate emotion for something deeper or more uncomfortable. What might that be?

Why is it a problem that they're irritated sometimes? Why is it a problem that YOU'RE irritated sometimes? What does it mean about you?

Bring it on back here friend.

it was mentioned that there is no need to do anything or everything in workbook etc for this program. once you fall behind, do you recommend skipping ahead to current week's stuff or work beck in month 1 on purpose, values, etc?

ANSWER:
Hello! Thanks for this question!

You have lifetime access to the video modules and workbook, and we HONESTLY believe there is no such thing as "Falling Behind" in Better Together. It can take you 5 years to get through the video modules and workbook, and you'd be right on time 🙂

We know you are busy and this course was made with that in mind.

It is absolutely fine to jump in at the theme of the week, especially if that theme resonates with you. It's also totally fine to take it slow and work your way through week by week if that feels right for you. There are no rules (which I know feels uncomfortable).

I wouldn't be a coach if I didn't ask you a few coaching questions 😉
- How do you feel when you think the thought "I've fallen behind in this program"?
- What do you see yourself doing/not doing from that emotion?
- What happens if you put that thought into a Model?

Circumstance - You are in Better Together. Were are in month 2 week 2 and the theme this week is welcoming feedback.
Thought- "I've fallen behind"
Feeling- _______________ (how do you feel when you think that a)
Actions- ________________ (what do you do or not do when you're feeling that way?)
Result-__________________( this is the sum of your actions)

Take a crack at it! So glad to have you here 🙂

Thanks for such a quick response! You're exactly right that I sent that thought model before I saw your reply : )

I'll jump right into your question.

- Do you think this is guilt ("I did something wrong and want to course correct"), or pseudo-guilt ("I SHOULD feel bad because of implicit expectations placed on me that I don't necessarily agree with or buy into"), and why?
I like how you differentiated the idea of pseudo-guilt and definitely think that's what I am working with here. I'm trying to think about my blueprint for a good mom and i suppose that might be where this pseudo-guilt stems from; ie a good mom has it all together, is highly involved and knows what's what in my kids' world. BUT i don't really see that as something i want to strive to be great at, in fact I dont really love that idea so I'm happy to start dismantling it. I can shine in other ways as a parent.

- You asked the hypothetical question "why does this bug me?". What do you think the answer to that question is?
ugh, I dont really know. I think its because once a week I have to interact with them at pick up/drop off and I havnt fully worked out the dynamic. So its confusing to me because I am trying to organize my thoughts on all of them as individuals and also getting this input like there is some kind of pecking order. And truly i have no interest in trying to play that game yet I feel some sort of social pressure to engage.

- Do you want to participate with this group? If so, in what ways? If not, do you like your reasons?
I do not. I think writing all this out has made that very clear to me. I would certainly be up for hanging out with a family one-on-one with our kids (and we have done that with a few families) but not in a group setting, no thank you. So now that I have clarity on this idea that what I am feeling is anticipatory pseudo-guilt for something I have no proof would ever happen I would like to dispense myself of that!

- How does it make sense that your brain is worried about your inclusion/rejection here? The part of you that is worried about this is trying to protect you from something. What might that be?
Well, I know that rejection can be a very strong trigger because evolutionarily if we were kicked out of the pack, it could threaten our survival. And social situations can carry that evolutionary baggage. But its kindergarten haha not the frozen tundra so a little self reflection could be helpful to turn off that alarm.

- Imagine your son is a teenager and comes to you to share that he feels he is left out of a group at school. What do you imagine he would need from you in that moment? What might you say? You might say something like "It makes sense that you feel ________", "I can imagine that ________". What else?
I would hope to say "I'm sorry that happened. I believe you and I am so glad you feel safe to tell me about it. It makes sense that you would feel ostracized. I can imagine that you are worried about what this means for you at school and it might be hard to navigate so we can keep the conversation going. Eventually it will get easier. What I can say for sure is that you are loved by so many people. Not everyone will appreciate your strengths... that's ok! Even though it feels hard now. You are not alone in this."

I am trying to find a convincing thought to replace my current model that is not too trite...here is a go at it, but would appreciate feedback on other potential thoughts

C: son in kindergarten and the parents socialize outside of school
T: I am here for my son and don't need to participate in the social hierarchy
F: content
A: focus on watching my kid run around before school, enjoy individual interactions with parents that may occur organically, acknowledge the part of me that might experience pseudo-guilt and thank it but say "not now, we're good"
R: engage with my son and find comfort in knowing I am a good mom who has a whole life outside of the school yard

Thanks!

ANSWER:
WOW! Incredible work here! I especially love the sentiments you offered in your final reflection about what you might say to your son if this were happening.

When you sit with the thought "I'm here for my son and don't need to participate in the social hierarchy", does that feel true and believable to you?

You may need to try it on "in the wild" at school pickup next week to see if it is believable or not in the moment.

If it's not feeling believable, that's OK, and a chance to move towards something a little more neutral.

Sometimes, it can be helpful just to notice and name what you are feeling in the moment.

Ex: Next time you see the posse, and your heart rate goes up and you get that wave of rejection and pseudo guilt. You NOTICE It.
"Oh! I notice I'm feeling that anticipatory pseudo guilt right now! There it is!" or
"There's that rejection feeling, right on time! Interesting!".

Just becoming aware and non-judgemental of that initial model when you move into it can be VERY powerful.

As a final exercise, I wonder how it would feel if if you take the sentiments that you offered to your son in the hypothetical example above and offered them to yourself here- where you are both the giver and receiver of that validation and reassurance. How would you re-write that message to yourself?

Keep it coming!

My model:
C: son in kindergarten and the parents socialize outside of school
T: they are excluding me
F: hurt and concerned that I might be missing something important
A: perseverate, worry, probably come off a little awkward and maybe even standoffish
R: not engaged with this community

ANSWER:
I suspect I was responding to your first post as you were writing this!

Great work on your model here.
You got really neutral on your C line. Perfect.
I wonder if your F line is "rejection". (that is usually the reason for the hurt)
What INACTIONS do you take from rejection or hurt?
You are spot on in your R line here, that you exclude yourself from the community.

This is a good model to look at, and give yourself a little recognition that you aren't operating from this model 100% of the time. Of course there ARE ways you are integrating socially into the school, even though it looks different from your ideas of how you should be integrating into this "posse".

What I'm interested in is how it is serving you to judge yourself about being in this model?

To get at that, we can try to understand why you have this model in the first place.
- How does it make sense that your brain is worried about your inclusion/rejection here?
- The part of you that is worried about this is trying to protect you from something. What might that be?
- Imagine your son is a teenager and comes to you to share that he feels he is left out of a group at school. What do you imagine he would need from you in that moment? What might you say? You might say something like "It makes sense that you feel ________", "I can imagine that ________". What else?

Bring it on back, friend! <3

I have tried to write this coaching prompt a few times, but I keep getting embarrassed and abandon halfway through haha. But here it goes!

My son is in kindergarten; he is adapting really well to the new school. He has lots of friends and loves learning! In a way I had a harder time with the transition than he did. One area that remains difficult for me is that most of the moms/parents seem to know each other really well and all hangout outside of school. They call it "moms night out" and I usually hear about the event after it happens. I suppose I just didn't expect elementary school to be a social scene; and furthermore, I didn't expect to not be in the cool crowd. My two main thoughts are 1) I'm cool! I'm successful! Why am I being excluded? and 2) I don't even actually want to have the obligation of having an active social life with these families but what if I am missing out on something that would serve my son in some way (ie maybe if I did hangout with these families I would be "in the know" about the inner workings of the school).

In general, my life feels full right now, I have many great friends all over the country, I am close with my family and have a challenging job that I love. So why does this bug me?? I'm not sure, but I can't shake the sting of being left out mixed with guilt that somehow I might be letting my son down.

Thanks for your coaching in advance 🙂

ANSWER:
Hello! Thanks so much for bringing this here.

I love what you pick up on in your first paragraph- you're upset about not being included in something that you don't really want to feel obligated to do, but still wish you were invited to! Not going to lie, I've felt this way before too! Congrats, you have a normal human brain, nothing to be embarrassed about ;). This sounds like Fear of Missing Out (FOMO) with an extra addition of "mom-guilt".

Guilt is a super powerful emotion. the emotion of true guilt can come from experiencing the results of actions we took that are outside of our values (intentionally or unintentionally). Guilt says "I did something bad", and can provide a strong motivation to apologize, correct, or right a wrong in a way that brings us back in alignment with our values.

Pseudo-guilt ("mom-guilt" counts, for the sake of this discussion), is trickier. Pseudo-guilt is like, "you SHOULD feel guilty about this, based on ABC norms, and XYZ expectations etc." And I'd argue that pseudo-guilt only benefits the patriarchy (which is a whole other soapbox of mine for another day). At any-rate, pseudo-guilt usually doesn't serve you.

Here's what I'm seeing here:
You are pretty clear that your son is thriving in school. He has friends, is loving learning, is doing great.
You are also clear that you are satisfied and fulfilled by the relationships you have with friends and family across the country, and rewarded by a challenging job that you love.
It doesn't sound like you have evidence that he is "being let down" in any way.

What is there to feel guilty for?

You hit the nail on the head that the sticky point, and the absolute thing to keep digging on here, is that you are feeling something like guilt (but I'd argue is pseudo-guilt) because you have tied your inclusion/exclusion among this mom group with your son's potential for success. You're extrapolating that thought error to mean that if you're not included, then he will suffer some consequence, and that will be your fault. So you're basically experiencing anticipatory guilt and responsibility for a thing that a) hasn't happened yet, b) might not happen, and c)even if it does happen is unlikely to actually be caused by your inclusion/exclusion/participation within that group. And all of this is probably based on social norms that you've incorporated into your concept of what it means to be "a good mom". This is probably pseudo-guilt.

Let me know if I'm off base here. How does this land for you?

I'm going to pose some questions here. There are no right answers, just things to explore. Feel free to bring anything that comes up here back for more coaching!
- Do you think this is guilt ("I did something wrong and want to course correct"), or pseudo-guilt ("I SHOULD feel bad because of implicit expectations placed on me that I don't necessarily agree with or buy into"), and why?
- You asked the hypothetical question "why does this bug me?". What do you think the answer to that question is?
- Do you want to participate with this group? If so, in what ways? If not, do you like your reasons?

Let's keep exploring this!

A resident is leaving my program due to interpersonal conflicts with other residents. I am having a tough time not making this decision personal and would love some coaching.

ANSWER:
Thanks so much for bringing this here. I want you to invite you by doing a though download, and just dumping out all of your thoughts about this situation right here in Ask For Coaching. Those thoughts might start with things like.

A resident is leaving my program.
- This means that I ________
- If I _________
- They__________
- I tried to ___________
- I wish that _________
- If only___________

Write as much as you can and bring it back here, or to a group or 1:1 Call.
We've got you!

This answer was so good; it was everything I expected it to be and more. I’m hoping to make tomorrow’s coaching call but wanted to submit this back to just get it down on paper. I cognitively know that when I have this type of unintentional model I’m in emotional childhood, but it definitely doesn’t feel that way when I’m in it. In the moment I feel so entitled to how I’m feeling, but of course that doesn’t help. I’m going to write out a few additional concurrent thoughts for my unintentional model, that really help me capture the emotional childhood part of it. Will bring this to live coaching when I can.
Concurrent Unintentional Thoughts driving my Unintentional Model:
- This isn’t fair
- What did I do to deserve this
- I don’t know what I’m going to do
- He has to change
- I can’t keep living like this
- Is this what I signed up for (in marriage)
- I can’t take more of this

In addition to the A line that you so beautifully summarized, it’s so clear why I’m feeling desperate. And it’s also clear, like you noted, that I’m panicking about the NEXT time that this happens, instead of just allowing the situation to be what it is in the moment.

I think that part of me is afraid that if I accept this type of behavior from him, that it will just keep happening, and while I can build confidence in myself to handle/process/allow the blame as it comes whenever it comes, I quickly go back to “This isn’t fair” and “Why do I have to be responsible for allowing/tolerating the blame.”

I’ll take you up on trying to process the desperation and irritation. I agree with you that my calm-mom voice is likely resisting, but I also am feeling the feelings underneath that, so what should I be doing differently to allow? Will ask more questions in live coaching.

ANSWER:
What a perfect reflection you gave us. In my experience, I am never able to realize I'm in emotional childhood until after the fact (and even then, usually with some coaching).

Feelings work is your jam here - there's nothing more to it than describing the feeling in your body. Write down physical sensations, do a little "HPI" on it, but stay away from thoughts *about* the feeling, only allow the physical sensations. Then just continue to watch, and if you can, even welcome the feeling to exist (knowing that it will anyway).

I am curious about this model you are carrying:
C: Husband's HTN reaction
T: If I accept this type of behavior from him, that it will just keep happening
F: Afraid
A: ??? (try to not accept it? Resist the things)
R: You continue to accept your non-resistance, with a narrative that maybe this time it'll work.

Looking at that T line, you are still taking responsibility for your husband's actions. Why do you thikn that his behavior has anything to do with you accepting it or not?
-What if it will also keep happening if you resist it?
-Or what if you accept it and it randomly stops?

Can you decouple your "A" line (and ultimately your F line) from his behavior? This is the key here.

A note: this is NOT advocating for you to "condone" or "encourage" any specific behavior that you don't want/like/believe in, etc. You may decide to take action to remove yourself from his presence while you are accepting and allowing the situation. You may also decide to hug him, continue to do chores etc. while accepting that that won't change the way he feels - in this place you decide on your actions because of what YOU want to show up, and how you get to feel in that space, regardless of your C line.

This is just a space to acknowledge that a whole spectrum of behaviors can and will occur in our environment despite how we feel and what we deem as "fair"

For instance, we can all agree (I think and hope) that child abuse is bad.
And we can all agree that it is happening all over the world. We know that humans are flawed and make awful horrible mistakes all the time, and that is just an inherent truth about us. If we fall into emotional childhood about Child Abuse as a "C", it may look like a lot of "THIS ISN'T FAIR! Human's should NEVER do somthing so horrible - I can't believe this is still happening, the world is failing us all" and fall into a space where we blame and shame society or whatever.
Emotional adulthood looks like: "Wow, this is horrible. I see that it exists, and I wonder why. I am so moved that I am going to advocate, educate and figure out what I can do to help in this situation."

What would it look like to step into emotional adulthood and show up in the way that serves you the most about your husband?

This is going to be a bit long of a thought download. My husband was recently diagnosed (by home BP cuff) with HTN in the low 160s. This came about because he was feeling “off” and decided to check his BP. Last weekend he checked with an old wrist cuff. He locked himself in the bedroom, kept re-cycling the cuff, called his best friend who is a gastroenterologist to ask him to prescribe him meds, took the metoprolol of a friend that was visiting because she had some in her purse, and overall got really worked up about it. By later in the evening he decides that it was all because of nicotine withdrawl because he’s been smoking less. The next day I bought an upper arm cuff, which then he decides he doesn’t want, but I encourage him to keep to track his BP anyways since he has a strong family history and is at risk. This morning, he’s again feeling ‘off’ and takes his BP and it’s elevated and the same spiral starts. I can tell that his anxiety is escalating, I’m trying to offer a variety of ways to help by offering to go do the groceries and take initiative folding the laundry and etc but he’s not thinking well and keeps making fights out of my attempts to help and tells me that I am 50% of the reason for his HTN. This culminates in an argument which involves him repeating over and over that “living here has become my punishment” and he retreats to our room to cry (he absolutely hates it when he cries and feels exceptionally ashamed). I do my best to offer comfort then give him space.

So I’ll offer a model but I also have a question. I’m a repeat participant here, and this is not the first time that I’ve asked for coaching or gotten coached about my inability to control someone else’s model and make them see that they aren’t helping themselves (particularly my husband). This is going to continue to be my work.

C- Husband is anxious about new diagnosis of HTN, concludes that I am 50% of the reason that he has HTN, says that “living here has become my punishment” and tells me that after my upcoming call week he is going to fly home [internationally] to “get a break from” living with me. (side note: this is a common threat, and the conclusion that I am the root of all of his problems is also a pervasive thought/conclusion for him).
T: Stop acting like a child, get a grip, can’t you see that your thoughts are worsening your anxiety and putting fuel on fire? I am not the reason for your HTN.
F: Irritated, annoyed, resentful that I’m being blamed
A: Really double down on keeping my calm-mom tone, try to not to let my annoyance break through, offer to take as much off his plate as I can think of but am annoyed while I’m doing this, comfort him as genuinely as a can but still with underlying irritation, wish for the hundredth time that he would be willing to engage with coaching and realize that I am not the one that is ruining his life.
R: I’m still irritated/annoyed, exhausted by this cyclic argument pattern in our marriage where he believes I am the source of all of his stress (and now health issues); expecting that this will just keep happening where I always get blamed; decide that I need to find him a coach (while acknowledging that this is me trying to change the C line by having him work with a coach instead of me shifting to an intentional model where I choose more helpful thoughts). Write in to ask for coaching with a fresh version of this chronic problem.

Note: There is certainly a part of me that can see that this is scary and terrifying for him, and that makes another model where I do have moments where I empathize and am doing what I can to support him, but then we just cycle into this me always being the problem piece, which I’m smart enough now to know that that’s BS.

***tightened up model***
C: Husband gets stressed and blames me for his stress. T: STOP blaming me. This HAS to stop. F: Irritated, almost desperate. A: Searching for ways to make it stop. R: Feeling stuck. Was also thinking that my intentional model might need to incorporate some sort of boundary. Will keep thinking on it. Thanks as always for your coaching. <3

ANSWER

Hello friend!!! Ok- you have seriously leveled up with insight into your own patterns here. I'll start by pointing out how VERY VERY common this patter (blaming the C for the F, in this case, you have a theme of blaming another specific person for your F, A and R) - which we call "emotional childhood." It's common because, in a way, for a brief moment, it actually can feel good. The rush of "justification" or "haughtiness" we get in this victim or defense mode can bring a bit of dopamine. The problem, is that this rush often disappears, and we are then left with the original feeling and now a model that doesn't serve us at all about the person.
I'm going to tighten your C even further:
C: Husband has BP reading of 160 and says you "are 50% of the reason for this HTN" and that “living here has become my punishment.”
T: He's blaming me and it has to stop
F: Desperate
A: Blame HIM for not having access to his own coaching tools (and being in emotional childhood). Double down on keeping my calm-mom tone (I'm guessing this is you "resisting" the feeling... how's that working? 😉 ), try to not to let my annoyance break through, offer to do chores for him but am annoyed while I’m doing this, underlying irritation seeps into all actions, wish for the hundredth time that he would be different. Searching for all the ways to make it stop.
R: You don't stop your usual pattern, and make this harder.

Ok- I don't think this is primarily boundary work. If he were physically harming you or your space, or if he were constantly raising his voice or name calling, then there is some boundary work (maybe this is the case, if so bring it back and we can talk boundaries). But him blaming you for his HTH is actually not boundary work. He is an adult who is allowed to blame whoever he wants for his HTN (even if it really doesn't serve him and even if it creates really irritating thoughts for you).

The primary work here is emotional adulthood - i.e. taking responsibility for your own thoughts and feelings. This is HARD WORK.

The first step is to stop resisting what is happening now. You are really wishing he would be different, so that you could feel better. But he doesn't have to be different, I promise. This is where your power lies, I think you are ready to unleash it.

Ok- to get ready for feelings week, I'm going to remind you of the 4 options you have with every feeling:
1) React to it (for you, this may look like snapping at him, being cold, or yelling back)
2) Resist it (this is how you are showing up with a forced "calm mom voice" all botteld up, but not authentica at all- often makes the initial feeling stronger)
3) Distract/avoid from it (this would be indulgging in something else, work, social media, alcohol, junk food, anything to not be in your feels)

aaaanddd the one we recommend:
4) Allow it.

Have you processed your desperation here? What's wrong with letting it be there? What if this is your week or month to play with irritation and desperation and not try to fix them?

I challenge you to keep this model and example all the way through the next 3-4 weeks with us and let's see if we can de-power it a bit.

Welcome to Ask for Coaching! Here is a guide for how to get the most out of this type of coaching:
1) Title your question with something memorable for you. Unless you identify yourself in the title or in your request, your coaching request will be anonymous to other readers. If you want (and to make it easier for you to search and find your old posts later), you can add a tag unique to you (Ex: #abc)

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