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

Thanks for the helpful response - this has prompted a lot of reflection for me.
New model that I am working on:

C: Colleague said words to me about my hiring process. Colleague offered to cover and then called out sick. Colleague has pumping breaks in schedule but has disclosed is not pumping.
T: I can be respectful and professional, without her needing to be, without liking her and while striving to remain true to my favorite self.
F: this is a little tricky, things that come to mind: in control, grounded, secure, but also kind of superior (which feels petty and not helpful)
A: I really like the ones you listed, and also added a few more
- communicate only about work in a brief, clear and professional manner
- don't speculate about motives
- offer/ask for coverage within job limits, no extra narrative. Ask her as a last resort.
- discuss problematic behavior directly -> report if it doesn't go well
- don't gossip with other colleagues/friends. If I need to vent, do it only with my partner
- care for all patients with the same effort
- model professionalism
- assume the most generous interpretation of her actions (this feels really hard!)
- model professionalism
- look for examples where she does the same for me (also feels really hard)
- check myself for passive aggressive tendencies
- say hi, even when she does not
- advocate for my and my patient's needs
R: respectful relationship that centers patient care and equity

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Oooh - such a great reflection!
I love how you’re holding the dual truths that professionalism and self-respect can coexist with frustration and imperfection.
You wrote that a few of the actions feel especially hard - and that is a clue that those actions aren't naturally being driven by the thought and feeling for you. When we find the right thought and feeling (that we fully believe and then think on purpose)- the actions come naturally, you don't have to force them or remind yourself of them at all. Here, some of these actions feel a bit like you'd be white-knuckling it right?

I wonder if it's in that part of the thought you insightfully pointed out cultivated more of a superior feeling for you... so this may not be the home-run go-to thought yet. But THIS is *the* work- you are doing a great job here. Let's dive a little deeper:
Do you believe that you can be your best self without her needing to be? Without liking her? Or is there a dark side of this thought ("I can be the bigger person" can feel good in the moment, but it often leaves us feeling distant, guarded, or even resentful later.....)?

“I can be respectful without her needing to be” can morph into “I’m the better person here,” so the invitation now is to soften into not-knowing: What if she’s unknowingly helping you refine your own leadership, boundaries, and compassion in ways a smooth relationship never could?

When you can hold the stance that nothing has gone wrong, that this dynamic is all part of your curriculum, you reclaim your power. You stop white-knuckling your professionalism and start living it with ease.

I want to push you here:

-are you positive you are being a better person here? Is it possible that you don't know the full picture of her, of your job, of life itself yet and actually things/her/the behavior is unfolding exactly as it should? What if this dynamic isn’t wrong or unfair, but simply what life has handed you right now to practice your values in more complex conditions?

-If you found out tomorrow that her behavior made total sense, what might that context be?

-What does being “your favorite self” look like when it’s hard?

I also have a challenging colleague dynamic that I would like coaching on. I tried to be as succinct and objective in my circumstance, but there are so many parts to it that I did not succeed - so sorry!

I am a new attending at my institution (started about 11 mo ago) and have a colleague whom I work closely with who has been there for about 10 years. She does the pre-op for the patients that I see in the OR on the next day and we both do the same speciality clinic on different days of the week. Since starting there, I have felt tension between us and have perceived her to be cold towards me, despite my attempts at friendliness. Recently, after becoming defensive when I suggested a change to how we handle the transition of care between us, she acknowledged that she has been treating me coldly and that this is because she feels slighted that she did not get the OR position that I have. We had an overall ok talk about this, but she said some things that felt petty/mean/unnecessary: she said that many people wanted the job internally and felt slighted by me (an outside person) getting it; she said that I probably got it and also have such a great schedule because they mostly really wanted to hire my husband and we were recruited together so they thought that by giving me a good schedule, he would also join; she also said it would be easier to hate me if I was an a**hole, but because I am sooo nice she thought she should explain her perspective and clear the air.

I have been working on letting her words go, although some of them do hit at insecurities I have. But I've concluded that her opinion is not really worth much to me.

About 2 weeks after we had this conversation, I reached out to her to see if she could cover the last 45 min of my clinic so i could make an urgent medical appt (she had 4 pts scheduled, I had 10 and I asked her 2 days in advance). She said yes. The next evening she texted me that she was really sick and needed to call out of clinic the next day. She emailed our department asking for coverage due to her severe illness (the clinic is considered an essential service and cannot be canceled). No one was able to cover, so our dept head ended up covering my clinic and I covered my colleague's so I could make my appt. The next day, a close friend/colleague of mine found an email from 2 months ago from this person, where she was asking for coverage of the clinic she ended up calling out sick from so she could do CME. On her provider calendar, her afternoon was also blocked off for CME as was another day that week. So my assumption is that she was not actually sick and said she could help me out when she in fact was never planning on it.

Another facet of this situation is that she has pump breaks in her clinic schedule, which she told me several months ago she was removing as she is no longer pumping. These have remained however, and it has led to my clinic being overbooked with patients as there are limited spots during her clinic.

Initial model:
T: She is the worst
F: anger
A: stew, vent to my friends, dread seeing her
R: have negative feelings about a job I overall like, stay angry, don't show up as my best self

Next model:
T: I do not trust nor respect her and I hate that I have to work with her. I don't know how to navigate this situation - I would like to advocate for myself but I am worried about the repercussions.
F: anxious
A: same as above, but also consider ideas on how to advocate for myself - should I try to have another conversation with her, should I talk to our dept head. Or should I try to let it go
R: same as above still I think

I would like to get to a result of having a respectful relationship with this person that centers patient care and equity. However, I do not know how to get there with her. And if that is out of my control, I would like a result of being able to provide high quality patient care in a safe and equitable way, but this feels hard when it is difficult to communicate with her about our shared patients' needs.

Sorry for the novel of a post, and thanks in advance!

=======================
Ooooo boy is this a good one! Your models and thoughts are incredibly relatable, I bet there's not a single person reading this that isn't thinking of their own tricky work relationship right now where we have that same first thought! And yes.... this almost always leads us away from how we actually want to show up. Isn't it hard to change? You nailed the human part of it: when someone’s behavior feels unfair or disrespectful, our primitive brain loves the “They are the WORST!” story. It feels protective, even a little righteous, like moral dopamine. But, as you noticed, hang out there too long and it pulls you away from who you want to be.

Your second model is a nice shift into specifically why she is the worst, and highlights how this situation is the worst for you. But, I think there may be some blind spots showing up there. This thought really doesn't leave any room for creative thinking, you are just believing that you are screwed.

My first question is: Why do you believe that you shouldn't have to work with anyone that you don't trust and respect? Is it realistic to believe that you will enjoy working with every single colleague? Of course not, but look at your brain rejecting this situation as "wrong" and ringing alarm bells here. You are, unsurprisingly for a doctor, in "fix-it" mode, believing that you need to find a solution to either erase her from you life or figure out how to interact with her so that you can feel better/liked. Instead, though, what if it's just uncomfortable and human, but not wrong?

I want to offer the possibility that you can achieve a relationship with her that centers on patient care and equity AND also not like, respect, or trust her.

One of your thoughts is that it's difficult to communicate with her. Let’s get curious about what’s actually hard. Is she literally obstructing communication (talking over you, covering her ears) or is the difficulty internal: anticipating judgment, reading tone, bracing for rejection? If it’s the second, that’s actually good news, because it means you have influence. You can manage your own thoughts and emotions without needing her to change to communicate.

Let's try a result model here (start with the result you want and the current circumstance and work backwards.... I like to write this as R-->A--->F--->T--->C, and keep asking myself "what would I need to do/feel/think etc to get that line?)

Result: Respectful relationship with this person that centers patient care and equity.

Actions: (???? what would this look like in practice for you? What are all things you would do/say/react, etc)? Ex: You communicate only about the work: brief, clear, professional. You don’t speculate on motives (illness, CME, etc.) for time off. You offer and ask for coverage or help within the expectations of your job, without guilt or extra narrative. You discuss any outright problematic behavior with her directly and if that doesn't go well, then report the problematic behavior to a supervisor, you care for all patients with the same effort, you manage your mind so that frustruations don't affect patient care, assume the most generous interpretation of her actions, modeling professionalism, and look for examples where she does the same for you, etc etc WHAT ELSE HERE?

Feeling: ???? What do you need to feel to do these things?

Thought: ???? (million dollar Q: what do you believe, truly, about this C that cultivated this feeling?)

Circumstance: Colleague said words to you about your hiring process. Colleague offered to cover and then called out sick. Colleague has pumping breaks in schedule.

(some T's to get your creative juices flowing:
“Her behavior doesn’t define my integrity.”
“I can be respectful without needing her to be.”
“This dynamic is uncomfortable, not unbelievable or the worst.”)

I am a new faculty at a new institution for my 2nd post-fellowship position. I left my previous position even after enrolling in (a different) physician coaching process and learning about CFTAR. In the modules, there is a lot of talk about how the circumstances don't have to change for us to feel better and have better work-life balance. I appreciated that at the module at the end of Month 1, there is acknowledgement that we can live our values and still choose to leave the position if it's not serving us.

What I am running into now is healing after making this decision. I've been reading this forum and thinking about how many of us have concerns and regret, and reflecting on the "arrival fallacy" and our broader systems issues in medicine. One reason I ultimately chose to leave my prior position is that my division head, (my "villain" at work), was resolute in her description of "the job." She even acknowledged in our exit lunch that she and her contemporaries in my specialty "probably wouldn't choose this fellowship if the job was then what the job is now." My new division head has been much more supportive in a lot of ways, but has also somewhat drawn the line at one of the parts of my job that brings me a lot of value. Half the time, I still wonder about heading back to primary care, where my subspecialty skills will still be valuable, but I will get to use the breadth of my training more, BUT I am scared about that job, too, specifically the sheer patient load and EMR tasks in primary care.

As I was leaving my prior position, the physician wellbeing head kept telling me, "the ideal job doesn't exist; you must create it and negotiate for it."

C: I'm starting out in a new faculty position after leaving my first position post-fellowship.

T: Excitement about this new opportunity. Appreciation for my new division head and a softer, gentler start. Second guessing whether this specialty is right for me, though, still. Regret about completing the fellowship, because that's when things soured in my personal and professional life. Wondering if I even know what my ideal job would be, since I have 5 million things that excite me, but struggle with overwhelm. Imposterism and feeling that I need to prove myself in this space (people keep treating me as if I'm just out of fellowship but I have 3 years under my belt, AND I'm already a decade out of medical school and feeling like I'm starting over in every part of my life).

F: as you can see, these myriad thoughts are causing a mishmash of negative and positive emotions. The overarching feeling that comes out now, though, is self-doubt and uncertainty. (I'm excited to get to month 2 modules, because I read ahead and saw the comment about how we become more fixed mindset as we go through training. When I was taking notes during the introductory module, I actually wrote this in my notebook: "I feel like in my life I experienced emotional adulthood in childhood and have regressed as I progressed through training."

A: I am spinning my wheels with the generous free time in this new position to get settled with my scholarly work and prepared for the clinic. I am procrastinating. I catch myself feeling excited with this new job and caution myself to not get too invested. I enrolled myself in the physician wellbeing program, which provides counseling and I also enrolled myself in this program. I know these to be solid positive steps, but they feel like fluff since it's self care during "work" hours.

R: I guess we'll see?

Q: back to the topic of my post; healing. How do I banish the thought from my previous division head that I'm not cut out for this job/specialty? How do I stop gazing at that possibly (but probably not at all) greener pasture of primary care?

I caught myself putting "feeling" words in a lot of the sections post F. It's a work in progress but I appreciate the growth "SOAP" note analogy you all have provided.

Thank you!
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ANSWER
You hit the mark on the nose: you can absolutely change your thoughts about your job to make it right for you, AND still decide to leave, just because you want to! And, if that was truly the case, then there wouldn't be any need to heal from that decision- since it would feel aligned, value-driven, and right for you. The fact that you are chasing this goal of "healing" means that you are still creating a problem for yourself with your thoughts. What are you making healing mean? What if “healing” doesn’t mean feeling peaceful, but simply being willing to feel the discomfort of growth without making it mean something has gone wrong? Is your need to “heal” your brain’s way of trying to close an open loop too fast....to avoid uncertainty? Let's look closer.

When you use the model, it's most helpful to pick just ONE thought, and ONE feeling to unpack. The meat should be in the A line (which you gave a lot of in your T). There are always a bajillion of them happening at once, and it can get messy if we don't stick to each model on it's own to see what each thought is creating. For this purpose, you specifically asked to "banish" the thought: "I'm not cut out for this specialty" that you adopted from your ex-boss, and you also want to stop thinking that the grass is greener elsewhere. Let's work on the first one here (and bring the second model back to work on after!)

C: I'm starting out in a new faculty position after leaving my first position post-fellowship.

T: My ex-division head could be right, maybe I'm not cut out for this job.

F: Self-doubt

A: Second guess whether this specialty is right for me. Regret fellowship. Blame fellowship for other things souring in my personal and professional life. Wonder if I even know what my ideal job would be. Create a story that since I have 5 million things that excite me, I can't find the right one, and indulge in confusion and overwhelm. Worry about needing to prove myself in this space (assume that people are treating me as if I'm just out of fellowship), continuously point out to myself how I'm starting over in every part of my life. Create emotional childhood by blaming others and situations for how I'm feeling. Spin my wheels with the generous free time. Procrastinate. Erase any good feelings with caution to not get too invested. Call any attempts at self-help fluff.

R: You create a negative past, and are on your way to a negative future.

Ok, my friend. Aaaaaalllllll of this action line is truly being fueled by that one little innocuous thought. The tragic part is that the thought was given to you from a person that I'm guessing didn't even know you (or the true you) all that well. Isn't it wild how we can do that, give others permission to run our own minds like that? I bet you wouldn't give your ex-division head permission to make even small decisions for you (like.... would you let her be in charge of your wardrobe? Or what you eat for dinner for a year? Or who you date?), but all of the sudden she gets to decide what your professional-narrative is??
Let's take the reins back. Emotional adulthood means that you take full responsibility.... NOT for what happens to you, but for what you make it mean.

Let's start with some questions to shift this thought.
-What evidence do you already have that you are of course cut out for this specialty, that your brain has edited out?
-How (specifically) might it serve you to believe that you are supposed to feel like a beginner again, over and over?
-Look at the story your brain is offering around leaving your last position. What parts is it leaving out that would serve you if you added them back in, and vice versa? If you wrote a version of this story five years from now, how could you create an empowering narrative arc?
-Where are you assuming the options are binary (stay in this specialty vs. abandon it for primary care), when reality might offer dozens of versions in between? (along those lines, when you picture the “greener pasture,” what are you idealizing, and also conveniently leaving out?).

Wow I'm already feeling like I'm in such good company with all these new attendings.

I am a relatively new attending and I work with residents on an inpatient service.
I recently had a stretch of inpatient that felt relatively easy/comfortable the first two days. Then, as I signed out to my colleague, I realized I had glossed over important details for many of my patients.
I tried to be nice to myself about this at first and I felt like I was doing a pretty good job of giving myself grace. However, throughout this week I keep finding examples of things I missed last week and it's honestly scaring me. One patient didn't get prescribed a very critical medicine. Another left without a new Rx too, but it wasn't necessarily a critical med.
Another patient got readmitted. Not with any new diagnosis, but probably because I discharged her a little too soon.

To be honest I'm not really sure what happened... maybe I trusted my residents too much to catch these details and sign the discharge med rec correctly? Maybe the new-ish interns weren't ready for this level of trust and the new-ish seniors didn't have the bandwidth to catch it?
Maybe I was trying to protect my work/life balance, so I didn't obsess over the charts as much as I normally do and I didn't double check everything?

I don't know but now I feel pretty shaken. I don't want to miss things like this in the future, but I also don't want to feel paranoid and anxious about all the things I could be missing... I want to be able to trust my gut while also finding a way to make sure I'm still thinking critically.

Model 1:
Thought: I provided sloppy, sub-par care last week. I must not be qualified or smart enough to handle this job.
Feeling: shame, anxiety
Action: start second-guessing myself, Spend way more time chart-digging or double checking things.
Result: less free time to recharge. Worry I'm going to get burnt out.

Model 2: (more helpful)
Thought: I'm not sure how to avoid the mistakes I made without becoming paranoid or second guessing myself all the time.
Feeling: anxious, confused
Action: I will probably reach out to mentors to get their advice on this (I feel safe asking our program director and respect her opinion)
Result: hopefully will gain some wisdom/insight that will help me move through this experience and learn something from it.

Any advice from a coaching perspective and a fellow attending perspective working with learners would be much appreciated!!!

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Wow — I’m so glad you shared this, and especially the way you framed it. This is an incredibly relatable thought download. I’m right there with you — I find myself in this mindset often and need the same coaching personally. As I put my coach hat on, it sounds like the core question underneath everything is: “Do I have to overwork, be anxious, and feel paranoid to avoid mistakes?” And right now, it seems like you believe you do.

Backing up a bit, it appears that you might have some guilt about the few things that you learned had happened on your service that week that you wish hadn't happened. And I could certainly coach you around the fact that we will never know if these events were actually preventable, how high of standards you want to set for yourself, how many mistakes are "allowed" for you in patient care, etc. etc. But I don't sense that is the most productive place to dive into here. The issue seems to be more around how you want to both treat yourself and move forward when you have the circumstance of doing (or not doing) something you wish you hadn't. The first stepping stone here is to recognize TRUE guilt- which is a feeling that comes from a thought "I did something wrong". It's an uncomfortable feeling, but if processed and allowed, it usually fuels corrective actions in the direction of our values.

In your model number one, you highlight the most slippery slope of the feeling true guilt, which is it's potential to accidentally slide into the feeling of shame (shame comes from the thought of "I AM wrong")- and shame, unlike guilt, almost NEVER fuels any productive action, and usually just has us falling further into a hole of hiding and avoidance, and beating ourselves up. So even if it feels justified, it's helpful to write out these models since we can see that shame isn't useful.

You did a nice job moving into your model #2 here, which certainly has the possibility of being more productive, however I see that you still haven't reached out to mentors or moved towards a direction that you like, and you still seem to be in a limbo place here (which I'm guessing also involves rumination, perseveration and some mental/emotional pain). I bet this has to do with your core belief that you need to be paranoid and self-doubting in order to not make mistakes, does this sound more true to you:

C: three patient care things happened while you were on service that you wish hadn't
Thought: Maybe I should be paranoid and second guess myself to prevent these things from happening
Feeling: anxious
Action: be paranoid and second guess yourself. Worry, ruminate, indulge in confusion. Consider reaching out to mentors, but don't move on it yet. Don't actually do anything except be hard on yourself in your head.
Result: Limbo. (paranoia and self doubt only getting in your way, you have no wisdom/insight yet).

Ok- so to get out of limbo, you've got to access and practice a new thought. This one is so far not true. Which is great since this one doesn't make you feel good 🙂

Let's explore the line between being conscientious and being paranoid. I can clearly see that this week’s discomfort is actually data showing that you care deeply about patient safety and also about your own well-being. Is there a version of “I care deeply, and I’m learning” that feels truer than “I’m sloppy”?
You are off to a great start by bringing curiosity instead of fear to the whole thing, that is the energy to hang on to.

Some Qs to get you started:
How could these experiences make you a *more* skillful attending, rather than a worse one?

If rumination doesn't make you excellent, what might? (reflection? care/careful? wisdom? something else???)

As you think about the kind of attending you’re becoming, what’s one small belief you could start rehearsing this week that aligns with that version of you?

These were great reflective prompts, thank you. For me, I giving myself grace usually involves me reminding myself that my feelings make sense (thanks Adrienne!). My internal dialogue is something along the lines of "it make sense that you're feeling this way and that's OK" sometimes, the F that comes from this T is the release of the energy and tension of it and moving on, and other times the F that sticks around is staying mad. I don't know that I DO anything for myself... this is a good observation.

I think "getting over it" would mostly open up less time spent in the negative (but human) emotion of anger, disappointment, and sadness. The truth is that in the grand scheme of things I don't actually spend much time here. "Getting over it" would also enable me to spend more time value-aligned with who I want to be and how I want to show up. I'm thinking here that maybe with this awareness I might be able to drop the anger faster just because I want to. The cost of getting over it seems low. I would have to part with maybe my ego a bit, and the need/desire to understand someone else's behavior and decisions. I think I'd also need to let go even more on the wishing it wasn't this way-- so I guess that'd be parting with an unrealized hope/expectation/desire; a willingness to welcome life just as it is.

ANSWER:
Love these reflections.

Is it a problem that the F that sticks around is staying mad? I ask this with genuine curiosity, because sometimes being mad serves us and is values/aligned. Being mad is not always bad.

What do you think that anger is telling you? Is there anything else it wants to signal to you or remind you of that's making it hard to release?

Of course you have the ability to drop the anger whenever you want to. And of course that will give your ego a little hit.

I'm interested in how you have a desire to understand the other person's behavior and decisions. Is this a thing you notice about yourself often? In what ways has that helped you or is that skill a strength of yours? In what ways does it serve you (or not) in this case?

What's next for you here?

<3

I have some feelings that I don't enjoy feeling related to a colleague at work. I recognize that my thoughts are driving the feeling. I'll give a bit of background then try for a model. Background: I was hired approximately 5 months after my colleague, and we were connected before either of us had started the job. We have a lot of similarities on paper and it seemed like a natural opportunity to partner together in research. At the institutions where I trained. faculty with similar interests had paired up to collaborate and offer mutual support and research resources. When I was in fellowship I saw this model work extremely well and was mutually beneficial to both parties. Before joining the institution I had suggested a similar set up, and again suggested it throughout my first year. It became clear that for whatever reason this person did not want to partner with me in research despite having nearly-exact overlapping research interests and need for similar resources and support. About 12-15 months in I made the decision to hire a research coordinator, and this person went behind my back to try to "scoop" the research coordinator from me. While I am glad that I'm not tangled in a research relationship with this person I still hold confusion about their actions toward me, including their behavior (which I will never have the benefit of understanding), and their underlying circumstances or perceptions. On the surface we are collegial and friendly colleagues, which almost worsens the situation and deepens my mistrust of the person. Here is the current circumstance.

C: I get email notifications of journal Table of Contents and PubMed alerts. I see that this person has published something. Also, the thing that she has published is very much in my line of interest and research inquiry.
T: I hate her
F: Anger (which probably masks continued hurt, confusion, rejection),
A: Be mad
R: Stay mad

also,---

C: I get email notifications of journal Table of Contents and PubMed alerts. I see that this person has published something. When I saw her name and I got angry/upset. (For what it's worth this also happens when I see her in person; when I see her it's almost like I feel like I've been punched in the chest and have to catch my breath. In person it's predominately sadness/disappointment/confusion; for this example with seeing her publication it was anger.)
T: I don't want to feel this way about this person.
F: Irritated/unhappy that I'm experiencing/projecting such strong negative emotions toward another human,
A: Try to give myself grace, circle back a lot to still feeling mad and still wanting to not feel mad.
R: Am disappointed in my ability to not find other feelings here/get over it.

Thanks in advance.

ANSWER:
Hello friend. Thanks for bringing this here.

Oof, I'm so sorry this is happening. This isn't the partnership you were expecting or hoping for, and that stinks.

Good awareness in your models. Be mad--> stay mad is FOR SURE the result.

In your second model you have the feeling Irritated/unhappy, and then the action of "try and give myself grace", but this doesn't work because Giving yourself grace does not come from irritation/unhappiness. We call this a "mixed" model. irritation and unhappiness probably actually leads you to continuing to scold yourself for holding on to this.

When you say, "Give myself grace", what does that mean to you? How do you offer yourself grace in this scenario? be specific. What do you say to yourself? what do you DO for yourself?

What would "Getting over it" open up for you?

What would the cost be, to you, of "getting over it"? In other words, what would you have to part with?

Bring it back!

I brought a scenario to coaching last week, and Tyra asked me to think about how/why it is good to see difficult patients. And I am trying....but really, as I think about what happened, I am honestly more stuck on criticizing myself and less so about the patient or having a difficult patient. I think I am pretty good at the ethos "he's a grown man, he'll do what he wants" and really accept that I can't change others - what I struggle with is my response to them. So I'd like to work through some of my negative feelings about how I responded to this patient.

C: I am a new attending and I saw a new patient and prior to the visit, had done chart review and had written down a piece of social history into my note. We didn't talk about that social history in our visit but it was still in my note when I signed it. He paged me directly one morning at 7:45am and was very upset at me when I called him back. I was startled to be talking to a patient and being yelled at by a patient and said words. He cancelled his follow up appointment with me and wrote in the comments that I was "rude and inappropriate and reluctantly removed the information he asked me to remove". The schedulers and practice manager saw this feedback and asked what happened. I explained what happened from my perspective. They are putting him in someone else's schedule.
T: I should have been more polite/less upset on the phone. I could've spent more time listening and less time responding. I shouldn't have told him that it was inappropriate for him to page me directly and that he should've called the office. Do I have a "reputation" now?
F: Shame, fear - what if I do this again?
A: Perseverate
R: Having trouble moving past this

I'm not sure how to break this loop. Of course if I had been more prepared for the conversation, I probably would've handled it better. And I suppose there are lessons that I'm taking away from this. I am just having trouble accepting a ladder thought of "I have thought about what happened and have ideas on how I can respond better if a similar situation happens in the future" to change the feeling I'm having. The ladder thought feels true. But it's not generating a new feeling. Is there a different ladder thought I should try?

Hmm....I just added the "do I have a reputation now"? thought and maybe that is the real issue....so what could be a ladder thought to get me away from that?

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ANSWER
Great job recognizing your loop here, and how hard it feels to move out of it! We could coach for hours around how this patient’s reaction reflects something about their experience, rather than about you, or about what parts of the situation were within your control, but my sense here is that you know this, intellectually. Generally, feeling stuck even when you know something rationally, is a sign that your brain isn't ready to adopt or move into a new thought for a deeper reason.

It sounds like you are really resisting how you showed up. You are wishing you had more time to prepare, more time to think about how you wanted to respond, and that things went differently. But, they didn't. The first place to start would be with this reaction TO your reaction.
The place you are in right now is:

C: Patient and said words to me about our visit that surprised me and triggered shame. I said words back that I wish were said differently.
T: I should have been different
F: Shame
A: Perseverate, worry about your future, that you have a problem with reacting, catastrophize about maybe having a "reputation"
R: You speaking to yourself in a way that isn't helping

Ok, the good news is that the entirety of the problem in this model is all in how you are treating yourself. How you are talking to yourself, defining the narrative of what happened, and considering how to move forward. This is good since nothing has to change for you to feel better in this model.

I want to gently look at this thought here (and the theme of allll the thoughts above) that you should be different. Is that really true?
Let's see if we can apply the same exercise here about looking for the good in what already happened, in what is. I know it feels like a stretch, but I promise this is where the magic happens.

What is good about noticing when you wish you acted differently? Get creative here and really ask yourself this. (do you really wish you never felt regret? what would be different about you if that were the case? Do you expect yourself to show up perfectly in all unexpected situations? Is there anything kind of nice/funny/reassuring/connecting about the very human way that you did show up? Are there any strengths that showed up in this response that you are disregarding? WHAT ELSE??)

Once you answer these Qs, I wonder if you could try on a different thought ladder, not one about your thoughts in the moment of stress, but the ones about your thoughts about yourself and your reaction after:

Some examples to get you started:
“Everyone has moments they wish they handled differently.”
“I am learning and growing.”
“It’s okay to be upset and to feel shame.”

-Who decides what the “top” of your training is? (what does that term even mean to you: skills? impact? recognition? fulfillment? patients cared for?)
I guess no one can really decide definitively what is the "top of my training" but in taking this private practice job, I gave up taking care of a certain patient population and also gave up doing procedures (the practice divides up the roles differently). So it does feel like a very specific thing to say that "I trained to do XYZ and I have numbers about all those patients/procedures from my fellowship training" and now I am not doing that. Impact is a tough thing to gauge too because everyone's a critic and positive feedback is limited, though I have had some patients tell me how much they like me. (This is probably another thought model - I really relate to the imposter syndrome spiral post - I thought I was doing so much better about not letting others' opinions define me but as it turns out, new attendinghood is definitely a time where I crave positive feedback).

-What parts of your decision still feel aligned with your values?
I wanted to have a job where I felt valued and where I wouldn't be a cog that is expected to work under crazy conditions. This is where I think I let my experiences in fellowship color me. In fellowship, it was routine for an attending to see 12-16 patients in clinic in the AM and then round on 25-35 patients in the PM. Notes got done at night or during "admin/research/education" time, which meant that there was little time spent on actually career development. I feel like my current job is aligned with my goals to NOT work like that, but I can't help but wonder if my experiences encouraged me to "call it quits early" with the job search.

-What parts of this job are perfect for your season of life right now?
I am home at reasonable hours! And the time I spend in charts at home is extremely minimal, which allows me to spend time with my husband and baby. Call is not too burdensome. I am close-ish to where my parents live and I could be there later that day if something happened.

Maybe the path forward is leaning into the thought that no job is perfect and that while this job isn't "top of my training", maybe it's good enough to have a reasonable work-life balance and also to help patients. The habit of being on the hamster wheel and racing towards the "next, biggest, fanciest, thing" is a real difficult habit to break.
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ANSWER:
This is awesome insight! Since you have realized that there is no judging body that decides what the top of your training is, could it be more accurate to say:

C: No job is perfect, in my current job I don't do X,Y,Z that I learned how to do in fellowship. I do A, B, C, etc. that I did learn in fellowship. My hours are #/week, call is #/week and I live # miles from home/parents.
T: Maybe it's good enough to have a reasonable work-life balance and also to help patients
F: ???
A: ??
R: ??

I'm curious what comes up for you in this model. My guess is that your brain is still attracted to re-joining the rat race out of habit, but perhaps also out of a belief that it's somehow "better"- could you explore this?

Does your brain equate "top of training" to a "busy academic job"? Just interesting to know if so. It makes sense, since you trained in that environment and likely admired a lot of the people for a long time. Medical education tends to idolize being overworked and self-sacrificing, so it's not hard to see why many of us end up accidentally placing some kind of inherent value or moral high ground on these facets. But I want to be clear that there is no job that is inherently more valuable just because of business, type of procedures or patient acuity.

Now- if we can't find and define the most valuable job, what should we be aiming for? Good news- it's the one you LIKE the most. 🙂 The question becomes: What kind of work life helps me feel most like myself? When you orient around that, “top of training” becomes less about prestige or volume and more about alignment and sustainability. We could even think about "top of my own life desires" or "top of this phase".

If you find yourself missing that type of patient care because you just intrinsically love those X/Y/Z procedures, then that's good to know. It doesn't have to direct you back there, but sometimes acknowledging real grief that may be there helps with closure and moving forward with your choices for right now. But when your thoughts are all tangled up in judging "top of training" or what you should be doing just because you saw others do it or trained in a certain way, you can't ever even figure that out.

Time to get to know yourself!

I am a new attending (I see a theme here!) and stayed at the same institution where I trained. I stayed because I love the department I am in, I know I can always ask for help and feel comfortable asking, and I feel supported and respected by my colleagues. Even so, I don't trust anything I am doing and it's leading to significant self-doubt about my knowledge, my clinical choices, and I feel a need for constant approval. I felt this in my training when I transitioned to a senior resident role, where I felt that I needed people to tell me I am doing a good job, but then felt that I can't trust what people are saying because they probably are only saying that so I don't become even more anxious. I also feel sort of paralyzed about making clinical decisions, worry I'm not advancing my patient's care, and likely am wasting time going over things again and again. If I calm down and think about what is true--I know I deserve this job and that I was hired because people saw me during my training and wanted me to be a part of this department, but I can't seem to make that thought overcome the more anxious thoughts.

C- I am a new attending, seeing patients on my own for the first time and supervising trainees
T- I am not sure I am doing a good job, I want someone to just tell me I am, but I won't believe them if they do
F- anxious
A- perseverating on clinical decisions I made last week, taking so much time chart reviewing patients and going over the same data to make sure I didn't miss anything, telling people "jokingly" that I'm not a real attending so I need to ask for help
R- not having good work/life boundaries (constantly rechecking charts at home), taking patient outcomes personally, not sleeping well, which all results in having less time to decompress from work

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

Oh MAN this is relatable. Very commonly, the transition from resident to attending comes with a steep drop in the amount of feedback you get (informal and formal), right? Like, of course, it does. But man I was in feedback withdrawal for a WHILE when starting my first job out of training. Then... the brain, doing what it does, fills that void with MEAN THINGS. "What are you doing? Do you know what you're doing? You're doing it wrong! People are going to think you're a moron!" Etc. That's what brains do when there is a void they think they need to fill and the inner critic is at the control desk.

OK jumping out go the pool now and putting on my coach hat.

Your model makes a lot of sense, right?
When you're thinking "I'm not sure I'm doing well, and I wouldn't believe anyone who said I was", it makes sense you're feeling anxious. When you're feeling anxious, it makes sense that you're perseverating on clinical decisions, spinning as you describe, and then it makes sense that those actions have you proving to yourself that you're not doing it right.

I totally get it that your other thoughts that you know are true
" I deserve this job" and "I was hired because people wanted me to be here" are feeling like a bit of a stretch to believe in the moment when you're spinning.

I want to do a model where we put this whole spiral and its existence up on the circumstance line.
What happens when we make it a circumstance that the transition to attending can come with feedback withdrawal and also some anxiety. Now what?

C- Attending transition. Less formal and informal feedback. Your inner critic is filling the void. You are experiencing anxiety and sometimes have a spiral about that. Sometimes people feel anxiety and spiral about that.
T-________________ (what do you think about that new circumstance?)
F_________________
A__________________
R_____________________

What are all the ways it makes sense that your anxiety is active right now?
What are the ways it doesn't make a lot of sense?
Your inner critic is working hard to protect you from something. What do you think that is?
What does your inner critic need to know from your inner wisdom right now?

Bring it on back here!

It has been so helpful to read others’ posts, esp those who are also starting new attending roles. I also have thought models about asking colleagues for advice etc but will post them separately. More recently, I have been stuck on this thought model.

C: I am in a subspecialty and I just started my first attending job. It is a community private practice job and in this role, I cannot do everything that I have done subspecialty training for. I did not apply to many academic positions due to geographic limitations and job hunting fatigue postpartum. I was also worried about staying in academics and the tight rope of balancing clinical care, education, and publishing for promotions, given what I had seen during my fellowship. Of my job offers, I chose this private practice job for location and quality of life. Someone recently asked me why I didn’t apply to X institution and I didn’t have a good reason why I didn’t apply.
T: I picked the wrong job. I should’ve applied to more academic institutions instead of assuming everything is bad everywhere.
F: shame for leaving academic medicine. Guilt for not practicing at the top of my training. Worried about getting out of touch with newer advances
A: ruminating. Is the grass greener elsewhere? Was I too blinded by the circumstances at the academic institution where I trained?
R: not enjoying the perks of the job I do have (which is so far, pretty great. The people are nice, they are easing my in slowly, and they really are focused on quality of life)

I remind myself that that I chose this job for valid reasons, but it still doesn’t quiet the feelings of guilt and shame and worry. Are there other ladder thoughts I can try?

Thanks in advance!
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ANSWER:
I love that you’re putting this into words—it’s such a common dilemma after training. One thing that might help is to streamline your model to focus on just one feeling at a time. Right now you’ve got shame, guilt, and worry all tangled together, which makes it hard to see clearly. For example:

T1: “I picked the wrong job.” → F1: shame
T2: “I should be practicing at the top of my training.” → F2: guilt
T3: “It’s too late to change.” → F3: worry

Let’s work with one:

C: Someone asked, “Why didn’t you apply to X institution?”
T: I picked the wrong job, should have stayed academic.
F: Shame
A: Ruminate, compare, doubt yourself, overlook the positives, make self-critical comments.
R: You create a lose–lose loop where you can never fully enjoy the job you did choose.

Ok- I also picked up on the prior thought "assuming everything is bad everywhere". Woah! Why assume that? Yes, no "C" is better than another inherently, which is true, but looking at it through a negative lens will always lead your brain to find the negative. Each practice has it's own downsides, you can't get the perfect medical atmosphere anywhere, etc is certainly true. But so is the fact that each practice has it's upsides, and you can MAKE it perfect for you with how you look at it.

Some questions to start nudging you towards thought flexibility:
-Who decides what the “top” of your training is? (what does that term even mean to you: skills? impact? recognition? fulfillment? patients cared for?)
-What parts of your decision still feel aligned with your values?
-What parts of this job are perfect for your season of life right now?

I am now starting a new job as a new attending. How do I balance asking questions of peers with the fear of my colleagues wondering why I am here?

ANSWER:
Hello! Thanks for being the first poster of the fall cohort.

We like to call what you are in a "FFT" or "Freaking First Time". That term was coined by Dr. Brene Brown about the uncomfortable feelings that come from doing something or being in a new role for the first time.

We are going to dig deeper into that concept more in month 4, but the first step in managing a FFT is by NAMING the FFT.

So let's start with that!

I'm going to ask you a few questions and I invite you to reflect on them and bring anything that comes up back here or to a live call for some more coaching. OK?

First we are going to try to get an idea of what your beliefs are and where they are coming from:
- Why might it make sense that you are very sensitive to what people might think about you right now?
- Your brain offers you that there is some amount of OK number of questions to ask but beyond that will prove you're an impostor. What do you think your brain is trying to protect you from?
- When you think the thought "My colleagues are probably wondering why I'm here". What feeling or emotion comes up? Let's put that into a model.

Circumstance- You're in your first year (or x months) as an attending (neutral fact)
Thought- My colleagues are probably wondering why I'm here.
Feeling- ________________ (name ONE feeling or emotion that thought generates)
Actions- ________________ (name as many things that you DO or DON'T do when driven by that feeling)
Result- ___________________(The sum for you of those actions.)

Take a crack at filling in the blanks in that model, and bring it back here when you're ready.

Looking forward to continuing this with you.

Welcome to Ask for Coaching!

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Bring it on, friends!

I wrote into a faculty call recently about how I'd been telling myself that I "shouldn't" get mad at residents. For context, this all stemmed from a single day with one resident who shared a LOT of opinions on patient management in the OR which led to a lot of debating on points where I knew objectively that he was wrong and I was correct. But as a new-ish attending I was struggling to handle the situation and have been ruminating on it for weeks to months now. Hence, the idea that I "shouldn't" get mad. But through the coaching call I realized that 1) I'm gaslighting myself and it is ok to get mad sometimes, and 2) my anger was more at myself for not knowing how to handle it than at the resident. I was given the task of thinking about what the "best" version of myself would have done.
I decided that my best self honestly would have still gotten mad LOL
But the best version would have also found a way to sit this resident down and give some feedback on what made his behavior inappropriate. So I asked myself what I'd have to feel to give feedback still. I decided empathy for the resident was what I needed. I tried thinking, "I want to give feedback because I care." That thought didn't resonate with me at all. (My annoyance is still pretty strong.) So instead I tried, "Even if I don't care about the residents, it still will matter to them how I choose to show up."
Can't say that thought is 100% perfect, but I tried it with a medical student a few days ago and it actually worked well! Progress!

ANSWER:
Thank you SO MUCH for bringing this here. We love to hear a win!

Thank you for sharing with us how we can have compassion for ourselves even, or ESPECIALLY when, we might not have been at our best.

Thank you also for sharing how "progress" doesn't have to be "perfect", when it comes to showing up nearer to your best self in these challenging moments.

I wonder what the full model is that you tried on in the wild. What feeling/actions did this generate that lead you to this win?
T- Even if I don't care about the residents, it will still matter to them how I choose to show up
F-?
A-? (get juicy here what were the things you did or didn't do when you were trying this out that made it feel like a step in the right direction?)
R- You show yourself the ways you DO CARE about how you show up

If you're looking fore more threads to pull on I spy a few more things to explore 😉

You said that you'd like to feel empathy for the resident. Have you been able to access that yet? It's OK if not. Today in a workshop we were giving (on feedback, no less), Tyra and I encouraged folks to try "radical perspective taking" to try to imagine what the trainee might have been thinking/feeling that day, and to challenge ourselves to find our most generous interpretation (MGI) of their behavior.
If you were to embrace extreme curiosity here, could you take a guess at the model the resident was operating from that day? You probably will never get to know what it was, but let's take a minute to take a guess that offers the most generous interpretation of their behavior

(this is from the perspective of the resident)
C- In the OR with Dr. X
T- "________________"
F- ______________
A- share my opinions about the management of x/y/z, offer defense of my reasoning, (what else)____________________
R- _____________________

You said the thought "I want to give feedback to [to the resident] because I care", and you said this didn't sit right because you are still feeling pretty annoyed.

Is it possible to care AND be annoyed at the same time? Why or why not?
Is it possible that you are annoyed BECAUSE you care?

Thanks again for bringing this back here and for being part of our community!

I am feeling like I may need a job change. I am a mid career physician and lately my job is bringing more stress and less joy. I have children and want to be able to be more flexible in the next 10 years and cannot see myself doing my job in this way for 5-10 more years. I have more recently been allowing this feeling instead of avoiding the thought and staying busy. The things that I specifically don't enjoy are weekends, overnights, holidays, increasing complexity of some of the work, time spent outside of work on work-related projects, and extra duties of being in an academic institution. I do feel that I have been fortunate and privileged to have a job where purpose is immediately apparent and I love my colleagues but I also feel TIRED of it all and find myself looking for an easy way out. Have been stuck in this feeling for a while and not sure how to navigate. Feeling vulnerable as I write this all out and realize that I am a privileged person. Thanks for any help.

ANSWER:
HI Friend!
I am really glad you brought this question. I love the work you are doing to "allow" and not "avoid" the uncomfortable thoughts that are coming up. this is THE WORK.

You've done some good digging here to really look at the parts of work that are most challenging from a sustainability perspective (nights, weekends, holidays, extra duties outside of work), and the things that you enjoy (your colleagues, connection, also probably service from what I gather here).

A few questions for you here:
Why does it make sense that you are longing for more flexibility in the coming years?
Why does thinking about how to gain that flexibility mean you are taking "the easy way out?"

So whenever we think we wan't to change our circumstance, it's because of how we think it will make us feel. On some level, you think that a different job (or maybe a break from working?) will mean that you don't have to feel stressed, frustrated, sapped of joy, stuck, tired. And that may be the case for a bit, but of course, because we are human, they will pop up again somewhere.

It makes sense that you do not want to feel those feelings about work though, and you might like your reasons for thinking about leaving. To figure that out I have a few more questions
- I notice a tone of self-judgement in your reflection here "Easy way out", Realization of your privilege, etc). What's the judgement about here? Do you think that because of this privilege, you're not entitled to choice around staying or going?
What does it mean about you if you stay?
What does it mean about you if you're thinking about going?
What does it mean about you if you actually do leave?

Here is a model to see how the "easy way out" thought might be playing out:

C- I am a physician who has worked "x" number of years.
T- I am looking for an easy way out.
F- stuck (does this feel right?)
A- avoiding thinking about how you feel, staying super busy, staying overwhelmed, judging yourself harshly for not being happy and appreciating your job and realizing your privilege
R-You make this decision harder for yourself. You create less ease for your work life (and your home life?).

How does that land?

Ok A lot up there to dig though so I'll leave you with it for now. See what comes up for you and bring it back!

This one is... probably not easy.

C: I have a personal history of sexual assault. I'm married. My husband and I recently started couples counseling and part of counseling will explore our sexual intimacy. I trust the counselor.
T: I don't want to do this part of the work.
F. It's like a visceral feeling of fear/dread/low grade panic
A: Wish I could just do all parts of couples counseling but this part. I'm going to put dread as a verb in the action line also here, as in I am dreading this work.
R: Still dread? It's feeling like my results are my feelings in this model.

I'm going to add one more set of C and F to the above model, let's see if it helps in any way.

C: The above C, plus also I really want to believe and have in the past held really tightly to the belief that my history of assault just was what it was and didn't really affect me much; and also that I'm just a person that doesn't have a need for sexual intimacy and that's OK because that's just who I am.
T: Oh fuck. These things might be more related that I've given them credit for; maybe I actually never really did process this trauma; I still love current me, I want to improve my marriage but I don't want to do this part of the work.
F: Same as above
A: Same as above
R: Same as above

I cognitively know that not doing this part of the work will not get me the result I want, which is a stronger marriage. Current me doesn't actually want anything more than my current situation in terms of sexual intimacy and is afraid of exploring this domain of my life.

I will probably bring this to a call at some point but thought like it might be good to start here. Thanks for your help with this.

*****Addendum*****
I'm not normally a journaler, but it's funny how writing out the model I previously submitted (which I had been feeling stuck in for sometime) has helped me access a new T- (which has, until now, felt unavailable). Intentional Model:
C: Same as before
T: I want my marriage to be stronger and this is part of the work. I can do hard things.
F: The feeling here seems more open, less dready
A: This new thought doesn't have me fighting with reality like the other model did; this is more maybe acceptance (as an action)? Acceptance that to achieve my goal of a stronger marriage that part of that process is doing the work.
R: More open, acceptance, less fear? Again, it seems like my R is a mix of my F and A line. There is still some fear floating around the edges of this model, but it feels much much less.

ANSWER:

Well, my friend, you may have graduated a bit more in the self-coaching realm here. I love seeing the evolution that happens with simply writing out your feelings (instead of the usual just letting them zoom around unsupervised in our head). And yes, I would put "resistance" as your R line in the first model, as you point out at the end.

I love the new T, and if it feels believable to you then try it out in the wild for a while.
And also, I wonder if there is a part of your brain that thinks your initial T ("I don't want to do this part of the work") is wrong or bad or should be different? I realize that, alone, that T is creating dread. But I wonder if there's a way to let that T still be true (since, I imagine it still is true for you) AND add in this new work.

Another question I have is around your link between exploring your sexual intimacy and a stronger marriage - it seems you believe you "must" do the former to get the latter. Now look, I agree that exploring your sexual intimacy will almost certainly bring strength to all of your relationships (most notably with yourself!), but I also offer you to open to the idea that simple curiosity around this topic (at first, perhaps withOUT the dread-y work part) could also strengthen your marriage.

Is it possible that talking about how much you dread and don't want to go there with open non-judgement (with and without your husband) could strengthen the marriage? How so? In what ways?

Combined bridge/intentional model:

C: Personal history of sexual assault. Married. Plan is for part of counseling with a trusted counselor to explore sexual intimacy. Past belief that history of assault didn't really affect me much; and also that you identify as a person who doesn't need/want sexual intimacy. Belief systems can change.
T: Oh, fuck. I don't want to do this part of the work, AND I love myself, want my marriage to be stronger and this is part of the work. I can do hard things.
F: ?? (try to name it - is it open? committed? curious? optimistic?)
A: cease the resistance, accept and explore both your sexual history beliefs and how to strengthen your marriage, however that looks.
R: You do hard things, strengthen the relationships.

What else belongs in this A line for you right now? Flesh it out a bit for me
(turning towards the inner protector? Allowing it to say what's ok and not ok for the time being? getting curious about what other beliefs you might hold that could shift in the future around intimacy? Writing them all out? Sharing them? Not sharing them? re-reading them at intervals? What feels right???)

Yes, let's keep going!