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

=========================
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!
==================
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!!!

===================================
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?

===================================
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.
===================================================
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!
========================================
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!

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

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

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

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

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

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

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

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

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

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!

There has been a lot happening around my position lately, much of which is outside of my control. I recognize that I can only manage my own decisions, but due to the ongoing turmoil, I’m feeling overwhelmed and unable to bring my best self to work. These challenges are also starting to significantly affect my home life. I had a 1 week vacation that I couldn't unwind and did not come back at all refreshed. At this point, I feel like I truly need a break. Since vacation requires 90 days’ notice, I’m wondering if it would be reasonable to request personal or “sick” leave under these circumstances? I can count on 1 hand the amount of time I took sick leave in my 15+ career (1 of which I was in labor ;o), so I don't take this lightly.

ANSWER:

Hi there, thanks for bringing this here. I want to recognize what a good job you are doing here of noticing your overwhelm and how it's impacting how you are showing up in your work and at home.

In our coaching hats here, we don't advise on what you should do, but I can absolutely help you work through how you can make this decision by aligning and supporting yourself and your needs.

You said you were feeling overwhelmed and you don't like how you show up when you are operating from that place. Based on your reflection here, I can tell that you have strong values of integrity, honesty, and service. You consider yourself a hard worker, and you like to be proud of the way you show up in your work. You're also a person who takes their work seriously and doesn't call in unless it feels really serious, right? What else comes up for you here?

I have a few questions I hope you can reflect on and bring back here for more.

When you say "I'm unable to bring my best self to work", what does that mean for you? Can you be specific. No judgement here at all. Just can be helpful to know what this means to you.

When you say it's also impacting your home life, what does that mean to you? Are there things you see yourself doing or not doing that tell you that you're meeting your limits?

When you think about your role as a physician, how have you (over years of training and practice) calibrated what "is" and what "is not" a "reasonable thing" to call in sick/take leave for? Are your rules for yourself different than they would be for others? If so, how?

What would have to happen for you to KNOW you needed to take leave starting now?

Will be here when you're ready.

I am experiencing a very similar situation to the “conflict in values” coaching question posted! I started seeing patients in my first job post residency November 18, I requested a slower ramp-up to my clinic schedule and have been called to multiple “touchbase” meetings with management about not meeting expectations, now focused on behavior but without specific examples. My patient feedback and scores have been overwhelmingly positive. I’m not sure what I’m missing or what to focus on. It’s really taking a lot of brain space away from patient care and is affecting my mental health, but also feels targeted and retaliatory, I feel it’s important to respond and defend my professionalism. It seems weird that this all started from a scheduling request.

ANSWER:
Hi there, thanks for this post! Let's put your thought download into a model and then dig into the value conflict

C: You are in your first year after training. You requested a slowed ramp-up template. Management has given feedback that you are not meeting expectations, and there is a focus on your behavior.
T: This is targeted and retaliatory
F: Defensive
A: Question what they mean without getting clarity, ruminate/perseverate on this, spend a lot of brain space on this instead of on patient care
R: Mental health is affected. You target this issue primarily in you brain

Ok- my main questions for you are around clarity in your C line:
1) what evidence do you have that this feedback is related to your schedule request? Has this been said explicitly? If not, then this is actually a thought, not a circumstance.
2) What specifically are the words that have been said about your behavior?
3) Who is management? Who else is involved in your job?

Once we can fully separate the circumstances from the story then the value conflict becomes clear -

-what values do feel are in conflict here?

(I'm guessing from your download that you are feeling a pressure to see more patients, and also that you feel comfortable/capable seeing only the current amount of patients - but this is an assumption- is this correct?)

Adrienne did a coaching session this week that reminded me of this poem. Also, I love to listen to everyone's coaching on the podcast as I find so many similarities between what others are navigating and what I am also figuring out how to navigate. So thankful for this community.

How Much More
by Kristina Mahr

When I donate blood, I don't ask how much
they'll take from me, I just assume that they'll
take what they need. I trust that they'll leave me
enough to survive, that they won't take too
much, but I wonder at what point I'd stop them.
If I would stop them. How light-headed would I
need to be? How weak-kneed, how dizzy, how
brave, yes, brave, I would need to be brave. To
stop someone taking. To say, I have no more to
give. To walk away from someone who says they
need more.

I would need to be brave, but how brave.
How brave. How brave. Oh god how much more
brave.

ANSWER:
Thank you so much for sharing <3

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

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

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

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

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

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

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

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

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

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

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

<3

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

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

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

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

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

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

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

Thanks for showing us what is possible here!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

F-Frustrated, Overwhelmed, Annoyed

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

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

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

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

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

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

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

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

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

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

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

Some questions to try to untangle this:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

How does this model resonate with you?

NOW-
How do you want to feel about this?

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

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

Try this thought model on-

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

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

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

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

Will let you know how it goes!

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

What do you think that model would look like?

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

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

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

A- ________________

R- ________________

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