“When you show up to those evaluation meetings, I want you to show up like a star athlete, wanting to improve in every way possible. We want you to become the best doctor there ever was.”
This was the response of an education specialist when asked how can residents cope with being constantly scrutinized and given “areas in need of improvement” at every assessment that occurs at least once a week.
Growth based mindset is a valuable asset in anyone, especially in young doctors who have so much to learn. HOWEVER, there comes a point where a resident becomes good enough to practice safely and competently according to practice guidelines. Beyond that point, it can be extremely demoralizing for residents to receive criticism on something that is not helpful for improving the quality of patient care in a measurable way. Specifically, receiving feedback for the sake of feedback, in a patient interaction where care was safely and competently delivered, can be exhausting for the learner. It can also impede their sense of mastery, contributing to burnout, anxiety, imposter syndrome, and demoralization. At the time of COVID-19 where residents are being redeployed into areas outside of their specialty in a particularly stressful environment does not make things any easier.
We see this outside of medicine as well. Social media bombards us with messages of “be the best you can be”, “achieve all that you can”, etc etc… While these messages can be motivating to a certain extent, it can also feel like a lot of pressure in this world that is already so competitive and stressful.
You ARE enough.
Did you get up today and go to work, even if you didn’t want to? Did you do what you could to finish the work that was needed within a reasonable time frame within the minimum required standards? Were you reasonably kind to others and didn’t hurt anyone, including yourself?
GREAT! In some days, even doing these things can be extremely difficult, so great job!
As a society, it is time we re-evaluate this “growth based mindset”. Growth is great, but so is happiness, satisfaction, and gratitude for who we are today. Striking the right balance between these essential aspects of life should be the focus, not endless “growth and expansion” at the expense of one’s wellbeing.
The sickness role is a psychological concept that we give to patients to help them recognize the fact that they are NOT to blame for having an illness. Being ill is NOT something to be ashamed of, something to apologize for, and they are certainly not responsible for being sick.
Unfortunately, some people have misunderstood this concept to mean that they have no role in their healing, that “others” should be entirely responsible for their care and recovery, and they avoid taking ownership of the fact that their actions DO matter in how their healing journey will go.
So yes, none of us are responsible for having an illness AND at the same time, we absolutely DO have a responsibility to take ownership of the healing process.
A good example that I often see at the ED are patients who are coming in due to various ailments, none of which are significantly impairing or acute, because they would like a formal diagnosis or a second opinion for their condition. These ailments are often things like chronic pain, tension headaches, mood instability, ongoing relational issues, etc. Many of these conditions have already been looked at by (often multiple times) a specialist/ consultant, diagnosed, and treatments have been offered. Yet, many patients come to the ED looking for another diagnosis, a different “sick role” that they feel would explain their condition better. While it is completely understandable that an individual would want a better understanding of their condition, I am often surprised at how many of these patients believe that their recovery is entirely dependent on receiving the “correct” diagnosis and meeting the “right” specialist.
There is a huge societal role in this as well – we are often bombarded with images of patients coming to the hospital to be “taken care of”, where they are tucked into the bed and nurtured like a child, while taking a completely passive role in their recovery. This cannot be further from the truth. Best care is delivered when the patient takes an active role in and ownership of their own healing journey; when they take steps to best serve their body and mind. I wonder what changes we would see in our society if we start sending this message that patients ARE capable of and SHOULD be taking charge of their own health.
For example, someone with chronically depressed mood that have unfortunately shown poor response to conventional treatments can become angry at the health care system and the doctors for failing them, and this would be completely fair. AND, at the same time, they can take ownership of their healing process, and start actively engaging in psychotherapy, exercise regularly, set up a sleep schedule, explore their spirituality, tap into their social resources, and make a commitment everyday to heal.
One can use this for patients who have terminal illnesses as well. Palliative care is a large part of our training. It is incredible how patients with months left to live can make a commitment to do the best that they can every morning that they are alive. When they could walk, they would take a stroll around their neighborhood daily. When they couldn’t anymore, they got on a wheelchair and sat by the window every morning. When they were too unwell to be on a wheelchair, they listened to audiobooks and enriched their mind.
We can all take responsibility and ownership of our own wellness, and make a commitment. Us health professionals depend on our patients to work as a central piece of the healing journey. Without the patient’s commitment, there is only so much we can do.
As a witch and a spiritual person in general, I deeply believe that we are an active agent of change in our lives and the lives around us. Our will, actions, and energy DO have an impact in our life journey. Just like the spells we cast and the intentions we put forward, our everyday commitment and actions to heal from whatever ailment, physical or non-physical, WILL direct us towards our highest good.
Culture of incompetence is a phrase that us, as resident doctors, came up to describe certain hospitals that have a culture that encourages a passive form of incompetence by discouraging productive change.
This does not mean that they encourage residents to make mistakes or to be incompetent in a general sense. Rather, it means that we are encouraged, either directly or indirectly, to abide by unspoken rules that are prohibitive of increased efficiency or innovative approaches to patient care. To give an example that I had mentioned in my previous posts, I had once worked in a hospital where working fast to speed up patient care was seen as putting pressure on the team and being a bad learner. Other residents had similar experiences in this hospital, where they were asked to adjust to the team’s pace, even when it was clear that there were areas of improvement needed to make the team more efficient. The hospital had set up an unspoken rule that it was happy with the status quo, despite the fact that it was no longer serving the giant and ever growing population of patients, resulting in months or even year long backlogs of patients to see, and patients waiting in the emergency department for days just waiting for a bed to become available in one of the inpatient units.
How does a culture of incompetence form? I believe that it starts from a seed of “leaders” that believe that what they are doing is near perfect, if not perfect, and that there is no room for improvement. Any attempts at productive change is seen as stirring up trouble or even being a bad learner. This kind of culture in turn produces an environment where those who agree with this worldview are the ones who decide to stay after their mandatory rotation ends, and the saga continues.
This kind of workplace culture can cause traumatic moral injury in young and motivated learners, possibly making them lose that spark that keeps them wanting to innovate and improve. Perhaps the reason why healthcare has seen so few innovative changes in the past many years is because this culture is pervasive in medicine. As residents, we get placed in a lottery system that inevitably lands us at a hospital with such a culture at some point during our training. While I wish I could say that most of us come out of the experience with our eagerness and dreams of a better future intact, it often marks the beginnings of becoming a bitter and burnt out physician.
I noticed this change in myself more recently when I pulled out a garnet bracelet from my jewelry drawer for work today. One of my daily rituals as a witch includes picking out a gemstone to support me at work and to set intentions for the day. Garnet, besides from being a protective stone, also encourages vitality, leadership, and positive growth. Since being burned by this culture of incompetence and many months afterwards, I was afraid to wear this to work in case it would push me to stand out more than a resident “should”, attracting negative attention and criticism. Today, for the first time in almost a year, I took out this bracelet for me to wear to work, feeling finally ready to return to my old self again.
If you feel that a productive and growth-oriented behavior that is appreciated by patients or clients is being met with resistance and even animosity in a new environment, I implore you to take a pause and to evaluate the environment before changing yourself. If you could find a way to hold onto that spark inside of you to ignite torches of positive change, a day will come when you are free to light up the world as you are meant to do.
Stay strong, my friends. Better days are just around the corner.
As a doctor, a lot of the care that I provide has nothing to do with prescribing medications or performing procedures. Sure, they form a significant part of my training and my day to day work. However, there are also many times where all I can provide for the patients is my presence, to be a witness to their suffering and to create space for them to grieve and mourn.
This was a huge revelation to me in the earlier stages of training – recognizing that there are many things we can’t just “fix” in medicine, and that care doesn’t end with telling a patient “I am sorry, there is nothing we can do”. I never realized how difficult it is to be truly present to witness someone’s suffering until I had to do it myself. It is so easy to give into the temptation to comfort, or to give false hope or even mislead. At the beginning, I told myself that it is because I care deeply about the patients, and it was difficult for me to watch them suffer. However, the more I did this, the more I realized I was NOT helping these patients by quickly wrapping up their suffering in a neat package to replace it with something prettier – I could see how this made them feel confused and lost. Why then, was it so hard for me to change my behavior?
Problem solving engages the prefrontal cortex of our brain – the part that allows us to reason, filter and regulate our emotions. Being forced to turn away from problem solving therefore leaves us feeling exposed, out of control and yes – vulnerable. However, in turning away from problem solving, we can truly be present and focus entirely on the suffering of the individual in front of us. In psychiatry, this is called “holding space”. Having the space to grieve without feeling pressured to go into problem solving mode can be a deeply therapeutic experience that allows one to just “be” and not be judged.
Think about our daily lives – how often do we simply listen to our friends, family or significant others and be fully present to witness their experiences? As children, how many of us had the luxury of this experience when we tried to share difficult experiences with our parents?
I tried to imagine what it would feel like to have someone fully present to witness my suffering, to have an understanding of how this could help my patients. My mind shifted to when I pray or meditate at my altar. Sometimes, I am looking for answers – but more often than not, what I desire is to have the time to sit in my grief and to let it all out, and to have someone sit WITH me in my grief. The sheer presence of my goddesses and spirit guides had always comforted me in my darkest times, and this is what I could do for my patients when there is nothing else I could offer as a doctor. Simply being present in their suffering was a service I could provide in those dark moments.
Now, when I deliver bad news, I sit with them, quietly, with a tissue box in my hand. I stay present with their grief, and in doing so I hold space for them to process their suffering.
It is true that this is much harder with family and close friends – those who we consider part of ourselves and can make us feel particularly vulnerable when they share their suffering. Practice makes perfect and I am still working on it.
I was reading “Maybe you should talk to someone” by the brilliant Lori Gottlieb this morning just before work, my little morning ritual, when one message really struck me: it is horribly difficult to sit with one’s own feelings, even for psychotherapists. I am no psychotherapist, but as a doctor, I always ask patients to reflect on their actions, thoughts, and feelings, and encourage them to do mindfulness exercises where they try to notice their thoughts and body without judgement.
The practice of witchcraft also asks one to recognize their thoughts and feelings, so that they can be used to enhance one’s craft and power. An aware witch is a powerful witch – she who rules herself can rule the world.
Why then, is it SO HARD for me, to sit with my feelings? I spend most of my days reading, watching TV, scanning through Youtube, or scrolling through my phone when I am not working in a desperate effort to distance myself from my emotions. In a way, working is almost an escape, because focusing my attention entirely to my patients shifts me away from thinking about myself.
A common concept discussed in psychodynamic theory and in family therapy is that a child who grows up learning that their feelings are invalid, internalize this and grow up to be adults who cannot tolerate their own emotions. The act of noticing and acknowledging their internal processes become associated with deep shame, rejection, and feelings of being misunderstood such that they learn to cope with this by becoming avoidant, not just of their own emotions but of that of others as well.
The difficult part of this is that our thoughts and emotions influence our judgement and worldview whether we acknowledge them or not. Being able to sit with, notice, and acknowledge our internal processes help us realize why we see ourselves, others, and the world the way we do, and lovingly readjust if there are biases at play.
This of course, doesn’t come easily at all. I realized my own tendency to avoid my feelings when a supervisor pointed out how I tend to get flustered if I don’t know something I think a patient wants of me, and how I would completely shift my behavior without even noticing that I am doing this. My supervisor asked me to sit and slow down, and notice the thoughts that arise in my head when this happens. This was an EXTREMELY difficult exercise – at the end, I identified a DEEP SENSE OF SHAME that arose when I felt that I wasn’t giving the patient what she/he wanted. Because this emotion was so difficult to tolerate, I avoided it completely, not even giving myself a second to think about it – unfortunately, this did not stop shame from influencing my behavior. Once I did notice the thought, also called “hot thought” in cognitive behavioral therapy, which in my case was “I am a failure”, I was able to lovingly tell myself: it’s okay to not know everything, you are doing the best you can. In slowing myself down and lovingly readjusting myself, I was able to be more present and authentic with my patients, which in turn made them happier.
When practicing magick, we ourselves form as much of the spell as the ingredients, incantations, and the spiritual forces that we summon to help us. When dark thoughts reside behind the spells that we cast without our knowledge, these thoughts can cause the spell to be weakened or even backfire. See the parallel here?
I still find sitting with my emotions extremely challenging, but I consider it an important part of my journey as a physician and a witch to become more self aware. I will be sure to keep you updated on that journey – wish me luck!
First post! I always dreamed of starting a blog but never had the courage to put my words out in public. At the same time, I always felt like I have a lot to say and share. Alas, being mortifyingly socially anxious and introverted, I knew that I would never get a chance to do this in “real life”. So here goes.
I am in the midst of a “vacation”, which in my field in the stage that I am in, means that I get to stay home instead of at the hospital while pounding away at yet another research project. Don’t get me wrong, I LOVE research – it is one of the few things I truly believe I can’t live without. This project is special though – I am forced to step away from the computer as this algorithm that I have running on my poor, old, and very abused computer is running now for 2 days with no signs of finishing anytime soon. Because of this, perhaps for the first time in years, I have been forced to step away from research and medicine to read something other than the two aforementioned topics.
Thanks to this fortunate/ unfortunate circumstance, I am now half way into a biography called “Initiated” written by Amanda Yates Garcia, a hereditary witch. The author writes of living in a world where taking part in LSD/ marijuana-driven house parties and large orgies were quite ordinary. As a reader, especially in medicine and science, it is difficult to NOT question if the spiritual experiences she had at the time were not in fact products of intoxication or withdrawal. Having said that, I come from a long line of witches and oracles, so I know that the world is so much more vast and richer than science can explain. Hallucinogens have been used since the dawn of time to invoke spiritual experiences, and it is difficult to explain how much of their visions were the product of rapid alterations in brain chemistry induced by these substances, and how much of it was a product of communication with realms beyond our own. I ask this because I have had two difficult interpersonal experiences lately – with two different supervisors, who, I am sad to say, have truly gone out of their way to bully me, a lowly learner. It is hard to explain why – It could be because I come from a science background and have progressed further in this area than they have despite being more junior in medicine, and/or because I outwardly rejected their abandonment of efficiency over “obtaining a deeper understanding of patient experience”. Mind you, I agree that there is certainly a place and a time where such endeavor is desirable and productive. However, I find it hard to agree with this sentiment when I know that there is a mountain of patients who would benefit from urgent care who are not receiving it simply because each physician is only seeing 6 patients a day in the particular institution that this occurred. I was quite literally told that I could do whatever what I want once I become staff, but until then, continuing as I am now will “get you flagged”. In an environment where co-learning is encouraged, and this was in fact, a matter of difference in philosophy and not competence, I was surprised that this resulted in a negative evaluation. The manner the evaluation occurred, was also quite baffling to me – this supervisor contacted my evaluating supervisor to ask her to give me a poor evaluation (despite my evaluating supervisor having already given me her feedback that she would give me a good evaluation).
As a practicing witch, I have a choice in how I want to interpret this situation. Do I take the road of the aforementioned author, and believe that this woman has been possessed by evil energies and spirits, and hence cleanse, forgive and move on? Would choosing to see the world with this magickal lens (fortunately or unfortunately without the help of psychedelics) take some sting out of the “evils” of the world? Do I accept that some people in this world are truly “nasty”, and begrudgingly hope for a better supervisor next time? Do I take the most realistic approach, and accept that the way to get through this period of training is to suppress my own philosophies and values and follow whatever the supervisor says is right, so that I don’t have to be “flagged”? Accept that my voice is never appreciated, and that some educators become educators so that they can feel that their way is the “right way”? Reflecting on the last point, I remembered some nurses commenting that this staff had been very anxious as a trainee, which impaired her ability to function quickly due to her need to know every detail before proceeding. Perhaps this feedback was given to her either directly or indirectly, and she became an educator to convince herself that her way was in fact, the right way, and others were wrong all along. Maybe this is why when she saw that I rejected her approach, it was so triggering for her.
In either case, I took the middle approach. After much reflecting and suffering over this incident, I cast a spell to invoke the three fold law – that she will receive three fold what she had done to me. I am a strong believer in Karma. Growing up, the many bullies in my life always received the poison they shared. When I spread poison, then I received it back as well. So, in invoking this spell, I chose to leave it up to the Universe and let it solve itself out. If she had truly meant ill will, well, she will receive it three fold. If her intent was truly, to educate, then she will receive that three fold as well. I will leave the wiser spirits of the Universe decide which one it was. My balcony gnome, who I recently became acquainted with, was watching me approvingly as I meditated on this spell, so I would like to think that it was the right way to go. I also decided to be a pragmatic and accept that to be a successful trainee in my field, I must become a master mime and a puppet, and accept that some educators enter the field for self-gratification, and therefore to be liked by them, I must, at all cost, make them feel good about themselves as much as I can. That means that I certainly DO NOT get to disagree with their philosophies in patient care (which would make me a bad learner).
I hope that I don’t lose who I am as a person at the end of this – it is one of my greatest fears. Did my three fold law spell take the sting out of having to accept this sad reality? Of course it did – it gave me back some sense of control. Magick, real or not, helps us believe that we can shape our own reality. It helps me be a more responsible and yes, less bitter person, which I think ultimately has a positive effect on my life as well as those around me. Especially being in this stage in my training where most of my sense of control over my beliefs, time, and basic rights (like sleeping and going to the washroom) have been stripped away from me, Magick keeps me sane – it keeps me human.