“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.
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 having my biannual review of competency today when my evaluator told me, “I am sure you are tired of people cheerleading you all the time but I just want to cheerlead you again, to keep up with your good work”.
I wish I could tell him how much his words meant to me. The thing is, at least in medicine where I work at, I do not get much cheerleading, if at all, for my successes. If anything, disclosing my research work or records of my other accomplishments have resulted in hostile behavior from supervisors and bias them to think that I am not invested in learning from them or that I think less of them because of my accomplishments. This is why I don’t offer up this information unless asked directly – even then, it is often met with, “Oh really? I guess you must be really bored here then”, or “Oh really? We need to make sure this becomes a good *learning opportunity* for you”.
This is a biproduct of an education system that thinks pointing out an individual’s flaws, instead of celebrating their accomplishments, is going to get them to learn more effectively. To this opinion, I would like to ask what evidence they are basing this on. Education theory 101 taught in teaching school states that for students who are internally motivated, strength-based teaching approaches work much better than criticism-based approaches. This is where the sandwich model of delivering feedback was developed, where teachers are coached to provide one constructive feedback in the middle of two positive feedbacks. Focusing only or mostly on short comings does NOT motivate a leaner to do better – it gets them to be comfortable with failing. One can call that developing resilience. Well, most residents would prefer to call it “learned helplessness”, which is one of the core dimensions of depression. If no matter what we do, all we can expect is criticism, then why should we try at all?
Of course, we are learners and there is MUCH we need to learn, and evaluations of those necessary skills make a lot of sense. However, evaluation for the sake of evaluation, not producing competent health care providers, discourages cheerleading and breeds and selects for educators who “get off” of criticizing learners to boost their own ego. The system that I am in even penalizes educators who give favorable evaluations to learners – someone please tell me how this makes sense. If we can’t count on our educators be our cheerleaders, in this harsh society where medicine and doctors are more demonized than ever, who can we depend on?
When I teach medical students, my first priority is to make sure that they are treating patients in a safe way and if they can’t, that they feel comfortable enough to come tell me. My second job after that is to make sure their learning goals are met in the context of what field they want to specialize in. If their field of interest does not relate to my field at all, then I make it a priority to get them home in time so they have the time to devote to self care and studying for their area of interest. Evaluations that I provide are always strength based, because more often than not, medical students are more than WELL AWARE of their short comings. I learned to do this from the many wonderful teachers I met in my life who have done this for me. My very own cheerleaders that taught me the joy of cheerleading for others and how rewarding that experience can be.
Cheerleading is not something to be taken for granted – many people, even in education, are not capable of this or know what it feels like. While this post was largely a rant of my frustrations towards the education system that I am in, I also wanted to take a moment to express my gratitude for the cheerleaders in my life – my husband, mentors, and of course my goddesses and spirit guides. May their lives be three fold as blessed as the light they have shone in my life.
I still have flashbacks of sitting in the room in a zoom meeting with one of my previous supervisors, a couple of weeks after the death of my grandmother. She knew about this, but it didn’t stop her from calling me “lazy” for asking if we might be able to order bloodwork for a patient through her family physician instead of ordering it myself. Ordering it myself would take half an hour of administrative work due to a system issue far larger than myself. This would be on top of 16+ hours of work that I had to do that day. I remember freezing in that moment. Was it SO wrong to ask for some decrease in my administrative burden at a time when I am barely holding on and trying to cut out any corner of time to take care of my wellness? Yes, asking the patient to get her bloodwork through the family physician’s office would have taken her another trip to the lab to get it rather than getting it done at our hospital. However, this was not out of common procedure – as the consultant, it was rare, if ever, for us to order the bloodwork directly from our office. This is why the system was set up so that there were many administrative barriers for us to order it – because it was not common procedure. Thirty minutes of my time that I could dedicate to properly grieving for the loss of my grandmother vs. saving a patient a trip to the lab. The supervisor could have offered to order it herself – with her hospital privileges, it would have taken her half the time to order the bloodwork than me. However, she did not. Instead, she chose to call me “lazy”.
I later found out that this was in fact, resident abuse, only after I had disclosed this incident to a resident wellness advisor. I was happy to get a different and wonderful supervisor, who is now one of my mentors, after parting ways with her and believed that this was a one-off incident.
I was wrong.
I worked in an inpatient unit that I mentioned in a previous post. Generally, the inpatient team consists of a staff physician, a resident and a medical student. These 3 individuals, in addition to the nurses and other allied health professionals, dedicate their entire day to seeing about 6 patients. Surprising – I know. Frustrating? Absolutely. I accepted that this was just the way it is, that it is normal to spend 1.5 – 2 hours per patient per day doing daily extensive interviews, of which very few of the information went into treatment planning or administering evidence-based treatment. However, in the middle of my inpatient rotation, I met a wonderful supervisor who showed me that this was in fact, NOT good patient care. She taught me how to perform efficient patient interviews that focused on gathering pertinent information to inform treatment planning. Patients were informed of the nature of the inpatient admission – that they were in an acute care setting and our goal was to return them to a place where they can return to outpatient care. From day 1, we focused on disposition planning. We were clear of our role as physicians in the team, where the focus was to obtain enough diagnostic and past medical information to figure out which medication was going to be most suitable to treat the patients. Anything outside of that was delegated to allied health professionals. There were clear drawing of boundaries between us and the patients and us and the other teams within the inpatient unit.
I thrived in this environment. I enjoyed watching patients return to their baseline much more rapidly than I had seen before. There was regular patient turn over. Every time I had emergency shifts, the nurses would tell me how happy they were that there are enough inpatient beds available to send the patients instead of turning them away simply because there were no beds. On top of that, both my supervisor, myself, and my medical student were able to go home before 5PM. We were able to spend quality time with our families, take care of ourselves, and have energy left over to devote to our passions outside of the inpatient unit. I went to work full of purpose, with a clear goal in my head – return the patients to baseline, have them reintegrated into the community, clear the beds so we can treat more patients in need.
Unfortunately, this did not last. Two new supervisors came along who were very triggered by my rapid assessments, in my redirecting of patients, and focusing only on the information that would directly inform evidence-based treatment planning. After one day of working with me, one of them sat me down to tell me that I need to spend longer with the patients and in the inpatient unit in general. She felt that I was rushing the patients and rushing the allied health professionals – to her credit I am sure some of them did feel rushed by my methods. However, what she said in that meeting still hunts me to this day. “I am sure you will have good work life balance with the way you do things. BUT you are not doing good patient care – you will get complaints.” She was sending a CLEAR message that, my work life balance, MY WELLBEING was in direct conflict with being a good doctor. Mind you, this very supervisor walked out on a patient crying in her room the next day when I wasn’t present. The other supervisor who agreed with her managed to agitate a patient one day when I wasn’t there – the same patient that I was able to maintain healthy rapport and boundaries by keeping the focus on clinically relevant information only. That didn’t help though. I spent countless hours talking to my mentors, trapped in the room by myself, staying awake from sleep, running that conversation over and over again in my head asking myself: can I truly NOT be a good doctor if I value work life balance? Does taking care of my wellness, wanting to be efficient, wanting 8-10 hour work days make me a bad doctor?
During that time, I went to work everyday and wished I was dead – and I am sure this was evident in my face, in my defeated demeanor… purposelessly and meaninglessly nodding my head feeling that I was trapped here, perhaps forever, until I just wasted away and didn’t exist anymore. I felt lost. I will just touch on resident suicide here, a whole different topic that I will discuss at another time. During this time, for the first time in my residency, I truly regretted going into medicine. I truly believed that there was no way out of this – that I was not meant to be a doctor because my wellness was important to me, and not being able to tend to my wellness at a time when so many things in my life were falling apart must mean that I am just not cut out to be a doctor.
It was only after I finally had the time to tend to myself, seek the guidance of my goddesses, gods, angels, and spirits that I was able to see how flawed this was. A very wise physician who once supervised me said “The best thing we have to offer to this world is our energy. Sometimes, the only thing we can offer the world is our energy.” Pushing me to work extra hours without clinical indication (I never minded spending extra time in the hospital if it was going to affect measurable outcomes) to the point where my spirit was broken from not having the time and strength to return to myself, perhaps not shockingly, made me resent my patients. Being ridden by anxieties that arise from blurring my boundaries only resulted in a toxic accumulation of negative energies inside of me until I dissolved into that dark, dark void. During this time, my patients did not get better. We went from having regular patient turnover to having no movement in the unit at all. Nurses at ED asked me what was going on, why are there no beds available. I shrugged my shoulders and turned away, trying to hide my tears from falling out. I was not well enough to provide good care to my patients at this time. I went from happily spending Sundays going over my patient list before I start working on Monday to feeling nauseous when I saw the hospital building while going to work. I had no energy to offer to this world or my patients.
It took me weeks to recover from working with this supervisor, which happened when I was transferred to a different rotation where efficiency was a requirement, not an option. Why? Because it was shift work – everyone is capped to 7-8 hours of work in 24 hours. That gave me 8 hours to sleep, and 8 hours to work on my research, to tend to my spirituality, and to return to myself again. My energy brightened, I started looking forward to seeing patients again – and they sure felt it. This was one of those times where I truly believed that I would be lost without my spirituality, my spirit guides. To have something to hold on to in the spirit realm when my physical realm fell apart – incantations, crystals, and eventually, to my goddesses – saved me.
Many residents are not as lucky. When their life in the hospital falls apart – their entire world falls apart. They have nothing left on this world to hold on to. Our institution tells us that they will build up our resilience, so that we can “cope” when the unavoidable crap hits the fan. What they don’t understand is that there is only so much resilience one person can have, especially when we are not given the time to recover it while constantly having it chipped away bit by bit. They constantly send messages that wellness is incompatible with being a good doctor, that we must put our patients ahead of our own well being, even if it means to the detriment of ourselves.
The dark void is behind me now. Now, I once again have patients that tell me how “shocked” they are at how happy I am to see them, often telling me how they never had this experience with a doctor before. I used to be surprised to hear this – but not anymore.
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.