resident – Ena's worlds

Culture of incompetence

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.

Sitting with your feelings

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!

Angels in our lives

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.