Maintaining your sense of self during medical training & beyond . . .

Listen in to a clip from our med student Dream Team with Dr. Pamela Wible & Sydney Ashland. (fully transcribed below). To join our next Dream Team call, contact Dr. Wible.

Sydney Ashland: Tonight we’ll cover the top five attributes that you need to cultivate in order to maintain your sense of self.

1) Number one is to refuse to engage fear messages. One of the common threads that I hear all the time from medical students and residents is that they are often controlled by fear. The first fear that often starts is the fear of not knowing. You leave high school feeling really, really smart. You get an undergraduate degree and you feel like you’re competent, and then you start med school and even premed sometimes, if you have already declared your major and you have those helpful, or not so helpful professors who start to try and train you early. The message that is all-consuming is now feeling like you don’t know, now feeling like (excuse some of the labels I’m going to use, but just to make the point) you feel like an idiot.

You feel like you’re the dunce in the class, that everybody is smarter than you are, that you’re absolutely terrified of what you don’t know not only because it’s embarrassing and you feel a sense of shame. For, you know how to study, you know how to buckle down and be serious. You have a vision, a passion, and to suddenly feel as if you’re dropping in the ranks, and somehow it might appear that you’re not really serious, that you are needing to learn how to study and how to apply yourself is just disheartening and jolting. It jolts your whole sense of self. Then it’s reinforced by professors who talk about in attendings, that you don’t know anything. The fear of not knowing. What if I don’t know what’s wrong with the patient? If you don’t know what’s wrong with a patient, you could kill somebody. If you don’t know what is wrong with a patient, they could end up suffering. You’re holding the class back. You’re embarrassing yourself on grand rounds, or when you’re explaining to your attending when handing off a case.

You start to worry. What if I’m not smart enough to figure it out? The answer is, you are. You are enough. Don’t buy into the messages of fear around not knowing. You do know. You know how to study, you know how to protect yourself, and do what’s in your own best interest. To really cultivate self-talk that has to do with, “I’m enough. I am smart. I’m up to this.” Keep track of your wins. Keep track of what you know. Keep track of your study groups where somebody says to you, “How do you always come up with the answer? How can you always figure this out? I’m just starting to get jumbled, and rummy headed, and can’t even think clearly.” Write those things down. Reinforce all your moments of clarity rather than focusing on the times you’re confused, or unclear. This is the number one, most critical piece about not engaging the fear messages.

When somebody knows how to study, when they’ve been top in their class in high school, or done well in premed, and then you get into medical school, and you start to feel like you’re not knowing enough, that you’re falling behind. The good thing about smart people is, smart people know how to ask for help. They know how to engage others on their own behalf. They know how to resource themselves, to look up resources and find what might be available to help them get over whatever struggles they’re having. If it’s a topic that you don’t enjoy, a class that has a teacher that is less than stellar, then to be able to do those extra things that will help you again, feel like you’re yourself. You are the brilliant self you have always been, and will always be. I want you to hear that phrase, and record it perhaps. “I am my brilliant self, the brilliant self I have always been, and will always be.” Reinforce those messages so that you can walk with your head held high. You feel like yourself. Because that’s some of what starts to happen.

We start to feel as if we’re an imposter. As if we don’t recognize ourselves in the mirror. We look haggard, we’re sleep deprived, we’re exhausted, but if you are reinforcing that you are your most brilliant self, and will always be that, and that you are a smart cookie. You know who to ask, and where to go to get the information you need. Then you’ll be able to keep that piece of yourself intact, and not engage that fear message. The second part of the fear message is fear of mistakes. Perfectionism is a major issue in the medical field for physicians. I would say at least 90 percent of physicians that I’m engaged with are perfectionists. That means that they can’t abide a mistake. The very idea of doing something incorrectly, of not being prepared, of putting somebody at risk, just is untenable.

Taking the job too seriously, taking your studies too seriously, it’s one of the big reasons that people develop test anxiety is they’re so afraid of making mistakes. They’re so afraid of getting it wrong that they immobilize themselves or they second guess themselves. They put down an initial answer, and then they sit with it for a few seconds and go, “I don’t know, maybe that’s not right. Let me read it again.” Then they change their answer, and the next thing you know, I’m getting a phone call, or Pamela is getting a phone call from somebody who says, “You know, the truth is, I missed it by three points, and part of that is because I was second guessing myself the whole time.” Or, “I totally crashed and burned because I had no confidence going in. I was so afraid of making mistakes.” We learn from our mistakes.

Every time somebody calls you on a mistake you make when you’re in training, you need to have the attitude of, “Thank you so much because you know, I learn from my mistakes, and every time you correct me, every time you point me in a different direction, or you nudge me, or you encourage me to pivot, that is a time where I can really learn something. Where I can become even a better clinician, a better student.” Look forward to the mistakes. Have some Post It notes on your mirror in the bathroom, or on your dashboard in your car that are humorous, about how making mistakes is actually what your goal is because every time you make a mistake, you become better. Surgeons learn that early on, that every time they don’t know something, every time they make a mistake, they say, “Well, I’ve learned it today. I will never make that mistake again. Now I know, and I’m better than I was yesterday.”

For everything you don’t know, for every mistake that you make, and you recognize it, you then have an opportunity in the next moment, to be a better, more qualified expert than you were two minutes ago. To feel that evolution of change, that transformation. Accept your humanity with vigor because in accepting your humanity, and refusing to engage the fear messages, you are going to absolutely go through medical school with confidence. You are not going to succumb to bullying, or gas lighting, or pimping, because you are confident. You refuse to let fear be your motivator. Instead, you’re motivated to be your best by holding onto your vision of who you are in the present, and who you can be in the future. Is there anything you want to add to the section on fear, Pamela?

Pamela Wible: What’s really important is to make sure that you’re not making fear-based decisions in your life. Most people in the world, if they break down their motivations from why they’re getting married to who they’re marrying to what they do or don’t spend money on to what job they take, they’re often making fear-based decisions.

It is so essential for you to make decisions based on desire. Which is why I title the retreats and seminars Live Your Dream and the Dream Team. Keeping the full-color version of your dream in front of you (or at least the bits and pieces that you have depending on where you are in your training) will propel you forward so that you start to make desire-based decisions, instead of fear-based decisions.

Medicine reinforces fear-based decision making. You’re afraid of a lawsuit. You’re afraid of making a mistake. You’re afraid of failing a test, that sort of thing. Do you see that Sydney?

Sydney Ashland: Yes, absolutely. Yes. Begin to make decisions out of what I want verses what I’m afraid of because the more you obsess on something, the more profoundly active it will be in your life. If you’re obsessing about your anxiety, the more anxious you will be. If you are obsessing about what you shouldn’t do, if you’re making your decisions out of fear, then the more likely you will make decisions that are not as sound because you’re engaging fear to such a degree that fear is fueling the decision. Fear is present to such a degree that it will remain. It’s really hard to make a fear-based decision, and not have fear remain.

2) Secondly keep your sense of purpose. I know for many of you listening, you might just sort of shrug that off, and say, “Well of course,” but Pamela and I can both attest that we talk to residents and physicians who have been in the field for years, and are experienced, mature physicians who have long, long, long ago lost their sense of purpose.

Even when we ask third or fourth year medical students or residents,”So, what got you into medical school in the first place?” There’s a long pause. That pause always concerns me because the closer you are to your sense of purpose, the closer it is to the tip of your tongue. When somebody asks me a question, “Are you thirsty?” I can say yes, or no in a nanosecond because I know. It’s right there. When you keep your sense of purpose on the tip of your tongue, in front of mind, then you will continue to fuel your training experience with your sense of purpose. It’s not something, “Well, when I graduate medical school, then I’ll be a resident. Well, when I complete my residency training, then I’ll be a true physician. Well, when I’ve been a true physician for five years, then.” All of those “Well, when’s,” are a journey away from your sense of purpose. You need to stay present. You are as dedicated a would-be physician today, almost physician today, as a mature physician who has been in practice for a long, long time.

You may even be more connected to your expertise because you’re fueling everyday with your sense of purpose, and your dream. Keep very handy, maybe in the front of one of your notebooks, or on the wallpaper of your phone, what your vision and passion is, so that you are constantly reminding yourself, “This is why I’m here.” This isn’t about how much school costs, and how deep in debt I’m getting. This isn’t about people-pleasing, and trying to go for that A in every class. This isn’t about competing with my peers. This is about truly keeping my sense of purpose, my original dream so close at hand that every decision I make is fueled by that inspiration. When you live a life feeling inspired, then you live a life that is purpose driven, that is filled with right decision making, it is connecting you to your authentic self, so you’re not going to lose yourself in the process. You will have a happier, healthier time through training. You will maintain relationships. You will just feel connected to your highest self if you keep that sense of purpose handy. Stay connected, keep your dream alive, remind yourself your reason for being here.

3) Number three is cultivate and maintain positive beliefs. One of the things that people often brush aside is the fact that there is innately some negative energy connected to medicine because you are learning about all the things that can go wrong in the human body. You’re learning about all the disease processes. You’re learning about all the things that could happen that you want to guard against, or you want to treat, and intervene once things have gone wrong. That’s a negative energy. It’s necessary, but it can begin to erode your positive beliefs.

You start to begin to focus on what’s wrong with people, rather than what’s right with people. You begin to perhaps engage the energy of worry because you’re concerned, you’re loving, you’re compassionate, you’re empathic. It’s sometimes hard to maintain your positivity when you’re faced with tragic stories of cancer, and system wide infections, and death, and premature birth.

Just the very topics that I just listed, impacted you just hearing the words. Just hearing the words, premature birth, we all go to a vision, a sound, a memory that we have associated with a preemie, a baby that comes early. Maybe it’s somebody in our family who lost a baby who was premature, maybe it was a sibling who was in an incubator. Maybe it’s something you read about in the news, but it puts your whole system on high alert, and you feel the negative energy of fear, and concern, and what can go wrong in the world.

When you connect that to the energy of stress that is inherent in the practice of medicine, and in the training of medical students, it’s really hard to be focusing on all these diseases, all these things that could go wrong. You’re stressed out. Stress is almost embraced as a lifestyle in medicine. You’re told to expect that you’re going to work long hours, that you’re going to be underappreciated, and overworked. That it’s a thankless job.

How many times have we heard that? That you’re sacrificing parts of yourself in order to be of service. Those are very negative messages, and even martyrdom is a negative message that makes it impossible to cultivate, and maintain positive beliefs. You have to refuse to succumb to the distorted and destructive thinking of medical training. You just have to. You really need to, as much as possible, be glass half full instead of glass half empty people because that’s the way that you’re going to protect and maintain your sense of self. If you came from a family that has a lot of fear based thinking, if you come from a family where there’s a fair amount of stress just in your family system, you could already be at risk of succumbing to more negative thinking, and negativity. You get to choose. You don’t have to just be victim to your thoughts, victim to the self-talk in your head. You can choose what you want to believe.

I would suggest that sooner, rather than later, you make a list of some of your beliefs around health, around work, around how people are valued, how you value yourself. Just those core beliefs that have to do with, I believe that basically, the world is a loving, and nurturing place. Or, no, actually I believe that it’s a dog-eat-dog world. It’s each man for himself. You’re lucky if you make it through alive people. If that’s the energy that you grew up with, or that somebody close to you has inundated you with, you are going to be at risk in a stressful training environment, of actually reinforcing and increasing your negative beliefs. You can stop that today by taking an inventory of what your world view is, what your internal beliefs are about yourself, and about the training process that you’re going through.

Then decide which beliefs need to go, which you’re going to say goodbye to, and erase off the sheet, or black out with a sharpie, and which beliefs you’re going to increase and validate everyday through affirmations, through having your mentor remind you that it’s all about positivity, and reinforcing that which is positive in your life. Maintain balance, and choose your beliefs carefully. Would you like to say anything about positive beliefs, Pamela? You are the queen of positivity.

Pamela Wible: How did you know I was aching to say something? Okay, I’ve been posting these actually, sharing them on our Dream Team chat. Some of them with comments. Regarding cultivating and maintaining positive beliefs, we are obviously in a medical system that is steeped in human suffering, pain and death. We go in with the notion that we’re going to help and heal others, but the fact is there are others that we can’t help. There are others that have sort of self-imploded by the time they arrived in full-blown MI’s and strokes, stillborn babies.

You are going to see things that are very disturbing for sensitive healers to see. Especially without mental health support on the job. We’re doing our best to support you here, but often when you see these things is the time when it would really be helpful to get some debriefing, or emotional support. That doesn’t always exist in a hospital setting where they tell you, “Time to see your next patient.”

I find for me that spirituality, and keeping a sense of the big picture of the world, and the universe is very comforting and helpful. Now, whether that is for you a religious sort of thing, like, leave it to God or Jesus, Allah, whatever you believe in that is the grand, spiritual force with some power over what’s going on with human destiny here, that can help you not feel like a personal failure if a patient dies.

Remember: “Do your best, and let God do the rest.” I really love that because it’s just something that makes me feel like, “It’s not really all up to me. I can just do the best within my human skills, and it will be okay.” I want you to understand, the western medical model, with it’s reductionist philosophy is really set up with the notion of success verses failure. Success being the patient survived. You cured all their chronic diseases. Or failure: like their cholesterol is still high, they died. You somehow feel like you failed. That is not your failure. That’s a patient’s failure—their life’s destiny—for a complex range of reasons that I don’t even pretend to understand. You’re just somebody who intersects with their life at one part of their journey, so please do not hold yourself responsible, and feel the guilt that some perfectionist medical students and physicians end up feeling.

A resident physician in Israel actually told me after a patient died, he took that patient’s chart home because he felt somewhat responsible because of maybe a dosing error. His interpretation was that he could have saved the person. He kept that patient’s chart in his closet for four years in his bedroom to remind himself constantly that he doesn’t know as much as he thinks he knows. Now, is that helpful to sleep in your room with a dead patient’s chart in your closet, or under your pillow?

I want to prevent you from going down that route of feeling personally responsible for other people’s outcomes when it is out of your control. Please do not succumb to that limited world view of reductionist medicine that you’re steeped in right now. That is just one little way of looking at the world, and of helping and healing others. Any thoughts on that, Sydney?

Sydney Ashland: You have power and control over your thoughts and your actions. Just because you may have a strong internal reaction, we all have reactions internally to things that we observe. In your training, you’re going to have big reactions internally, but you get to choose what your thoughts are about that later. You get to choose how you’re going to relate to what you just observed. You don’t have to just fall victim to the circumstances. I think it’s all about staying really, really present and intentional, where you say to yourself, “Wow, I just saw a stillbirth. I just witnessed this. In fact, I did more than witness it. I was a part of it.”

Even in studying, some people have talked to me who are extremely sensitive, that even some of the pictures that they are exposed to are traumatizing. “I just saw this horrific picture of someone who was in a motorcycle accident, and had horrible injuries. That’s sticking with me, and I’m obsessing about it. I’m afraid if I were to ever confront that.” You get to choose what your thoughts are. You get to choose to have responses verses reactions. What Pamela just described was absolutely right on, and it really leads into the next . . .

4) Number four is trauma and PTSD. We see a high, high rate of trauma and PTSD in physicians. This is two-fold. I want to say this, and I want everyone to really take it in. Many of you have experienced some trauma in your past. In school, in your family of origin, maybe with strangers in some traveling experience. Life is complicated and complex. Very few people make it from birth to death without having experienced some type of trauma in their life. Untreated trauma becomes PTSD, and even if it’s an isolated event in childhood where you say, “Yes, well, that was only that one time where I was thrown off the horse, and this injury occurred.” If you don’t deal with it fully in the moment that trauma stays with you.

Working in the field of medicine often triggers old trauma and PTSD. We hear it all the time. We’re witness all the time to the effects of this early trauma in your life. It’s important to acknowledge and heal your trauma as soon as you’re aware of it. In medical training, my recommendation, and these resources are listed here, it’s okay, and even encouraged on my part for you to be in therapy. To have a place where you can talk to people, to someone, and maybe it’s with Pamela and I, or maybe it’s with a therapist, to be able to deal with your trauma.

Also keep your connection to nature, to exercise, to music, to self-help books, classes, activities, because those are all interventions that will help you stay present with the trauma, and work with it to heal it, so that it’s a distant memory. It will always be with you, but it doesn’t have to be an activating event that reactivates PTSD in your current clinical situation. That’s an important piece. Often times, people don’t really want to hear it. They don’t want to deal with it. We minimize the trauma we had as a child. “Oh, well yes, my stepdad was abusive, but he left after four years.” Well, those four years were important years.

The first time you’re going to deal with an inebriated patient, you could really get activated, or when you’re doing your psychiatric rotations, or when you’re studying about psychiatric conditions. It’s really, really important for you to deal with your trauma.

5) Lastly it’s really, really important (mandatory not optional) is to have a mentor. If you don’t have a mentor, you are going to be at risk of isolating. That’s something that really, really happens very, very frequently in medical training is people start to isolate. It happens. It’s insidious. You just are a good student, you’re studying, you’re working, you’re doing so much that you don’t take the time to really cultivate a mentor relationship, and when you don’t have a mentor in your life, you are at risk of going offline more, and more, and more where you’re compartmentalizing your mental health, your professional and personal needs.

You can’t do that with a mentor relationship. The whole point is to share honestly, to be vulnerable, to ask questions, to share the truth of who you are without apology, and receive all the amazing support that the person who is mentoring can possibly give you. When you can receive that, and you’re in gratitude, and they begin to see how profoundly this mentoring relationship affects your life, they are rewarded by being engaged in that relationship with you.

There will be times when you’re the mentor and there will be times where you’re the mentee. It’s absolutely critical when you’re getting your medical training that you identify a mentor. Maybe even two or three individuals, depending upon who you feel you most need support from. It could be someone who is in the field, and an expert, and that you’ve had a connection with for a long time. It could be someone that’s a coach, someone who is a peer that’s in a different state in a different medical training program who is a little bit ahead of you. There are lots of options for mentors that you can choose, but choose a mentor. You really, really need to.

Those are my five ways that I suggest everybody cultivate to maintain your sense of self right from the beginning, so that you can be confident, assertive, walk through this intense time. It doesn’t have to be hard. It can just be intense. Intensity isn’t a bad thing. Pamela and I are both intense personalities, and we love that about ourselves, but it doesn’t mean that we have to make it hard for ourselves. We can be intense and have a sense of ease, a sense of confidence, a sense of being in the flow, and being present. That’s the gift that I want each of you to have during your training, your rotations, your experience in the medical field.

Pamela Wible:  I just posted all of your points as you went through them on our Dream Team chat. Regarding choosing a mentor, we’ll have a separate call just on how you do that. How you select a mentor, how to ask them, and how to set the relationship for success, so it’s not just something that you’re winging.  So many medical students, and physicians, and I’m talking about physicians in their fifties and sixties have told me, they have never had a mentor in medicine. I just think that is so sad to go through your whole career, and not have somebody that you could look up to, and have mentoring you. This is one of those things that you don’t want to miss out on, and it’s so easy to do.

Again, the mentor by teaching and taking you under their wing even receives more than you get from them because the process of teaching and helping somebody else keeps your mind alive and open. The relationship is beautiful for both people, so don’t feel guilty as if you’re taking time from somebody. You’re actually bringing honor and beauty and love into their life as well by even asking them to be your mentor and that’s an honor.

If you need a mentor or would like to join our medical student/resident Dream Team, contact Dr. Wible.

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