DTD 168
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This is the Drive Time debrief, episode 168.
Hey guys, welcome back to the podcast. I'm Amanda. I'm Laura. And I'm Kendra. And before we get into the meat of this, the most random thing happened and I'm an overthinker and so I was gonna ask you all your opinion on this. So I did get to go to EMRIC, [00:01:00] which is emergency medicine for rural and indigenous communities in beautiful Washington.
I have never been there before, but oh my gosh. I get it now. And when I was checking into the hotel, the guy was like, do you want a room by the elevator? And I was like, oh, maybe he's trying to hint that there's a really good room or something. I was like, I don't know, should I get the room next to the elevator?
And he was like, yeah, sure. You know, whatever. So I get to my room and I'm like, expecting, I don't know what I was expecting, but it was just a room that was close to the elevator. And I started thinking, well, wait, why did he think that I would want a room by the elevator? The other side of the hotel had this view of the mountains.
I mean, every view from everywhere was gorgeous. Mm-hmm. But this one was like overlooking the top of the building. You know why? So then I'm like, [00:02:00] was I like gasping for air when I got up to the front desk, or does he think like I run late and need to be close? I have no idea, but I'm an able-bodied person.
That's the only thing I can think of if it was really difficult to get around. Mm-hmm. Does anyone, do you know of anyone that requests rooms next to the elevator? Oh, sure. Like I can think of a hotel that is super windy and long. Like, I think of those Las Vegas casino hotels that are so crazy and you have an early flight.
Maybe you wanna be right by the elevator. Maybe. I have been appreciative of being by the elevator when I had a super early flight. Okay. Yeah. I was like, is he calling me old? No. Oh my gosh. I'm like, I'm walking just fine. But anyway, I did learn there's always winning or learning. I did learn, yes, I don't care to be by the elevator.
I will walk for view. So that's all. Yeah. How old was this person? I mean young. He was a youngster. Okay. He probably thinks everybody has some kind of mobility issues. Yeah. Anyway so moving on, let's get to the point of the [00:03:00] podcast. So we recently did a podcast on nonviolent communication. Hopefully that is helping you all.
But I was talking to a client about specifically nonviolent communication and was trying to get the link for her if she wanted to, you know, purchase the book for herself or whatever on the internet. And I stumbled across Sina Rama Krishnan's summary of the book of Marshall Rosenberg's Nonviolent Communications.
And when I was reading through it, I was like, oh, here's a little cheat sheet. I'm gonna get my little cliff notes version here. And when I was reading the section on chapter nine, which is connecting compassionately with ourselves, bullet point number three really struck me, and here's what he says.
In our language, there's a word with enormous power to create shame and guilt. This violent word, which we commonly use to evaluate ourselves is so deeply ingrained in our consciousness that many of us would have trouble imagining how to live without it. The word should. As in I should have known better or I shouldn't [00:04:00] have done that.
And I just thought we haven't had a dedicated episode to the word should. We have mentioned it before for sure, but it deserves its own episode to be honest. This is a good word to talk about for a whole episode. I just last week actually, you know, talking to my daughter, she's a freshman in college, she's wrapping up, it's finals week and she called like super coming unglued.
Like it was just a lot, you know, she had a whole bunch of tests. And she got done with the test and it was like, this shouldn't be so hard. This shouldn't be something I can't handle, like, that should word was coming out. And I, you know, just sat there and listened because it was clearly she was in this emotional brain and very, you know, just coming unglued.
It was overwhelm and stress and I could hear all the things, but it's just amazing how [00:05:00] I think if that narrative hadn't gone through her brain, maybe the level of stress and overwhelm wouldn't be there because she really couldn't tell me like, okay, but it is, and so now what? Or something, you know, it was just mm-hmm.
The ability to really turn this situation that like, of course it's her first year in college and having finals week and everything, but like realizing that should it, I mean, could we ask the question: should college be hard? Yeah. Like, yeah. Like should it not be hard? You know? And so, you know, after a time when we kind of revisited the conversation, you know, it was kind of like,
well, but you're in college now. We're leveling up. Like, I'm not really sure what the expectation was, but this is a level up and, you know, maybe asking better questions. I constantly, Ava's probably gonna not listen to this episode. She'd roll her eyes like, oh, my mom's always telling me to ask better questions.
But that's the thing, like, [00:06:00] like we talked about before, before you go to freak out mode, like, do I have enough information to freak out? And so we're always talking about getting more information or asking better questions. And so yeah, this is very timely in my own private personal parenting moment.
Yeah. Episode alert. One of the other principles that we'll be talking about from Byron Katie's Loving What Is will be arguing with reality. Yes, exactly. And how that gets you nowhere. Yes. Yes. I think that goes hand in hand. So what does should really mean? Well, we just talked about it. It really implies a moral obligation.
It's an external judgment and a denial of choice. And we talked about this before. Should is really, I mean, should is could just with a bunch of shame thrown on it. So in nonviolent communication should is seen as a form of self alienation. For example, when you have a busy day but maybe you're just feeling like the waiting room never gets [00:07:00] smaller or if you work in an office setting and you know it's busy season, like flu season or whatever, and you really should see more patients, is that, is that really connecting with our own needs? We would probably argue, no, it's actually a disconnect. Using the word should actually disconnects us from our own needs and also maybe even showing up as our best self for our patients. There's a Freudian concept of internalized authority, which is the internal critic, or super ego that polices behavior, presumably that's where should comes from. Albert Ellis, founder of Rational Emotive Behavior Therapy coined the phrase, stop shoulding on yourself.
So how does this show up in our medical culture? Well, we're gonna go back to that inner critic and, and exactly what I was trying to give my daughter perspective on. Only it took several more conversations, you know, circling back. But that internal dialogue is, I [00:08:00] should be charting right now.
I should see more patients. I should do something about the waiting room. I should do something about wait times, whatever it is. I should never complain about this not being able to see more patients like it really can, we can spiral, we can really go to the nth degree on this one. So that's that inner critic, that self narrative that really is just all about self-sabotage.
Because when you're intentional about showing up for the day and then that voice starts coming in the brain and you start listening, it gets louder and louder. It's really just self-sabotage. Then you have peer comparisons. So that resident always stays late. I should too, or that, you know, surgeon does this many cases I should too.
There's institutional expectations. You should prioritize productivity over presence. Right? That's the, oh, the fight, the pain of the struggle [00:09:00] is just that. And then the result obviously that you get from all of this is guilt, shame, overwork, disconnection from intrinsic motivation, disconnection from self which we continually prioritize.
And so what happens when you're constantly arguing with reality and constantly putting that should into the narrative? Well, you get emotional consequences like guilt, resentment, shame, anxiety. We talk a lot about shame. Brene Brown talks about this in all of her books that we've talked about, but that really is the recipe for shame and that shame spiral.
So in order to not go down into that depths of despair, we gotta learn how to recognize it and then nip it in the bud. There's behavioral consequences like over-functioning. We talked about this before. People pleasing, talked about this before, and ultimately, compassion fatigue. There's physiological consequences like the chronic stress that we were never supposed to be in [00:10:00] for hours and days at a time, which obviously leads to burnout. And there's real things like high blood pressure, insomnia, high anxiety, just all of those are, you know, what can manifest after just living in this should state. So an example might be, you know, Dr. X says I should go to my kids' recital, but I have clinic.
So now it's the internal conflict. Now we're going back and forth with ourselves. What you're doing is debating that internal value system, the things that you hold as most important, now we're trying to negotiate or disempower that. It's really a no-win scenario. And then obviously the more times you do that, you battle with not aligning your internal values.
You can see where pretty soon that constant battle of what should I do is going to lead to burnout. Can I add one should that we have not talked about? I should have caught that. I should not have missed that. I shouldn't have missed [00:11:00] that diagnosis. Mm-hmm. Yeah. And this one will circulate in our brains forever.
Mm-hmm. This is, it's a practice of medicine. Everybody misses stuff. Mm-hmm. You missed it. You missed it. Mm-hmm. So, that's what happened. And telling yourself you should not have missed it doesn't change the past, and it actually puts you in more of a state of anxiety and less likely to make the right choice in the future if you keep ruminating on it and shoulding. I love how he calls should a violent word.
It's violent.
It's really good. And you know, we would challenge that. Like did you really miss that? 'Cause like the patient made it into the hospital or the patient got medication or the patient got the treatment or you, I don't know. I think we catastrophize a lot of situations. Yeah. Yeah. And a lot of times the patients are fine. Right. And a lot of times the patient actually still really likes you. I mean, the facts are they're still fine. Or if you're in primary care and you had a [00:12:00] 10 minute slot, really? You were supposed to pick up everything? No. Right. So explain to me how, see, we would challenge that. Yeah. Yes. So anytime you wanna click the link below and meet with us, we'll make, we'll show you how to get, you'll feel good for 30 minutes at least. Yeah. So why should we replace should, right? Mm-hmm. So should really implies you have no choice. You're acting under duress or guilt, or responding to external authority, even if it is internalized. It seems like an external locus of control or an external focus of control.
When you say, I should chart it subtly implies I don't want to, but I'm forcing myself, this creates resistance. Resistance leads to resentment and constant tension, constant stress, or even if you do force yourself to go through it or get it done, 'cause you know you just gotta get it done. That is not enjoyable.
And it's like when I think about just like that forced hand, you are gonna rebel against [00:13:00] that at some point. I can speak to psychological reactance. I know, right? I can speak for myself if I'm constantly like, ah, this is such a force, like I'm gonna rebel at some point. I don't know.
Marshall Rosenberg argued that when we use should we disconnect from our authentic motivations and underlying needs.
Instead, we can create internal alignment by becoming aware of our needs and choosing actions to meet them. This is really getting clear on your values or what's most important. Because we are well aware we have to document a patient encounter. That is what we submit for payment and how we develop our, you know, standard of living here.
However, there are ways to maneuver this not only in your brain, but where you can remain in alignment with yourself, show up for yourself, take care of your needs and it can be a both/and, and do the thing that [00:14:00] we have to do in order to get paid. We're all in this yes, to help people, but we gotta get paid.
So there is a way to do this where it can be a both/and. So moving on to, we never want to just be like, Hey, here's this huge problem, and then there's nothing you can do about it. That's like our least favorite thing. Yeah, that's the worst. Thanks. Yeah. Great. I'm ready to be demoralized. Here we go. Okay.
So here is a three step process for turning should into a conscious choice. The first step is to catch the should. Always. Just awareness is the first step. Even if you aren't skilled enough yet to do anything differently, awareness is step one. So start noticing thoughts like, I should go to that meeting.
I really should say yes. I should have already known this. I shouldn't have missed it. I should stay late. I should do my charts before whatever. I should give myself more credit. Any should, or should not hopefully will start to light up [00:15:00] like, oh, oh, I'm doing it again. So then step two, when you notice it, ask:
What need am I trying to meet? So you can use Marshall Rosenberg's needs inventory to identify what's underneath. Needs are universal human motivators, not strategies or actions, but something deeper than that. And so here's some examples like something that might fall within the category of connection is a need for belonging or appreciation or support or a need for understanding.
Within the category of meaning would be a need for purpose, contribution, integrity, learning. A need within the category of autonomy would be a need for choice, freedom, space, authenticity. Within the category of rest: sleep, relaxation, recovery, or peace. One that I think drives a lot of physicians is a need for competence.
So that would be a need for mastery, skill development or achievement. There is a common human need for physical [00:16:00] wellbeing, so that's a need for safety, nourishment, movement. Within the category of fun and play would be needs like joy, humor, creativity, and within the category of honesty would be things like authenticity, clarity, self-expression.
Why is it that you're saying that you have to go to that meeting? I should go to that meeting, pause and ask what need am I trying to meet? Maybe you are wanting to feel a sense of belonging by being part of the group. Maybe you have a need for contribution and by attending that meeting you could contribute in some sort of way.
Maybe you have a need to be seen as competent and showing up is a way to do that. Your values, your needs, the categories that drive you will start to highlight why you are shoulding on yourself. And then you can reframe that.
Step three is to start to reframe it into choice language. So start to use phrases like, I choose to attend this meeting because I value contribution. Right. You [00:17:00] don't have to go to the meeting, just don't go. But you can choose to. You don't need to be shoulding about it. You can choose to because you think that's time well spent, or I want to actually show up for work today in order to meet my need of paying my electric bill.
That's perfectly legitimate. Okay, that is fine. Or I'm not going to pick up another shift. I'm not going to insert your example, and that's okay because I'm honoring my need for whatever, and that's okay. It's okay that I'm not picking up that shift because I really need to rest and reconnect with my family, and I haven't done that in a long time.
That is totally fine. So that is the three step process: awareness then ask yourself what needs you're trying to meet and then start to reframe it into choice language. Yeah. So here are some examples of how to reframe that original should thought into a needs [00:18:00] based reframe where you're creating meaning out of it and not just cultivating a bunch of resentment and psychological reactance.
So first example would be I should stay late, and one that we see in the ER always: I should stay late and help because the waiting room is so busy, I should stay and keep seeing all these, you know, non-urgent patients so my partner doesn't have to. And then the reframe of that would be I choose to stay because I value supporting my team or, and you know, the first one we would, I think,
encourage you to use rarely if there's like an actual severe crisis going on. The second one, I'm going to leave on time because I need to rest to be present tomorrow. So both ways you're meeting a need, you're meeting a need for competence and belonging by staying [00:19:00] and you're meeting physical and likely emotional needs by leaving.
So you can choose. You always get to choose. The next example would be, I should agree to serve on that committee. So we wanna challenge that. Is it a committee you actually wanted to participate in? Does it align with your values? Does it align with your career goals? Or is it just another thing somebody asked you to do because they knew that you would do it 'cause you're a people pleaser? If it's the last thing, let's rethink it. I want to contribute, but I also need space for myself right now, which is likely the correct answer if you're saying I should, and you're not saying, oh, yay, I get to be on this committee. So it's okay. And in fact, it's imperative to recognize your own needs and take care of them.
It's not anyone else's job to do that. Other people, especially in hospital systems, typically [00:20:00] will not help you take care of yourself. They have other priorities and your wellbeing is usually not high on the list, so it has to be our own responsibility to do that. Next one is, I should be more productive.
We hear this a lot. It's interesting the stories that we tell ourselves about these arbitrary numbers that we think we should be seeing or doing, to be a quote, good doctor. It's one thing to want to increase our productivity, to be able to help more people. It's another thing entirely to shame ourselves for what we're currently doing.
So if we actually want to see more patients and be more efficient with our time, great. We can say it like this instead of, I should be more productive. I want to be productive because I value purpose and growth. I want my patients to be able to be seen without a long wait. I want to get my charts done [00:21:00] on time so I can go home and have work free time at home.
What would that look like today? Without judgment, without judgment. The shift isn't just linguistic, it's psychological. So you move from compliance and it's natural for our brains to think like this. Many times we grew up being told, you should do this, you should, you know, how could you have done that?
You should have done this. So it's normal language to our brains. It's important for us to rewire it because life gets so much better when we realize that we're choosing things and we're not being compelled to do anything. We are freer than we like to tell ourselves sometimes, and when we're telling ourselves we should do things, we're creating kind of like a little psychological jail cell for ourselves.
Also when you find yourself saying, I have to, yes. That might even fit, like stretch this just a little bit when you're like, mm-hmm. Oh, definitely. I have to be more productive. I have to [00:22:00] stay late. I have to pick up, you know, an extra shift or serve on that committee. Yeah, same. Same principle. Yeah. Same principle, like what happens if you don't?
Right. Right. Like the hospital stays open. They do even if you die. Yeah. We have seen many examples of this. Sadly. Yes. Life just keeps on rolling, so. Mm-hmm. Take care of yourself. So don't die. Yes. Don't die. Don't get sick. Take care of yourself. So why does this work? Autonomy is a basic human need. Like if you think about animals, you put them in a cage universally.
If they're, you know, coming from their native state and being put in a cage, they try to get out. We don't wanna be controlled, we don't wanna be bossed around. Even small, perceived threats to autonomy can trigger resistance, psychological reactance, and internal rebellion. And all of that typically resides down in your limbic [00:23:00] system.
So it's not gonna be the best part of our brains operating. According to self-determination theory, which we are huge fans of, reference our previous podcast on that, or podcasts on that. Psychologists Deci and Ryan are credited with this. And I think they're at the University of Rochester now. They did a bunch of research investigating what helped people thrive at work, and they discovered that humans thrive when their needs for autonomy, competence, and relatedness are met.
And I like what Greg Guldner said in those podcasts about how he calls it the ABCs: autonomy, belonging, and competence. We all need those things to thrive, not just at work, but in our relationships as well and in our relationship with ourself. So when we replace should with values-based language, we are reconnecting ourselves [00:24:00] to our intrinsic motivation. What are our values? What is really important to us? What would we choose given the option? And when we're choosing something, rather than feeling pressured into it, the energy changes entirely. And we can recognize our autonomy, recognize our freedom to choose and we feel better about the thing that we actually want to do.
Classic: I have to go to work today. Well, you're gonna feel terrible about it if you talk about it like that. I'm going to work today because I like to help my patients. I like getting a paycheck. I like keeping my skills up. That's why I am going. I don't ever have to go again after today if I don't want to.
I don't have to go even today if I don't want to, but I want to. And that changes the whole experience for our brains. So here's some action steps if you would like them. Do not tell yourself you should do them, but you can do these if you would like. You can journal about it. What are your top [00:25:00] five shoulds?
What are the things that you are telling yourself you should do or should have done, and then you can practice reframing. You can keep the shoulds if you want. Our offering is that it's not helping most likely and can create a lot of misery, so learning how to reframe them using needs or choices can help.
Practice mindfulness. When you hear yourself should, notice it. Pause. Okay, what need am I trying to meet? Why am I saying I should do that? What is it? What is the need that I'm trying to meet? And choose an intentional thought. Choose a thought that you can pull up when you notice yourself shoulding yourself. One offering would be I release should. I don't need to use should. I choose.
With awareness and compassion, you can come up with your own version of that where you can decide you're probably gonna keep shoulding yourself for a while. We all do. One believable bridge thought that we might use would be, I'm working towards using the word should less. I'm working towards recognizing my autonomy in everything that I do, and that will feel better than [00:26:00] I should do this. I should stop shoulding myself. Okay. Not helpful. In fact, I was talking to a client just earlier today about, oh yeah, I've been coaching, I've done these other programs and I've been doing this so long and now it's just terrible 'cause I know all this stuff and I use it against myself.
Hey, no, don't do that. Mm-hmm. If you were treating yourself with anything less than compassion, you're committing malpractice on yourself. You're causing harm. First, do no harm. So everything comes back to curiosity. Why am I doing this? Why do I choose to do this? What value does it fulfill for me?
What need does it fulfill? And compassion. Of [00:27:00] course I did it that way. That was a really busy day in clinic and it didn't occur to me. I was feeling stressed. Of course, I took things at face value and now I might do it differently. I might not, but I release the idea that I should have been any different than I was.
I would say that also while we were talking about, you know, our own self critic or our own narrative, you know, I would be really aware of when you're talking to either other colleagues or patients like you should be more this. Mm-hmm. You should. Mm-hmm. Mm-hmm. So take this or your kids, oh, don't do it to your kids.
Mm-hmm. You should, you know, if anything y'all today is just awareness day, right? We have lots of awareness days, mental health awareness month. It's, you know, all these awareness days. Today is should awareness day. We are declaring it, but being aware guys is really the key because before, like Laura said,
it's getting down into [00:28:00] our emotional brain and when we reflect back, we can kind of see like, oh, I didn't sleep very well the night before, or I got a lot going on at home. Or I got a busy weekend coming up, or whatever it is. You can really allow for that self-compassion. You can allow that space.
But yeah. Can I add one more thing? I totally thought about this earlier, but I forgot to bring it up, is that we didn't talk about the neuroscience of it. Like we talked about the Freudian idea of it, but Jill Bolte Taylor, who was the author of Whole Brain Living, she would say that this should persona, this one that keeps shoulding is in your left limbic system and you can use the other parts of your brain to neutralize it and to
treat it with curiosity and compassion and say, Hey, I see what you're doing. I see you're trying to keep us safe by helping us prevent embarrassment, humiliation, you know, getting cast out, whatever, and we're okay. So our podcast with her [00:29:00] that was podcast number 100. That would be a helpful reference in her book as well.
So good about how to calm down that inner critic. That's good. So we hope that this podcast has helped y'all. We, like we said, just be aware and hopefully you can start to practice the reframe because we all want to build, you know, better pathways for our automatic negative thoughts to turn into our default, you know, personality builders, and we want to work on choosing the best possible
self to show up. So if this has helped you leave a review, it helps other doctors find us and it moves us up on the list. And if you have any experience with this or anything you wanna talk about, obviously email us anytime. We always say this: [email protected] or scroll down, click the link, meet with one of us.
We'd love to talk about it. And also, we have a new free video called How to Crush Physician Burnout for [00:30:00] Good Without Cutting Back Hours, Quitting Medicine, or Sucking It Up in Silence. Scroll down and look in the show notes. You can click the link or I challenge you: send it to someone that you know has been shoulding on themselves a lot lately and send it to 'em.
So until next time, you are whole. You are a gift to medicine and the work you do matters.
