DTD 187
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[00:00:00] This is the Drive Time Debrief, episode 187.
Hey guys. Welcome back to the podcast. I'm Amanda. I'm Laura. I'm Kendra. And today we are gonna talk about something that bothers me frequently, and that is ruminating thinking. And so let's talk about it. So ruminations are repetitive, often negative, thinking about distressing events, [00:01:00] feelings, and especially the uncertainty. It's your mind when it gets stuck in gear.
It's going over the same ground, it's going over the same information over and over and over without resolution. So to me it's really helpful to know why your brain's doing this in the first place. 'Cause it can feel like you're broken or something. You're not broken. Your brain is wired to try to solve for uncertainty.
It wants to feel safe. And for a lot of people, uncertainty is something that we have a difficult time accepting. But it's just a fact that some uncertainty cannot be solved no matter how hard you think about it. Like you aren't always gonna know what a patient's outcome is gonna be after discharge, no matter how much you think about it, unless you're willing to make a phone call or something, are you gonna figure that out?
But usually it's just me like perseverating on it. Like, God, I hope she's okay. I hope she's okay. Like, and no phone call. So what, like what? What am I doing to myself there? The more you mentally try to solve the unsolvable, the more things that come up that [00:02:00] also are unsolvable, so it makes you more and more anxious and mentally fatigued.
So ruminative thinking has this false narrative that like your brain literally feels like if I could just think longer and harder about it, or maybe if I regret things even more deeply than somehow I can go back and fix things. I have regretted things for days and days and days and days. What, what? I really feel like my brain was convinced if I could just regret it even harder, that somehow I could go back and fix things or like, maybe it's like a self-flagellation sort of thing.
I don't know, but another problem is we hold ourselves to an impossible standard, refusing to accept mistakes or setbacks. And so even when others have moved on, we're clinging to that. We're clinging to what happened. And then lastly, one therapist when I was researching for this, mentioned that ruminating is a way to avoid your emotions because you're stuck up in your head thinking about things. I see that a lot in [00:03:00] docs is like, if I just think about it harder, then I don't actually have to grieve. Mm-hmm. If I think about it harder, then I don't have to feel disappointed in myself or like just actually going through those feelings of feeling guilty or regret or whatever. That's an interesting take that therapist had.
So it turns out there are four types of rumination and they weren't inherently clear to me, so I'll just explain it at my best understanding. If there is a therapist out there and I'm off, please let us know at [email protected]. But the four types are brooding, reflection, intrusive rumination, and deliberate rumination.
Brooding is just the like pervasive, self-critical thing. Like I'm just a screw up, like it's just the like negative self statement that's not aimed at any sort of resolution. It's just painful without any sort of future focus. Reflective rumination. Okay, so the hard ones for me are reflective rumination versus deliberate rumination. [00:04:00]
The best I can gather is that this can be useful when you are thoughtfully reviewing something aimed at an insight. And for reflective rumination, it's like a self insight. Like, why was that triggering to me? Why do I feel this way? So you can see how that could be useful in moderation.
It's aimed at an internal awareness. Intrusive rumination is where you get that. This happens to me in my closet for some reason all the time, just like a flashback, unwanted, uncontrollable thought about stressful events that just, maybe they're unprocessed, who knows what. But they pop up and then deliberate rumination as opposed to reflective where you were reflecting on yourself and your own, like internal state.
Deliberate is like an intentional analysis trying to get to the bottom of an issue. So it's more about the external situation, the process that you're ruminating about instead of like internal enlightenment. So what does the brain do? Brains like to make sense of things. It is literally a prediction machine and wants [00:05:00] to understand the why behind events.
Brains also like control. They are control-seeking bowling ball weighted organs in your head. A mental rehearsal feels like, and you can see how you could fall into this. It feels like it's preparing you or somehow going back to prevent mistakes, and that can be useful, but often it's just replaying the pain over and over and over.
Sometimes there's emotional processing. The brain uses rumination to try to digest unresolved feelings, but in high stress jobs like medicine, the volume and the stakes overwhelm this system. And then survival wiring, evolutionarily scanning for threats and reviewing past errors kept us alive. Makes sense why we're doing this.
We want to be able to predict when there's gonna be harm, but in modern life, this just ultimately leads to unnecessary suffering. So often, yeah, we don't have to run from bears much these days, or the saber-toothed tiger. So might as well stay at that moderate level of safety, but [00:06:00] we can look a little bit how this shows up.
If what Amanda was saying hasn't triggered anything, which as she was talking, I'm like, oh, yep, that, oh, yep, that, oh, yesterday I did this. Oh, yeah, last week. So for example, when she was talking about the brooding type of rumination. Say you worked an ED shift and you keep replaying a moment you snapped at a nurse or got short with a staff and you tell yourself, gosh, I was a terrible physician there.
I was a terrible teammate or a terrible leader in that situation without really considering the context or like that patient was sick. It was stressful because that patient is like actively trying to leave the earth, DC to JC we say, right? So you're like, it was stressful, it was a young patient and like what?
Like that context is, no wonder you're like trying to consider to stay two steps ahead so you can keep your team on top of their tasks. Meanwhile, this patient is spiraling. So instead of considering how you could [00:07:00] learn from the situation, you're just saying, I'm awful. I'm an awful leader. I'm an awful physician. I shouldn't work in the ER or this, I should just like quit and go to Jenks Beauty School, which is what I've told myself lots of times. That was my backup plan. Jenks Beauty College and for everyone, I grew up in Jenks, Oklahoma, so that was the thing to do, but I have told myself several times, what am I doing? I was meant for Jenks Beauty College.
So reflection example. So this is where if you see a patient that's triggering, whether it's the type of patient you see or whatever, you can't get that interaction out of your head. Why did it bother you? Why is it so triggering? Why did he or she say that? Did I say something wrong? Did I deserve that? What did I do? I just showed up in the room, right? So you're reflecting, and you're trying to really get to the bottom, like, make sense of this. Just like Amanda said, our brain wants to make sense of the situation, but in the moment when you're seeing 10 or 12 patients, you know, and so, so busy, like you can't get that out of your head, [00:08:00] especially driving home when you're replaying that entire shift and you remember that one sample.
An intrusive example might be when you do get home from work and you finally get to go to bed, right? You finally get to unwind and lay down, and you are just laying there, eyes wide open, cannot shut the brain off. You're reliving the expression on the patient's face, the words they say, the interaction with the colleague, the fact that you had to deliver bad news or had a bad case that day and you're just playing that over and over and it can become intrusive because it's impossible, it seems at the time to turn that off.
And then there's the deliberate example, like intentionally running through every step of a complicated surgery in your head to make sure that you didn't miss something or make sure you did all the steps right, even hours after the case is complete, and this can happen, whether there was a bad outcome or not, I mean, it could have went totally smoothly. And some people, they'll just get trapped in that, oh, well, [00:09:00] could I have been faster? Could I have gotten them out faster? Could I, whatever, whatever.
In contrast to reflective rumination, this is less about understanding yourself and more about the process. So like, you know, my day could have gone a lot smoother if I would've been able to flip rooms. The process in the OR is so inefficient. They're not sterilizing, they're not preparing the next room, they're not good, blah, blah, blah, blah. And you can really spin up and you can see going from there as not that productive.
So why is this such a problem? Well, there's already high uncertainty built into medicine. On top of that, we're a bunch of perfectionists. And so we're already scared of any kind of error, whether it's built in human error or not. We have a sense of moral responsibility and letting go of any control whatsoever is very hard.
And then rumination drains our mental bandwidth. It delays emotional recovery 'cause we're constantly spinning out and thinking of all these things. And it contributes to burnout through [00:10:00] perseverative cognition, which is the sustained activation of the stress response, which we talk about a lot. That staying at that moderate to high level of stress beyond what we were ever meant to be, that is going to obviously lead to burnout.
Really paying attention to how our rumination is making you feel. So am I ruminating because it's solution focused and leaving me empowered for the next time? Or is it just beating me down and creating more distress and making things a lot worse? So how do we stop doing it? I mean, sometimes it just feels like I thought this is who I am, but no.
In fact, it is not. You are more than your rumination. So we're gonna give you a few strategies. One of them, which we'll call an anchor strategy, is uncertainty exposure. And you're not gonna like this. I know. Mm-hmm. And growth never feels good. Yeah. Guys. Right? Just know that the end result is good. Yeah. With the process. Say the end result is good, stay with Yes. [00:11:00]
So just notice when you're trying to solve something that's unsolvable, especially in the past, totally unsolvable until we have time travel. It's definitely unsolvable. And then notice as we're noticing that I'm trying to solve something that I can't solve, this is rumination, and then allow the uncertainty to exist without trying to force a solution.
We know in our rational minds that there is so much, so much more that we don't have control over than that we do, and allowing that takes down our suffering. Remember that old equation we use: pain times resistance equals suffering. So this is allowing to reduce our suffering and then shift gently into present moment focus.
Take a deep breath, notice what's around you. Notice how your body feels below your neck instead of the practice that we doctors [00:12:00] need a little help with. Because it's not natural for us to notice what's going on with our bodies. Notice who you are in the present moment, who you want to be. So here's some type-specific interventions.
If you're the brooding ruminator, practice some self-compassion. Replace "I'm terrible" with, and you may not be able to go straight to something better, but "I'm working to believe I'm not terrible" or "I had a tough day and I'm learning." Eventually we want you to say, "I'm awesome. I'm getting more awesome all the time," not "I'm terrible."
That'd be great. If you're a reflection ruminator, use this technique called time boxing. Set a 10-minute timer to review things, then shift to something else, whether it be action or rest. Discipline yourself not to allow your brain to keep going on and on. If you're an intrusive ruminator, use some mindfulness anchoring.
So Amanda, whatever's happening in your [00:13:00] closet over there, label your thought. Mm-hmm. And then redirect to sensory input. Get back into the present moment, and the more we can redirect our brain, the weaker we can make that initial thought loop that we had. The more we indulge it, the stronger it becomes.
So we definitely want to try to discipline our brain to pull over to something more helpful and useful for us. If you're a deliberate ruminator, externalize the analysis. Write it down. Writing things down is so helpful. Look at it, store it until tomorrow and give your brain permission to rest. This is so, so good.
If you're having insomnia, write all the stuff down. Because a lot of us have so much going on that we are ruminating, so we don't forget stuff. Mm-hmm. Use a planner, use a notebook, write the stuff down, set reminders. Don't try to keep it in your brain. Some other general rumination breakers: accepting that the past is unchangeable.
No amount of what-ifs will rewrite it. Actually, in [00:14:00] a lot of ways it only still exists in our minds, so it's not a great use of time to really focus on that. Mindfulness and grounding to return to the present. You're up in your head again. The only thing that is real is this present moment. Switch from "what if" or "if only" to "what can I do about it now?"
And I would offer that we're actually not even, we're not even up in our head. We're down in our limbic system and we need to get back up into the prefrontal cortex. And nothing works for that like mindfulness and meditation. That will help so, so much.
Forgive yourself. Every single human makes mistakes. It's part of why we're here. We're here to learn. We're here to grow. You can't get everything right the first time. You just can't. So forgive yourself a little. CBT or cognitive behavioral therapy style reframing to challenge distortions. Like notice the thought errors, and we have a bunch of podcasts about thought errors.
If you need a [00:15:00] refresher on that, notice when you're catastrophizing or overgeneralizing. Physical activity. Highly, highly recommend this. This will help burn off stress. It helps increase blood flow to the prefrontal cortex and refocus the mind. Such a good way to get out of rumination. Other engaging activities that require your full attention: conversation, hobbies, music.
I love going to the movie theater, to the movies 'cause it's so immersive. It's easy to get out of a thought loop if I'm in someplace that's really fun, engaging, and interesting, like that. Supportive conversation with a trusted peer or therapist, or we would say a coach, especially one who's also a doctor because they get it and they will help you not ruminate.
They will help you get out of your co-rumination, where sometimes you might talk to a spouse about things and they might co-ruminate with you. Oh yeah. Because they get all anxious too. Mm-hmm. So if rumination is chronic or distressing, [00:16:00] there is a therapy modality called rumination-focused cognitive behavioral therapy or mindfulness-based interventions, which are evidence-based for breaking the cycle.
There's also a little thing called Prozac, or I just know some family members who have OCD really do well with the Prozac to help with rumination. So that's my last little 2 cents. Sounds good.
Well, Kendra usually takes us home, but technology would suggest that she has vanished off of this call. So, so here we go. I'm gonna wing it here, but thank you guys so much for joining us. If this has helped at all, share it with somebody. If you have a comment, email us at [email protected].
And until next time, you are whole, you are a gift to medicine and the work you do matters.
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