This is the Drive Time Debrief, episode 220.
Hey guys, welcome back to the podcast. I'm Amanda. I'm Laura. And I'm Kendra. And Kendra is going to do the intro today.
I want to start with a moment I think a lot of you will recognize. Getting home from a super long shift, you're finally in your car, hands on the wheel, and you tell yourself, "Tomorrow has to be different. It will be different. Tomorrow, you'll leave on time. Tomorrow, you'll chart in real time. You'll be more patient at home, more present, and maybe — maybe — you'll make it to the gym or just do a little walk or something." And you really mean it. You're not lying to yourself. But then when tomorrow comes, somehow you're just right back in the same pattern.
And I did this for years — always feeling behind, always feeling rushed, always reacting instead of responding, and just totally exhausted. And if we're really honest here, there's this quiet thought like, "Why can I not get this together?" And I'm sure you've said some form of that at some point — maybe when your kids were little, or maybe you're in a season like that right now.
And you know, when I had my own version of this, it was like, yeah, I know a bunch of stuff I should be doing. Maybe I should be teaching it, maybe I should be telling someone, maybe I should be collaborating about it, but I could not consistently live it. And that disconnect really felt frustrating. It felt defeating, and over time it just kind of chips away at how you see yourself. Like, "Am I ever going to get this together?" There was probably a solid five to eight years where I was like, "I don't even know if I'll ever get on top of everything I feel like I should be doing."
So today we're going to talk about what's really happening here, and it's not a discipline problem, it's not a time management problem, it's not even a motivation problem. It's a learning problem. And once we break it down and you understand how it works, everything really does start to make sense.
So we're going to talk about the conscious competence learning model. This was developed by William Howell. There are four stages, and it explains how we move from effort to automaticity.
In medicine, if you remember, we've lived this process over and over and over again. Think about the first time you took an H&P. Think about the first time you cut into somebody and did a surgical procedure. How about when you ran a code, or intubated, or dropped a line? You weren't calm. The patient's heart rate was 180. Your heart rate was 180, right? Remember that? It wasn't smooth. You were afraid you were going to forget something. You had to really be intentional and think about every step. And now — I'm sure a lot of veterans out there can give us a holler back — you just kind of walk in and your brain just does it. It just knows what to do. When you intubate, your steps are just there, and you feel like you don't even really have to think about it. But that didn't happen because you tried harder. It happened because you moved through stages of learning. And here's where the disconnect is — no one ever showed you how to apply this to your actual life.
So let's break it down.
Okay, so first we're going to talk about stage one, which is unconscious incompetence. The language for this is: you don't know what you don't know. This is doctors with emotions a lot of times. I personally remember feeling like my emotions were my entire experience. Like, I didn't think about my emotions — I had emotions. They seemed very, very real. And I didn't really have a way to ask, "Are the thoughts that these emotions are based on actually true?" So having that skill of metacognition — to be able to step back, look at what we're feeling, and make a choice — I didn't realize that was a thing. I thought, "I feel what I feel, and it's true, and why don't other people feel this way?" So there's a perfect example of not knowing what you don't know.
An example with a patient may be someone with type 2 diabetes, or who had been kind of on the border of type 2 diabetes, who comes in with uncontrolled blood sugars and says, "You know, I feel fine. I don't think this is a big deal." They're not being some kind of medical rebel or noncompliant. They just don't know. They don't know the impact of having those blood sugars for a prolonged period of time. And for me, it looked like not realizing the impact that choices I was making in my schedule, or even in my sleep habits, could have on everything else. Certainly we were trained to try to survive on as little sleep as possible during training, not realizing that we are not superhuman, and that it really can have a huge impact on everything else in our lives.
Stage two is conscious incompetence. That's when we start realizing that maybe the way we're doing things doesn't work for us, and we haven't been able to fix it yet. So now you see it, and it's uncomfortable. You don't know how to do something, but you can see your ignorance and your lack of skills. You can also see the value of gaining knowledge to address that deficiency and begin seeking growth.
This is something we see when we're working with clients all the time, when they start developing some of that awareness of their emotional states. Say someone feels like they're too emotionally reactive in certain situations. In the past they may have just flown off the handle and not even realized it was happening. Now they're learning, "Oh wait — when I notice that my teeth are clenched and my fists are tight, that's my clue that something is about to happen." And they may not be able to stop it yet, but they're starting to get some awareness of it, rather than just thinking, "My feelings are my feelings and other people need to deal with it."
So again, thinking about that newly diagnosed type 2 diabetic — they understand the consequences now. They've done diabetes education, they've been scared, they've heard about amputations, blindness, et cetera. They know what they should be eating. They know they need to check their sugars, but they feel overwhelmed, and it feels like too much to implement all at once, and their blood sugars might still be all over the place.
This is where many doctors live emotionally, and even in the way we manage our schedules. We might know: I should set boundaries. I know I do not want to be saying yes to all these things that don't impact my life for the better and don't align with my values — and yet I'm still doing it. I know I want to manage my time differently. I know I want to leave work on time with all my charts done, and still I'm not able to do it. I know I should rest. Resting can be the key for all the rest of the things happening — just kind of a side plug for rest.
If I knew I should be doing all that, or I wanted to do it and have it align with my values, but I wasn't doing it consistently, it might feel like failure. It might feel very frustrating, like I can't change anything. And one thing we like to tell people is that when we're forming a new habit or making a change, it can be completely normal to only do it twenty percent of the time at first. That still counts. It's not failure. So we have to give ourselves grace — even the awareness and any progress we make along those lines is great.
So now, once you move from that stage, you go into stage three, which is conscious competence — meaning you're doing the thing, but it takes effort. You're having to think about it. Now you know a great deal on the subject and can reliably perform the tasks involved. However, you're definitely having to think. It's not automatic. It requires a great amount of effort. This is like when you're learning to pitch — you're having to think about where your fingers are, really concentrate on the glove, and all of that sort of stuff.
A patient example, continuing the diabetes example, would be the patient who's actively managing their diabetes. They're checking their blood sugars. They're reading labels now. They're making intentional choices, but there's still some resistance to it. It's not automatic. It's not a lifestyle yet. It requires attention and diligence every day. And I think this is the stage where you're like, "I'm trying to make a new habit, but gosh, this is hard." And you're like, "Maybe I'm just not cut out for this." No, no, no. This is stage three — making it automatic in your life.
A personal example: this is when in your own journey you might be intentionally making and sticking to a schedule, but you're constantly having to check it. It's not a routine yet. Or you set a boundary or two, but then you're like, "Oh crap, did I do this right?" You're double-checking with the person, making sure they're not mad at you. Maybe you're replaying the conversation over and over in your head, ruminating on it. It's just still uncomfortable. Or you leave work on time, but you feel guilty the whole drive home because you feel like maybe you abandoned your partners. You've still got those remnants of people-pleasing mode. And none of those things sound bad, but when they're consuming your life, that's where the problem lies. You're actually doing the thing, but it's requiring a lot of effort. It might be uncomfortable still, and it might be consuming a lot of intentionality to continue the habit.
And then you move into stage four, which is where it becomes unconscious competence. This is where it becomes part of your identity. It's part of who you are. You have practiced this and performed the task so much that now you don't have to think about it. This is when a ball gets hit at the pitcher and their arm goes out and they catch it — they didn't have to think about that. It was muscle memory. It's the same with when you've practiced your habit enough that, "Oh yeah, this is the time where I put my shoes on and go for a jog." You don't have to force yourself to do it anymore. It's part of who you are. You can now perform this task effortlessly and unconsciously, even while doing or thinking about something else. Learning to walk — when you were a baby, you had to focus on it. Now you can do a hundred things and walk around with ease. You don't even have to give it another thought.
So the patient example: this is where the diabetic has fully integrated their lifestyle. They don't think twice about carbs. They just know this is how they live. The personal example might be that after a lot of practice and reminding yourself to live in alignment with who you want to be going forward, boundaries no longer feel dramatic. You've done them enough times. Your schedule runs with less friction. It's not chaos all the time. It's intentional, and it's in alignment with your own priorities. This is where you can start to feel present at home, and you can leave work at work — not because life got easier, but because you trained this into your new identity automatically.
Yeah. So hopefully this gave you the 10,000-foot view. When you expect yourself to perform at unconscious competence in areas where you're still at conscious incompetence, you can see where that mismatch can really show up and create a lot of frustration. It's like telling that diabetic at the very first visit — when you're having that first conversation — that you expect them to have a perfect A1C or get it all controlled in one week. We would never expect that from our patients. But why do we expect it from ourselves?
So realizing that at some point we can operate in the world differently than our former self — when we didn't know what we didn't know, it was just ignorance. But then when we started to see the value of boundaries, the value of time blocking, the value of living in alignment with our values, that former self doesn't have to come into our present, and it definitely doesn't have to go into our future.
Now we're going to have new experiences, new perspectives, new skills, new habits, and form new relationships, and those can start to influence how we behave and what we see. And so we don't lose sight of where we've been. We don't have to pretend that was all for nothing or that those experiences didn't get us to where we are today. It was just moving from stage one to stage four, affecting that perception and that decision-making.
So let me give you a real quick look at how we can make these shifts and implement them today.
Start by identifying your stage. If you're thinking about a situation like, "How do I prioritize being present at home?" — identify your stage. Instead of judging yourself, like "I never feel like I can turn off," just get curious. Say, "Okay, where am I in this process?" You might say, "Okay, I see the value of being present at home. I see the value of getting in the car and having a chance to decompress on my way home so that I can show up present. Maybe that's where I'm at. Maybe I just don't know how to do it yet, but I realize the value." Okay — so just name that stage. You're in stage two.
Then expect effort. You've recognized you're in stage two. How do we get to stage three? It is going to require some intentionality, and it's going to feel hard, because you're probably not going to nail it right away — like we said, expect maybe twenty percent success the first week, or maybe even less. Give yourself some grace. Cut yourself a little slack. But that's okay, because if it feels hard, that means you're doing the work. You're moving into stage three with intentionality, on your way to stage four.
And how do we get there? We build reputation. The first week we were one for ten — maybe next week we're three for ten. And the week after that, we build on that.
Like I said at the beginning of this podcast, sitting in your car after a long shift, telling yourself tomorrow will be different — what if the problem really isn't you? What if you were just expecting to go from stage one to stage four and skip everything in between? You wouldn't do that clinically. We don't go from "I don't know how to intubate and why is it even valuable?" to "I drop a tube in 60 seconds." That took time. That took maybe a whole residency, I don't know for you.
But just pick an area where you find yourself saying "I know better" or maybe "I just want better" but can't quite be consistent. And instead of trying to totally overhaul it, just go through those steps. What stage am I in? Identify without judgment, expect effort, start with intentionality — it's going to feel hard, and that's good, you're doing the work — and then build reputation through structure.
Can I add something to that too? Yeah. I was talking about this with a client the other day, and she was frustrated with herself — "I'm not doing it." And we talked about a different way to think about it, because when we are frustrated, we're likely not going to be able to do the thing, because it's a self-fulfilling cycle. So we chose the intentional thought: "I'm building something sustainable." And that takes away any judgment. It's just, "Yes, I am in this process." And the feeling that goes with that is hope. And I don't know about you, but I feel much more able to regulate and show up the way I want to when I feel hopeful than when I feel frustrated.
Another example that comes to mind is numbing out. A lot of docs numb out after shifts — be it with alcohol, TV, or scrolling. There's a whole lot of scrolling these days. That wasn't really an option when I was a young Padawan. Could be shopping, it could be any number of things, but you know what it is if you're someone who does it.
If you are somebody who doesn't want to process your feelings once you get home and would rather just numb out — well, at one point you figure out that that's what you're doing, that you're avoiding your negative emotions. That's stage two. You've moved from not even realizing that's what you're doing to now knowing what it is, but you're like, "Yeah, but I'm going to go ahead and turn on Netflix anyway." That's stage two. You're aware. That is a step, so you have actually made progress.
And then one day you're like, "You know what? I'm not going to turn on Netflix." Then you're moving into stage three, where there's still a lot of resistance. You want to. It's not the natural thing for you to do. It takes some effort to not numb out after a shift. But then you practice — that's stage three. You stay in stage three for a bit, you practice it over and over and over, and then next thing you know, you're not even thinking about it. You just do whatever it is that's a healthier way for you to wind down. And not judging Netflix if it's not consuming your evening — I would come home and just watch it at the expense of my rest, late into the evening, still having to get up in the morning. So yeah.
And then one day you're like, "I don't even identify as a person who numbs out anymore," and you've made it. Yeah, that's all great, because that's the thing — this isn't about perfection, right? It's just about getting to that automaticity, and hopefully we're able to give you a little bit of a framework that's simple. We love simple. The less convoluted, probably the better the adaptation into our lives.
And you know, after I read The Gap and the Gain by Dan Sullivan and Benjamin Hardy, this concept was in that book — a fabulous chapter about just learning how to not only start a business, but then finding your "who's" and 10X-ing and all of the things. It's like every stage that you move through in business, or anything that you're trying new, you don't realize what you don't realize — but then you start to see the value of learning new tips and finding tricks and getting things done. So this can be applied to a lot of different things, and I thought it was very applicable to what we do as physicians every day.
Well, thanks for listening to us today, guys. We hope you found this conversation helpful. The best way to support us is to subscribe, so click the button now and rate us — we'd love five stars — and leave a review. It helps other physicians find us, and it moves our podcast up on the list. And if you have had any experience with this, or know about the conscious competence learning model and want to talk about it, email us at [email protected]. And don't forget to follow us on the socials at The Whole Physician — we love connecting with you there.
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