EP 226
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[00:00:00] Guys, welcome back to the podcast. I'm Amanda. I'm Laura. And I'm Kendra. And today, we are gonna talk about something called clean pain versus dirty pain. So you know what it's like to have a patient die. Maybe you don't, but I do. You feel genuine grief, but then immediately your inner critic might start knocking, and suddenly you're replaying the case, wondering if you missed something, catastrophizing about, like, would they have done better if my colleague had seen them?
What does this mean about me as a physician? Am I even good at my job? And by the time you pull into your garage from your shift, you're not just sad Hopefully you're not, but I would be a hot mess. And so today's topic is clean ba- clean pain versus dirty pain. It comes from the world of behavioral science and psychology.
Most physicians have never heard this framing, but once you understand it, you're gonna start to see it everywhere. This is important for physicians because medicine hands us an enormous amount of both kinds of pain, but training teaches us to [00:01:00] suppress one and literally marinate in the other. So we'll get into that.
The three things that we're covering today are what clean pain and dirty pain actually are, why physicians are especially set up to get stuck in the dirty kind, and then what it looks like to move through pain instead of spinning and wallowing in it. Okay. So definitions, clean pain is the emotional pain that is a direct and appropriate response to what's actually happening.
So it belongs, it fits the situation. Here's the key thing, it moves, not fast and not without hurting, but it just has a direction. And on the other side of it, you're usually more human, more present, more clear. Clean pain actually refines you, so it just allows a time of editing if needed, but then it just, you can keep going.
So there's a direction and there's movement. So an example would be losing a long-term patient. So s- maybe someone you've known for years, you've taken care of for years, and like you know the [00:02:00] family, you, you know, it could be a spouse you know, you take both- care of both the husband and wife, but you know their story.
and then they become elderly, right? So they may have been in your practice for a couple decades, you know them well, but they become elderly, they have comorbidities, it makes sense that their time has come, right? And so there's grief there, and that grief is appropriate. It belongs there due to the fact that you've just established a relationship, and it's actually evident that you cared about this person, not just a patient in your registry.
And if you let yourself feel it, like actually feel it, not just register it and immediately redirect it will move through you. It doesn't have to destroy you. Other types of examples that might resonate for us physicians is like the fear after a near miss. So you're like, find out some information after you admit the patient from the ED, or like maybe later, you know, after you admitted a patient and they got discharged home.
I don't know. But you just get that like [00:03:00] information, like, "Remember that patient?" You're like, I immediately, my brain goes mer, you know, it's like the, the dog that goes ruh-roh. Or something like the sadness after delivering a terminal diagnosis.
Like, that is never fun. But it's appropriate, and it's there, and it can move through you. Or maybe the disappointment when you did give everything and it wasn't enough, and I've felt this. I've felt this a lot. And then Elle can speak to this, the honest exhaustion of a brutal stretch of shifts. Like, woo.
And then the grief of realizing the career you imagined isn't the career you have. I can attest to that one as well. So let's contrast that, or let's talk about the other type of pain, is dirty pain, and that is what we add on top. So it's not coming from the situation, it's coming from our thoughts about the situation, and this is really where it can heap up.
Specifically, thoughts that loop, escalate, [00:04:00] ruminate, compound. Basically, they go over and over and nowhere useful, right? They do not have a direction. They are not there to refine you. You get stuck, actually. There is no movement. So maybe an example of, quote, "dirty pain thoughts" is why does this always happen to me?
Everyone else seems to be handling this. If I were stronger, this wouldn't affect me like this. I, I think I'm guilty of that one. what does this say about me as a physician? Really? And then here's one: Nobody in this system cares. This is completely broken, and nobody's doing anything. Yes. But none of these thoughts move you through anything. They spin you in it. They keep you stuck, and there's a difference. You either move and have direction, or you stay stuck and you spin. That's the whole framework. And listen, we all spin in dirty pain sometimes. This is universal.
This is humanity. This is a human thing. When the brain is under [00:05:00] stress, it reaches for thoughts that feel productive, things like blame, analysis, resentment, rumination. These all feel like they're gonna be real productive because at least they feel like they're doing something, but they're not moving anything.
They're just generating and heaping on more suffering. And so this might be a little surprising, but we often run toward dirty pain specifically to avoid the clean pain. Clean pain- That- ... the real grief- That's so crazy ... the real fear- Wait, what? ... the real vulnerability. Yeah. Say that- Yeah ... again. Like, that's- Yeah
so crazy. Yeah, so in our crazy humanity, we'll run toward the dirty pain specifically to avoid clean pain because clean pain takes courage, and clean pain actually may be set you up for some growth. And we always know that growth is not always painless. Growth- Yeah ... can be one of the most, can be on the other side of fear, can be on [00:06:00] the other side of pain, can be on the other side of that.
But it's uncomfortable, and, and it, and, and clean pain can be uncomfortable, and we tend to, to try to avoid uncomfortableness. I think y- w- clean pain requires vulnerability, and that's, I think that's a trigger for a lot of us physicians. Yeah. Like, that's not allowed. Let's- Mm-hmm ... overthink it. Let's, surely if we think through this one more time, we'll get to it so we don't have to be sad.
Right? Yeah. Or like, or we'll keep digging 'cause surely there's information somewhere in here. Yeah. Useful information. But yeah, dirty pain by comparison, it feels more active. Like, resentment feels like agency or self-criticism feels like accountability. Rumination feels like problem-solving, right? We're gonna keep digging 'cause surely- Yeah
the surely is there somewhere, surely. We just keep going. Next time, We'll hit the treasure box, yeah, of information. So the brain offers that dirty pain as an escape. So here's an analogy. You bond with a friend or colleague over complaining, [00:07:00] right? There's genuine connection happening. You're validating each other.
You're not alone in the situation, but the original pain hasn't moved. There's no plan. You haven't chosen to accept your situation or even do anything about it. So you've just added resentment to it and called it connection. So the goal isn't zero pain. The goal is learning to tell the difference and to stop running from the kind that actually heals you.
Ouch. Ouch. Bang. I, because I will say, you know, that complaining and venting to each other or even gossiping does generate some oxytocin, which feel ... You know, that's the bonding hormone, and it feels better temporarily. But if you reflect on it, generally afterwards you don't feel so great, so I think, too, there's a big difference in, like, a one-time thing Mm-hmm
but if you're the same thing 50 times- Yeah ... then are you really solving anything, or is this just a [00:08:00] bonding where maybe you could go see a movie together? I mean, co- collaborating or corroborating, whatever you wanna say, over something- Yeah
definitely feels like you're connecting, and you're like, "Yes, we're on the same team. Go team." You are. Yeah. I'm gonna need to look this up. It's like, if you complain to somebody once, you're... God, I gotta look it up. I'm gonna botch it, but it's like you're connecting. But if you complain to the same person about the same problem twice, you're not trying to problem solve.
You're, you're needing attention. So it's just like - Yeah ... oh. And I think- Or- ... I think the word that I would use there is colluding. Like, you're- Mm ... conspiring to keep each other stuck because you're- blowing off enough steam to just, like- Yes ... make it comfortable, but You're doing nothing to change it.
I think it makes a big difference how you feel when you go home after it. Yeah. Like, if you feel empowered and connected, then there's, It's just, it's one of those gray zone things. If you go home- Yeah ... more [00:09:00] angry, more resentful about the same problem that you've had for the past five years, like, I think that's how you could probably gauge it, if it's truly beneficial or not.
Yeah. I think that's true, and that's where, like, learning to pay attention to how your body actually feels. If you feel more energized in the moment but actually feel more tired or more inflamed, if you know what I mean, that feeling of just, like, your body, it doesn't feel good, that's good information.
All right, so we're gonna talk about why physicians are set up to get stuck and what dirty pain looks like in medicine. Medicine creates nearly perfect conditions for dirty pain to take over. I know you're all stunned and shocked. But here's why- What? I know, it's shocking. What? Perfect little career that we chose.
Point one, training teaches physicians to suppress clean pain. So from day one, the message is, " Feel it later. Don't... We don't have time for [00:10:00] that. Push through. compartmentalize. The patient needs you right now." And, you know, in acute moments, that's, that's functional, that's true. You can't process your feelings when someone is coding.
So temporary compartmentalization is, is a real helpful, useful clinical skill. The problem is what happens after. And for ph- for most physicians, " feel it later" became "never feel it." Stuff it down in the basement of your soul. And I love what my daughter's psychology professor said, and I've said it multiple times on this podcast, but you stuff your feelings down into the basement, they go down there and lift weights, and they come up stronger than ever later.
That compartment door gets locked and like I think about those scary trunks in the attic that have the chains on them and the dust and, like, something in it's, like, shaking, trying to get out. Physicians become very good at that one specific [00:11:00] skill, noticing they're having an emotion and immediately shutting it down.
Yeah. I feel, I feel it. So the clean pain, grief, fear, moral injury, genuine exhaustion never gets processed. It doesn't disappear. It just accumulates like all those little chained-up chests in the basement or the, or the attic. So point two, unprocessed clean pain finds its way out as dirty pain. The physician who never grieved the patient who died starts snapping at a nurse.
The physician who never sat with the fear after a near miss starts overworking to prove something to themselves. The one who never acknowledges what moral injury actually costs starts to build resentment. I mean, that doesn't take long. Nope. That's easy. Takes, like, five minutes. Yep, toward the administration, toward the system, toward colleagues who seem to have it easier.
And remember what [00:12:00] we say about that kind of resentment is drinking poison, expecting other people to die. So all these things are coming out of those locked chests like zombies or ghosts that are not very attractive. That resentment and irritability and cynicism, that's just often displaced clean pain.
The dirty pain is a covering. It even feels righteous sometimes. But underneath it is grief, fear, and hurt that was just never allowed to be just what it was. So I'm gonna talk about an example now. A bad outcome or difficult case So a physician loses a patient or has a complication or delivers a life-changing diagnosis.
This happens to all of us if you've been working for more than three weeks in medicine. Clean pain is available there. That's the real grief, the real, the pain of having made a mistake or the sadness of having to share this [00:13:00] bad news. That pain belongs and it makes a doctor more present. It makes us more compassionate if we let it in and we process it and let it move through us.
What actually happens instead so many times is that we register that hurt for about 30 seconds, maybe less, close the door, and within two minutes our brain is running a replay loop. Did I miss something? Should I have ordered that scan? What does the family think? Would my colleagues have done a better job?
Oh my gosh, I hear that so much. Other people are faster and better than I am. What does this say about me? That replay loop is dirty pain. Rumination, preemptive shame, self-attack. Basically stories piled on top of the pain. We are so creative. Our doc- Yeah ... you know, our, our smart doctor brains are just so good at coming up with all these crazy stories to make us miserable.
And it feels like the right thing to do. [00:14:00] It feels like accountability. It's not accountability. It is suffering without direction. Wow, that sounds pretty bleak and pointless. And it doesn't produce growth. It produces exhaustion, defensiveness, and emotional numbing. All right, example two, brutal shift or brutal clinic day.
Imagine you're working in a place that's short-staffed with high acuity, patients in the hallway, impossible metrics. Hmm, hard to imagine. Moral injury at every turn. And just as a reminder that moral injury just means that you know you should be able to deliver better patient care than you are able to do given the constraints of where you're working.
And so most of us experience that. Clean pain is there. That's legitimate grief about working in a system that just doesn't support good care, and that pain deserves acknowledgement. What often happens instead, we get home, [00:15:00] we spend three hours in a loop while we're probably trying to numb our feelings with s- food on the couch and watching trash TV.
Get resentment towards specific administrators. Comparison to other specialties. Guilt about their mood around their family. Shame for not being more resilient. And more often that will look like it's not looking like I'm just not resilient enough. It's looking like I'm weak or other people can do this better than I can.
Guys, we've talked to enough doctors. It's just not true. This stuff is near uni- near universal, okay? We all experience this They can't even name what they're actually feeling anymore. They're just numb or dysregulated or just like don't even know what their feelings are doing and definitely don't have any emotional control.
The clean version of this, which, which is available even if it's harder and it takes practice, and [00:16:00] that's probably another career-long pursuit if not lifelong pursuit. That sounds like today was genuinely terrible and I'm genuinely depleted and that's okay. That, that makes sense it, and it matters. It's okay.
The sentence could lead somewhere like maybe a real conversation with a partner or a friend. Maybe you can journal about it. Maybe reflect and decide, " Is there something I wanna do about this? Is this a sustained problem? Do I need to, make some changes about how much I'm working or where I'm working?"
Just five minutes of sitting in the car before going inside, five minutes, okay. Two, three hours like I used to do, that, that's not, that's not what we're going for. That's a, that's a red flag that you got something more serious going on Something. So that clean pain drives us to something that will actually change things.
[00:17:00] And example three, the comparison spiral. Oh, boy. Medicine is is set up for comparison. It's set up like a factory, and we are the workers on the assembly line. And how many units? I mean, if you think about us as like Amazon workers, how many boxes are we packing per hour? There's not-- there's no measure of, like, what was your genuine emotional connection with people?
You can't even say that about Press Ganey's because that's more like, did you order the test that they wanted you to order? So the parts that we really feel like were important to us when we came into medicine, we don't get measured on. Nope. assembly line. It's RVUs, productivity. Maybe it's even leaking into our personal life with parenting or fitness or, you know, again, charting speed, how fast we see patients, how well we keep up with our inbox or are, [00:18:00] are we in a chart hole?
And because doctors mostly see the social mask that other people wear, the, that professional polished exterior or the Instagram or TikTok, you know, curated life that gets posted, most of us assume that they're the only ones struggling internally. And again, I will tell you that is not true. More of us are struggling than are not.
The ones who are not usually are practicing something called dermatology So this creates a very specific dirty pain thought. Everyone else seems to be handling this fine. Why am I like this? What is wrong with me? And guess what? That a lot of times just sucks, most of the time just sucks the energy out of us more, makes us have a harder time to get those charts done or makes us slower in, in seeing patients.
Does-- It definitely doesn't move anything forward in a good way. It just makes us spiral. The [00:19:00] clean pain underneath it is usually simpler and more honest. It's like, "I'm really struggling, and I feel completely alone in it." This is a tragedy of medicine to me, is that there's no public acknowledgment that these things are common, and there is such a culture of shame and fear of public shame that most of us just don't feel like we can talk about it.
That, that sentence that I'm really struggling and I feel completely alone in it, it's vulnerable, which is not safe, doesn't feel safe to us in medicine, but it's also the one that could, that could open a real conversation, and that's the thing that actually drives human connection. It's the way out of loneliness.
So here's the deal: Physicians weren't trained to process emotions. In we were trained to do exactly the opposite. We've told you before that our emotional intelligence goes down during training. They've researched it. We [00:20:00] suck at emotional intelligence, and that is by design. We were trained to override our own needs, especially our own emotional needs, and the brain very predictably found another way to get that crap out, found another outlet.
You are not broken. This is just the way you were trained. So what would it look like to stay in clean pain instead of generating the dirty pain? So it's not as easy as it sounds. A lot of this stuff I'd never even heard of until I started doing coaching stuff, and especially if dirty pain is a decades-long habit.
Anytime you're trying to do something new, it's gonna be a lot easier to fall back into old habits. But just as a, just as an idea, this is what it could look like in practice. So to start, you're going to learn to identify which kind of pain you're in. The distinguishing question is simple: Is this emotion moving me through something or [00:21:00] spinning me in something?
A question like, " I wonder if my colleague had seen that patient, if they would've done better," there is no answer. There will never be an answer. Who could possibly know that? That is just dirty pain. That is such a painful thing to say to yourself, your brain is just offering up that, that your partner, it would, everything would've come out rainbows and daisies.
Why is it picking that story? Of all of the stories it could tell you in the world, why that one? That one's so painful. So just notice it. There's no answer to some of these dirty pain questions that come up. So clean pain moves again. if you really sit in grief, you might cry, you might bawl your eyes out m- maybe for an hour, maybe for a couple of days, but eventually it moves through you.
Eventually it stops. Grief, sadness, real fear, real disappointment, these are experienced, but they have a direction. When you allow them, they release themselves. That energy is it doesn't stay within you. It's, like, let out of you. So yeah, [00:22:00] you might have tears. It might shock you into stillness, but something is happening and it's moving through you.
Dirty pain, though, you're just sitting there marinating. So rumination, resentment, self-pity, comparison loops, shame spirals. It's the same thought over and over without any sort of forward movement. So at 2:00 a.m., you're replaying the same loop of the case over and over. The cycling list of everything wrong with your department.
I spun in that for, I don't know, 15 years. Wasn't, wasn't moving me anywhere. You know that feeling like when you've been thinking hard for something about an hour, and then somehow you're u- you're worse than when you started? That's dirty pain. So just notice which one you're, which one you're in.
That awareness alone interrupts the autopilot. Suddenly you're getting back into your prefrontal cortex like, " Oh, wow, look at what my brain's doing. Look at this nice helping of dirty pain." So [00:23:00] next, this is good news. Don't even try to think your way through either one. This is where we get tripped up as physicians because we're looking for, like, well, how do I solve it?
Okay. That's- Ah ... that's why we go to dirty pain 'cause it feels really useful, right? But a feeling is just an experience in your body, so analyzing it, while that's our default mode, that's not helpful for clean pain. When we're in pain, the instinct is definitely to think harder, review the case again, dissect what went wrong, understand what system failed, figure out what to do differently next time.
But the irony is that gets you back into your dirty pain. It doesn't do anything for the clean pain. Thinking harder about a bad outcome just starts up that rumination loop. Thinking harder about burnout just grows your resentment more. Thinking harder about a difficult colleague just makes you more and more miffed, right?
So what moves clean pain is not thinking, it's allowing. It's being a human being. It's getting out of your head and into [00:24:00] your body long enough to let the emotion exist without fixing it, explaining it, or suppressing it. And we like to joke that physicians are basically floating brains- Cut off at the neck.
Like, we don't check in with what our body... Half of us go through an entire shift and never go to the bathroom. That's, that's a disconnect between our head and our bodies, right? Yeah. Or like- This dissociation ... s- we're working when we're sick. Like we are, we, we are really good at cutting off any experience that's going on in our body.
So that's step one is to start being step two is actually notice if you're in clean pain or dirty pain, step two is allow it. So driving home after a terrible shift, the instinct might be to call someone and rehash the same thing that you've been complaining about for the past 50 times. Maybe you blare your radio to drown out what just happened.
Let's definitely not think about the, the pain for sure. You can rehash everything unfiltered that you would get to say that you would, that you would love to say if you, [00:25:00] if it wouldn't get you fired. Like, I've had these imaginary conversations in the shower for whatever reason is what triggers it.
Like, "Oh yeah, and I should have said this, and then I should have said that. They would've been sorry," you know? Yeah. No, they wouldn't. So I don't know what, I don't, I'm just getting myself all worked up, right? So instead, just for five minutes, turn it all off. Turn the radio off. I drive home in silence now.
Just notice where this lives in your body. Is your chest tight? Is your jaw clenched? Probably your shoulders are up to your earlobes. Is there an exhaustion that's deeper than anything physical? Don't try to analyze it or make it mean anything. Just notice it. Let it be there. It's allowed. You're a human being.
Just breathe and maybe you say to yourself, "Today was a lot, but I'm human and, and I'm allowed to feel this." That's it. That's all, that's all you have to do to allow clean pain. It sounds so simple, and it's also one of the most, most underutilized skills in physician wellness. So you've, you've decided if you're in clean or dirty pain, you've allowed the [00:26:00] clean pain, and now finally, when you notice dirty pain, name it and give yourself permission to put it down.
This is different from suppression because suppression is locking the door without acknowledging what's behind it in the first place. Like, it's the little dog in the fire that's like, "I'm fine. Everything's fine." Mm-hmm. And the place is burning to the ground. This is different. You're acknowledging it, recognizing it for what it is, and then choosing not to keep feeding the monster.
So when that 2:00 AM loop starts, should I have ordered that scan? Did I miss something? I always do this. Instead of engaging in that loop, acting like you're doing some useful problem-solving, you can say, "Hey, I know what this is. This is dirty pain. This is not helping me. Nothing productive is happening here."
You might still feel the anxiety. That's okay, but at least now you're gonna stop generating more of it. And then this is what takes a little practice. You redirect toward the clean pain underneath. I'm scared. I care about that patient and I'm scared. That sentence you can [00:27:00] sit with. That sentence you can do something with.
It's got somewhere to go. What keeps physicians from doing this, though, is that many of us carry the belief, whether it be through our training or our upbringing or whatever, and, and often we've never examined it, that letting ourselves feel the pain means we will never be able to function again. We feel like if we experience the sadness, if we let ourselves cry, as if, like it's never gonna end, it's just all gonna overtake us and be years of just tears falling and you- you're not able to function.
But if you really grieved, if you really sat with the fear or acknowl- acknowledged how much pain you're in- We think that we're gonna fall apart, like, like it- we're just Mount Vesuvius ready to blow. But here's what's true, is that suppression is what creates the dysfunction over time. It creates numbing, cynicism, detachment.
It creates the burnout. That's the result of years of locked compartments that are below the surface. So allowing the clean pain, truly [00:28:00] grieving, acknowledging the fear is what keeps physicians human, sustainable, and present. I will tell you, when I have a client that starts coaching, it is the weirdest thing that sometimes they'll log on and just tears start flowing, and they don't know where they're coming from.
But that's that pent-up stuff that they have put-- they've never had a safe place to be with someone else who knows what they're going through. And it's such a relief to just start to let that out. You're not gonna fall apart. You-- This is what's gonna allow you to move through. So your actionable takeaway is, listen, you're, you drive home from your work already.
Use it. So before you hit play on a podcast or a sports game or something that's gonna distract you, take five minutes and ask yourself three questions. One, what did I really feel today? Am I really angry or am I hurt? This is not the time to ask you what you should have felt. You don't need to look for a silver lining or coach yourself or anything.
[00:29:00] That's not what you think would be normal to feel in this situation. What did you actually feel? Name it. Was it grief? Was it fear? Was it exhaustion? Was it guilt? Was it frustration, satisfaction? Did you actually have a good time, God forbid? Whatever's true, that's just information. It's just good to notice.
So number two, is there any clean pain I closed the door on? For a good reason, maybe I was coding somebody, but is there something that I need to work through now? Would, would, would it be better not to keep it trapped within me and to let it go? So this is where any grief, fear, or honest sadness that you shut down mid-shift, that you didn't have time to process, give it 30 seconds.
Just acknowledge it exists. You're a human being, and you are worth this. You deserve this. You don't have to solve it. You just need to let it be real for a moment. number three, what dirty pain am I carrying? What have you been spinning on, ruminating, comparing yourself to, catastrophizing or resenting?
Just notice it. You don't have to [00:30:00] fix it. You're allowed to have these feelings as a human being. you don't have to sugarcoat yourself. Just say, "This isn't necessary, though. It's not helping me. I'm allowed to put this down." That's five minutes. You're not overhauling your life. You're just starting to treat yourself as you would take care of any other human being
So clean pain versus dirty pain, simple distinction, but it does reframe a lot. Mo- most of us were trained explicitly and by example that the right response to pain in medicine is to suppress it, push through it, or basically just not have it, right? Just don't, opposite of Nike. Just don't. Nobody ever asked whether the pain was carrying us...
Nobody ever asked whether the pain we're carrying is moving us anywhere. And here's what's true: the clean pain, the grief, the fear, the honest acknowledgement that this work is costing us something real, that pain deserves to be felt. Not immediately not, [00:31:00] not turned into a lesson or a productivity goal, just acknowledged and allowed.
And when you let it, it moves. And the dirty pain, the rumination, the comparison loop, the resentment, the shame spiral, that's not required. You don't have to do that. A lot of what we call burnout is what happens when years of this suppressed clean pain comes out sideways as chronic dirty pain, and that pattern can change.
You went into medicine because you're someone who cares. That was never the problem. That was actually the whole point. Learning to let the clean pain do its job instead of building walls against it is one of the most sustainable things you can do for your career, your patients, and yourself. So that's it for this episode, friends.
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