DTD 229
===
[00:00:00] Hey, guys. Welcome back to the podcast. I'm Amanda. I'm Laura. And I'm Kendra. And today we're continuing our series on schema therapy and the early maladaptive schemas that commonly show up in physicians. In last episode, we talked about what schema therapy even is, where it came from, how schema are basically old emotional templates, meaning the patterns that we learned early and how they shape how we see ourselves, other people in the world.
But today we're gonna talk about one of the big ones for doctors, which is, oh no, I can already tell this- Mm ... one's gonna hurt. Unrelenting standards. Mm-hmm. It's the schema that says, no matter how much I do, it's not enough. No matter how well I do, I could've done better. No matter how tired I am, I should be able to keep going.
And if I make a mistake, it means something terrible about me. And this one's tricky for physicians because part of it looks like excellence. Part of it looks like diligence. Part of it looks like being conscientious. None of us want careless doctors. We don't want sloppy [00:01:00] surgeons. That'd be awful. We don't want indifferent emergency physicians.
That would be utter chaos. We want physicians who care, who prepare, who pay attention, and who take responsibility. But there's a big difference between having standards and being held hostage by them. So that's what we're gonna talk about today. Okay, so the unrelenting standard schema is the belief that you must meet extremely high internal expectations in order to avoid criticism, shame, failure, rejection, or collapse.
It's not simply I like to do things well, it is if I do not do this exceptionally well, then I'm not okay. Healthy excellence says, "This matters, so I will bring my skill, attention, humility, and care." Unrelenting standards say, "If this is not perfect, I am not safe." Healthy standards are values-driven, and we talk about this a lot, going back to our why and [00:02:00] really anchoring things that you do to your values.
Unrelenting standards are threat-driven. So you can see where that would elicit a stress response. Threat detection equals stress response, right? Healthy standards allow learning. That's that growth mindset. I'm not there yet, but I'm working. We also talked about the four stages of learning not too long ago, so this is all the growth process.
But unrelenting standards demand punishment. Healthy standards allow rest. Unrelenting standards say, "You can rest when everything is done," which actually means never. And for doctors, this schema often hides inside very respectable language. Sounds something like, "I should be able to handle this." I've said that more than once.
" Other people have it worse. I need to be more efficient. I can't let anyone down." I've said that once or twice. " I should have known better. I should not need this much help." Yikes. " Good doctors don't make mistakes like that." Oh, yeah, I forgot they're [00:03:00] superhuman. " And then I'll rest after I finish everything."
Oh, that will never happen. So... But the problem is that everything is never finished, and there's always another chart, another inbox message, another patient, another committee, another family need, CME, licensing, certification, blah, blah, blah, blah, all the things, right? So the doctor with unrelenting standards may look successful from the outside and feel constantly behind on the inside to where it is almost like you feel totally bankrupt.
Yeah. I, and I know, I know a lot of you are like, "But this is just how it is, and we're just gonna offer to you that it doesn't have to be that way." You can, you can have high standards and also rest sometimes. Let's talk about how this particular schema develops and how it shows up in doctors. Like most schemas, unrelenting standards usually begins as an adaptation, and what we mean by that is it's a way that, as a [00:04:00] child, we did something to help us feel safe or make more sense of the world.
So for some people, love or approval was tied to achievement, and this is true for a lot of doctors. You know, I think you knew that your parents loved you, but you really knew they loved you if you brought home a gold star or an A or an award or a medical school acceptance, then you really knew. So It, it makes sense that this kind of stuff feels important to our brains.
For some of us, criticism was more common than our parents just delighting in us, and we achieved to avoid that criticism. For some, mistakes were even met with anger or withdrawal. Sometimes we were shamed. Certainly in our training, we were shamed for mistakes and even contempt. And for some of [00:05:00] us, there was enough chaos in our homes that control became a way to feel safe, and that, that was true for me for sure.
For some of us, becoming-- being the smart one or the good one, the responsible one, even like the spiritual one, the talented one, or the exceptional one became that role that earned us connection with the people we craved it from. And our nervous systems learned I'm safer when I perform well. I would argue that this is probably present in the majority of physicians, because otherwise, how did we wind up in this crazy job?
And, you know, again, this does not mean that we're blaming our parents. Our parents did the best that they could with the knowledge that they had. It just means that we're understanding the adaptation that, that we created for ourselves to help us feel safe. And when we're that child who creates adaptation, eventually we grow up, and maybe we become a doctor.
[00:06:00] And guess what? Medical training and the medical system says, "Awesome. Fantastic. We can use that." We love people like you who will over-function and over give and overachieve because it feels like you need to to survive. And I think we can recognize that medicine rewards a doctor who... Rewards or I don't even know if rewards is the right word.
You're gonna feel less punished, I guess, if you are staying late and, you know, not checking things out to your partners or your... If you study longer, you catch every detail, never appears to be affected by lack of sleep or is able to anticipate other people's needs, says yes to every committee, and really treats every error as unacceptable Then we're avoiding punishment more.
And, you know, that part of that can make [00:07:00] sense. We're dealing with human lives and details do matter. Being skilled matters, preparation matters, and being accountable matters, but where the schema distorts something true is where there's no room for error, no gray to the black and white of I am either good or bad as a doctor or as a human.
The truth is that patient care is, you know, it's really important. That's what we're here for. That schema says, therefore, I am never allowed to be human, and that's where we as doctors can get trapped. here's an example. Unrelenting standards shows up so many different ways, but maybe it's the doctor who stays up charting late because the note does not just need to be accurate, it needs to be perfect.
And if you feel called out, if you're one of our clients hearing this, it... you're not alone. It's extremely common for us to obsess over these notes, [00:08:00] and it, it just punishes us. It's the doctor who replays one bad consultant interaction for the rest of the day. Like, " he must think I'm an idiot," or, " Why is he such a jerk?"
It's the doctor who receives 10 compliments and then one neutral evaluation, and the neutral evaluation is the only thing that their brain holds onto or even a negative one. Many times the feedback that we get, if it's negative, it's more about the person giving the feedback than it is about us. So we need to be able to discern what's actually true and what actually we need to reflect upon and what's just, just noise.
Maybe it's a doctor who can't delegate because no one else will do it right. We hear this over and over again. No one else is gonna do it. Well, if we don't let other people have a chance to try to do it, w-we're gonna put ourselves in charge of a whole system, and that's not sustainable. Maybe it's the doctor who overprepares for every talk, [00:09:00] every meeting, every case, or every difficult conversation, feels irritated or even contemptuous when other people seem less conscientious.
And this-- that's one that shows up a lot too. So we can have super high standards for ourselves. We shame ourselves if we don't meet those high standards. That also is gonna make us more likely to shame other people, at least in our minds, and look down on them if they don't meet the same standards. And yeah, you can do that.
Is that how you wanna be? Do you wanna be a contemptuous person who thinks you're better than other people? Or is there an alternative? Maybe it's the doctor who turns wellness into another performance project, like per-perfect sleep score, perfect workout plan, perfect morning routine, perfect nutrition, perfect meditation streak.
Maybe it's the doctor who can't celebrate success because the second something is accomplished, that schema says, "Yes, but what's, what's next?" That arrival fallacy where we think every time we get somewhere that [00:10:00] we're gonna feel so great and it doesn't last. So these are some of the hallmarks of unrelenting standards.
That finish line keeps moving. You finish residency, but now you need the fellowship. You get the job, but now you need the leadership role. You publish the paper, but now you need the next one. You give the talk, but now you replay the one sentence you wish you had said differently. You survive your day of work, but now you're behind on charts.
You catch up on charts, but now you're failing at home, or you think you are. You finally rest, but you feel guilty for resting. If this is you feeling guilty for resting, this may be one of your schemas because the schema always moves the finish line, and over time it creates a terrible internal bind.
You're exhausted from doing so much, and you're ashamed that it still does not feel like enough
Ooh. Well, that's the end of the podcast. No, I'm just kidding. I hate it, I hate it when we're like, "Here's the terrible news, and there's nothing you can do about it." There [00:11:00] is ... There are things that you can do about it. So how do we begin healing some unrelenting, unrelenting standards? First, I wanna name the fear that often comes up for physicians when we talk about perfectionism or unrelenting standards.
A lot of doctors hear, " Stop being a perfectionist," and their brain translates it as, " Stop caring. Become mediocre. Lower the bar. Just don't care, l- and let, let patients get hurt." That is not at all what we're saying. We're not trying to make you more careless. No one wants careless doctors. We're not trying to remove excellence.
No one wants not excellent doctors. We're trying to remove the fear and the shame and the self-abuse from the way you pursue that excellence. So step one is to notice the schema voice. the unrelenting standards voice often uses words like should, must, always, never, unacceptable, ridiculous, lazy, weak, slacker, behind, [00:12:00] pathetic, not enough When you hear that voice, it doesn't sound very kind, does it?
It doesn't sound very grounded. It rarely sounds like somebody who loves you. So when that voice appears, you might simply say, " This is actually unrelenting standards," not, "This is the truth," not, "This is who I am," just, "Huh, this is the schema showing back up." So step two, ask what the schema is trying to prevent.
What is it trying to protect you from? Is it trying to protect you from criticism, from shame, from disappointing somebody, from being seen as incompetent, from losing control? Is it trying to keep you from needing other people or feeling ordinary? Or is it the fear that if you slow down, everything will fall apart?
When you identify the threat underneath the standard, you can start to work with the actual fear rather than just obeying the pressure. Step three, define enough ahead of time. this is super important because if you wait until you're already deep within the [00:13:00] schema, enough will keep moving. The goalpost will keep moving farther and farther and farther.
So before the chart, before the talk, before the family conversation, before the patient message or project, ask yourself, what would be enough here if I were allowed to be both excellent but also human, and not just a robot that doesn't need sleep or nourishment or whatever? A clear, accurate note is enough.
A perfect note is not required and probably not even read by anyone. a thoughtful response to the patient message is enough. A response that guarantees they will like me is not required. A competent presentation is enough. A flawless performance is not required to get the point across to help the audience.
A repaired parenting moment is enough. A flawless parenting existence is, first of all, not possible, and luckily, since no one's ever had a perfect parent, it's not required. A values-aligned [00:14:00] workday is enough. Completing every possible task is not required, and that's not lowering the bar. That's putting the bar somewhere humane Finally, step four is practice healthy adult language.
A healthy adult does not say nothing matters. A healthy adult says, "This matters, but I also matter." A healthy adult says, "I can care deeply without punishing myself. I can learn from mistakes without becoming the mistake. I can pursue excellence without abandoning myself. I can re- be responsible without being endlessly responsible for everything.
I can be a good doctor and still be a human being within limits." This is the work of healing unrelenting standards. Notice that none of that sounds like becoming sloppy. It doesn't sound like becoming indifferent, but it's letting excellent come from values instead of fear or judgment
All right. So let's make this concrete. Imagine a [00:15:00] physician gives a lecture and it goes, goes well. Multiple people say it was helpful, but afterwards she can't stop thinking about one slide that felt clunky and one sentence she wished she had said differently.
The event is one imperfect moment in an otherwise really good or excellent lecture. The schema is unrelenting standards. That schema is gonna say, "That should not have happened. You should have prepared more. Other people would have done better. You looked unprofessional. People are gonna think you're an idiot."
The coping style might be surrender, where she believes that shame and decides that she's actually not good at this and doesn't belong. Or it could be avoidance, where she stops wanting to speak or, or teach because the emotional cost feels too high to her. Or maybe it's overcompensation, where she spends 20 extra hours preparing for the next talk so she never has to feel that exposed again.
[00:16:00] And that, that all sounds, if you think about it, it does sound pretty childlike. But the healthy adult response sounds a little bit different, and it says, "That moment was uncomfortable, and also it was not a complete disaster. The talk was helpful. I can improve that slide next time. I don't need to punish myself in order to grow.
And, you know, people probably got a lot of benefit out of my talk even if I had an error or a typo or one slide that just didn't work." So when we can look at that... And I would argue, I've noticed that when I can name whatever schema, if I'm starting to feel like flooded and stressed about something, I can ask myself, "Is this a schema coming up?"
And if I can name it, then that actually helps start that healing in real time.
Yeah, that, that hits pretty close to home. I gave a talk, and it was at our national conference, [00:17:00] and I screwed up at the end. I, like, paused for a moment 'cause I forgot where I was, and I definitely said some of those things when I got off the stage. Like, immediately I went to, like, "I should not have been up there," like, all the things.
But one of the things I think that I said was kind of like that, but just more to the effect that, you know, it wasn't meant to be perfect. Hopefully, you know, it You know, landed with at least one person in the audience because one person was worth it, or something like that. And I think also it... You know, when you put yourself out there like that, it is vulnerable.
And so it's not... It, it isn't surprising that you have unrelenting standards when you're on stage like that. So it honestly is definitely what we're talking about today, a growth, you know, process where you experience it, you learn from it, and you, and you have that growth. And, you know, that's what we always are [00:18:00] here to do, is to encourage you to continue growing.
Because if not, we'll just stay stuck in our own old patterns, and we may or may not have an excuse for them, but we just more or less weren't aware before, but now you are. And so choosing what to do next is one of those really powerful moments. So this week, I want you to notice where unrelenting standards show up for you.
Not with judgment, just with curiosity. Like, where do you feel like no matter what you do, it's not enough, right? I just gave you the example of my lecture. But it could be something even like showing up as a mom or showing up as a wife or showing up as a something, you know, a different role than just being a doctor.
But just asking yourself these questions really allows for you to approach them in curiosity. And if you do it when, like, you, you didn't just screw up like I did when I got off stage, you're more likely to adopt these in curiosity or at [00:19:00] least think about them with curiosity. When something just happened, you're less likely to be, like, graceful and compassionate towards yourself.
Another question might be, where do you move the finish line as soon as you reach it? This is a big one, I think, for us physicians, 'cause we had so many, quote-unquote, "steps" to get here that we were always pushing for the next thing, graduating med school, graduating residency, getting board certified, being session chair or d- or department leader, whatever, whatever.
We're just always striving for the next thing. So it's really easy to get caught up in moving that finish line. Another question might be, where are you calling it excellence when you're actually driven by fear or insecurity or maybe pride? And maybe where your healthy adult m- might show up and say, "Actually, this situation matters," or, "This keeps coming up, so it obviously is a big deal to me," and it's because you matter, too.
And so in the next episode, we're gonna talk about self-sacrifice and subjugation, and [00:20:00] th- these schemas turn so many physicians into a person everyone can count on, except themselves. And we've talked about that self-integrity in the past, so we will get to that. S- so some of these questions we talked about, there are a few more we'll include in the show notes if you want to check them out, and uh, just encourage you to view them at a time when you have space mental capacity to actually look at them through the, through the lens of curiosity.
So that's it for today's episode, friends. If you found this conversation helpful, the best way to support us is to subscribe, so click that button now and leave us a rating, five stars of course, and a review, because it helps other physicians find our podcast, and it moves us up on the list. And if you do leave a review, take a quick screenshot and email it to us at [email protected] and we will send you a free e-book on emotional regulation, which is actually one of our most requested impactful [00:21:00] topics.
And just before we go, we want to remind you that we are hosting our first exclusively physician-only wellness retreat at Bodhi Tree Resort in Nosara, Costa Rica. We are collaborating with MedTreks International, and we are so looking forward to this. This is a sanctuary built for renewal.
It's designed for doctors. There's so much to do to immerse yourself in. We will be there, your TWP team, providing just a little bit of programming in the morning. And for everyone that comes, you'll get access to our course online as a part of your retreat fee. And we are just looking forward to this November to see all of you there.
So if you're interested, we'll have a link in the show notes where you can sign up. Thanks for spending time with us today. Until next time, you are whole, you are a gift to medicine, and the work you do matters
