# DTD 230
Welcome to the Drive Time Debrief with The Whole Physician, a podcast to burnout-proof your medical career with candor, humor, and encouragement. You spent tens of thousands of hours learning how to care for others, but now it's time to learn proven tools to care for yourself. If you're tired of feeling stuck, disillusioned, and exhausted, you're in the right place.
Start your journey to bring back contentment and purpose. Now, here are your hosts, three board-certified emergency physicians: Doctors Morison, Cazier, and Dinsmore.
Hey, guys. Welcome back to the podcast. I'm Amanda.
I'm Laura.
And I'm Kendra. Today we're continuing our series on schema therapy and the early maladaptive schemas that commonly show up in physicians. In the last episode, we talked about a very painful topic: unrelenting standards.
And that's the schema that says, "No matter how much I do, it's not enough." Today we're talking about two schemas that are incredibly common in medicine.
:** That's self-sacrifice and subjugation. These are the schemas that make many physicians incredibly useful to everyone else, and increasingly absent from themselves. Self-sacrifice says other people's needs matter more than mine. It might even be something I've heard repeated in medical culture all the time — but what about the patients? Patients come first. It sounds really good, but it's also called self-sacrifice. Subjugation says, "I don't really have permission to say no, disagree, or have needs." When you put those two together, you get the perfect doctor trap: the doctor everyone can count on, the one who will stay late, pick up that extra shift.
They'll smooth things over. They'll tolerate an unreasonable request. The doctor who will keep functioning with no food, won't even go to the bathroom, doesn't need emotional support, and has no margin. It looks like a doctor who is compassionate from the outside but may be completely disappearing on the inside.
Yikes. Good news, though — let's start by defining these two schemas. Self-sacrifice is the pattern of over-focusing on other people's needs while minimizing or even ignoring your own. This might be closely associated with a feeling of guilt — guilt for resting, guilt for saying no, guilt for disappointing someone, guilt for needing help, guilt for having limits.
And subjugation is the pattern of suppressing your preferences, limits, emotions, opinions, or needs because expressing them feels unsafe — maybe selfish, disruptive, or costly. People-pleasers, anyone? This is the birth of the people-pleasing phenomenon. Welcome to the fam, fam.
Self-sacrifice says their needs matter more than mine. Subjugation says I do not really have permission to say no. Together, they can create a life where you are constantly serving, constantly accommodating, adjusting, constantly absorbing — but rarely asking, "What do I actually need? What do I actually want, and what is this costing me?"
And pause here, because I want to be very clear: this is not an anti-service episode. We're not saying sacrifice is bad, or compassion is bad. We're not saying you should never inconvenience yourself for another human being. Medicine actually requires an element of sacrifice. Parenting requires sacrifice. Marriage does too. Some friendships, leadership, faith communities — there is always an element of service that probably requires some sacrifice. But healthy sacrifice is chosen. It's values-aligned. It's time-limited, and it's actually mutual over time. Because it's aligned with your values, you're doing it out of a sense of your "why." Something about it aligns with the person you choose to show up as, and it doesn't require you to disappear.
Schema-driven self-sacrifice is different. It's compulsive. It's driven by guilt, fear, identity, or the belief that your needs are less legitimate than everyone else's. Healthy service asks, "What is wise and loving here?" Schema-driven sacrifice asks, "How do I keep everyone from being upset with me?" Those are very different questions, and they require very different levels of energy.
Not mad about that. So where do these schemas come from? Like we've talked about with all schemas — including self-sacrifice and subjugation — they usually begin as adaptations. Maybe a child learns that love comes through being helpful, or that security comes through being helpful. The child may learn that their needs create stress for other people. Maybe they learn that conflict leads to anger, withdrawal, criticism, or punishment. Or maybe they learn to monitor everyone else's emotions before speaking. They become responsible too early for the emotions, needs, or functioning of adults.
And we've talked about this before — children will take on responsibility for creating their own safety rather than believe that their parents are unsafe or that it's the parent's issue. The child will say, "It's my fault that they're upset," because it gives them a sense of control. You can see how quickly this becomes maladaptive when these patterns follow us into adulthood. That child becomes responsible too early for the emotions, needs, or functioning of adults. Maybe the child becomes the easy one, the good one, the peacemaker, the helper, the achiever — the one who does not cause problems.
Our nervous systems then learn: I am safer when I'm useful. I'm safer when I don't need much. I'm safer when I keep other people okay. Again, this is not about blaming childhood or blaming our parents — this is about understanding the adaptations. Because if any of this is resonating with you, you know that child grows up and becomes a doctor.
And medicine looks at that adaptation and says, "Awesome — we can use that. It's exactly what we want." Medicine rewards the person who stays late, who picks up extra shifts or extra call. Or maybe it punishes us for not being a "team player," or looks down on us in some way. I think a lot of us are driven by the fear of being looked down on or cast out.
Medicine rewards the person who absorbs the system's dysfunction and calls it professionalism. It rewards the person who apologizes for having limits, who smooths things over, who over-functions, tolerates disrespect, skips meals, skips bathroom breaks — and then feels guilty for wanting to go home.
I hope you're hearing yourself in this, if this is you — because it's so, so common among doctors. In doctors, self-sacrifice can look like saying yes to extra shifts, extra committees, extra call when you're already depleted. It can look like answering messages on your day off because you feel guilty if you don't, or apologizing for asking for basic staffing support or sleep. It can look like absorbing everyone else's emotions — patients, families, nurses, consultants, administrators, partners, children, residents, med students — and never asking, "What about me?"
It can look like over-functioning for under-functioning people around us, whether at home or at work. Subjugation can look like staying quiet in meetings because speaking up would make you "difficult," or tolerating disrespect because confrontation feels worse than feeling resentful. It can look like saying, "It's fine" — like that little dog in the meme, sitting in the room that's on fire. "It's fine. It's fine. Everything's fine." No — when it's not fine, and we're saying it's fine, that's subjugation.
It can look like needing permission to have a preference, or always letting someone else choose. Do you even know where you like to go out to dinner? Do you even know what you like to do in your free time anymore? If you don't — and you find yourself always yielding to what other people want — that could be subjugation. It can look like feeling trapped in commitments you technically chose but didn't feel free to decline, and eventually resentment shows up.
And this is — Brené Brown, I love the way she talks about resentment, that it's a signal to us that we have allowed our own boundaries to be violated, or that we haven't set the boundaries that were appropriate — and it's our job to take responsibility and hold those boundaries.
A lot of doctors feel ashamed of resentment. They might think resentment means they're selfish, bitter, ungrateful, or not compassionate enough. But it's usually not a character flaw — it's data. It's the smoke alarm that tells you self-abandonment has been happening. It may be the part of you that still knows you were supposed to be included in your own life.
So if you're feeling resentful, look at that as information: Where have I abandoned myself? Where have I not been honest? Brené also talks about this — we can't actually be very compassionate from a place of resentment. We often think of ourselves as nice people just letting other people have their way, and that will turn us into not-so-nice people.
It's nice, but not kind.
Yeah... we should do a podcast on that sometime.
Yeah.
Okay, so if you're feeling called out — here comes the soothing balm. How do we begin to heal these schemas, self-sacrifice and subjugation? First, we need to name it. Let's talk about the fear that often comes up for physicians when they hear the word "boundary." Some of us will immediately feel guilty. The brain says, "If I stop overgiving, I'll be selfish. Patients will suffer. My team will resent me. My family will be disappointed. I'll be seen as difficult. I'll lose connection."
A family member of mine once said, "If I don't go above and beyond and do this stuff, it's not very Christian of me." And that was, honestly, the most unhealthy, zero-boundary situation. I don't think that's what's in the Good Book.
So healing these schemas does not mean becoming selfish. It means becoming honest. It means your yes becomes cleaner because your no becomes available. It means your compassion becomes more sustainable because it finally takes you into account.
The first step is noticing the guilt. For many self-sacrificing physicians, guilt is not always a sign that you're doing something wrong — sometimes guilt is a sign that you're doing something unfamiliar, and that's not a bad thing. If you've spent decades equating goodness with self-erasure, then including yourself may feel a little awkward at first. It might feel a little selfish — but that doesn't mean it is selfish. It means it's new. The healthy adult can say, "Guilt is here because this is unfamiliar, but that's okay. I can feel guilty and still make a values-aligned decision. Someone else's disappointment does not automatically mean I did something wrong."
The second step is separating compassion from compliance. Compassion asks, "What is loving? What is wise? What is a sustainable response here?" Compliance asks, "What will keep people from being upset with me?" Those are not the same question. A lot of doctors think they're being compassionate when they're actually trying to avoid someone else's disappointment, anger, judgment, or disapproval.
So before you say yes, pause, take a deep breath, and ask yourself: "Am I choosing this from love and from what actually matters to me — one of my values? Or am I choosing this because I'm afraid of what will happen if I don't?" Maybe you're scared somebody won't like you. Maybe you're scared somebody will whisper, "I can't believe she did that," under their breath. It's going to be okay, I promise.
The third step is practicing capacity before commitment. Before you agree to anything, pause and ask, "Do I actually have the capacity for this?" Not, "Can I technically force myself to override all my human needs to accomplish this?" Not, "Could I make it work if I sacrifice sleep, exercise, family, and emotional stability?" But, "Do I have real capacity for this?" I'd go even further and ask, "Do I have the capacity to do this at a level I'd be proud of?" If the answer is no — if you're just going to be slapping something together — then maybe you don't actually have the capacity for this. Many physicians are so used to overriding their limits that they confuse possibility with capacity. It is not the same thing. Just because you *can* force it doesn't mean you truly *have* the capacity.
The fourth step is practicing small, clean boundaries first. We're not asking you to go from zero to a hundred. Most self-sacrificing doctors don't need a dramatic personality overhaul — they just need to start doing the reps.
With a lot of this stuff, we tend to focus on what's going wrong. I'm a visual person, so I picture someone who only does arms and chest and never leg day — walking around with these little toothpick legs. We just need to start doing reps: practicing small boundaries, evaluating our actual capacity, starting to say no. We'll get there. Soon our legs will look just as strong as our arms and chest.
So doctors need to practice saying clear, non-defensive, non-overexplained sentences. "I'm not available for that shift." "I can help with X, but I can't take on Y." "That timeline doesn't work for me." Or, "I want to support the team, but I also need this to be sustainable" — just naming it, because that's actually accurate. When it gets pointed out that the ask is unsustainable, well, now we actually have to deal with something.
Maybe it looks like saying, "I'm not able to give that the attention it deserves right now — I need to check my capacity before I commit." Or, "I'm going to pause before I answer that. I need to sleep on it." A clean boundary does not require a courtroom defense. Many physicians overexplain because they're trying to get the other person to approve of the boundary. But if the boundary requires the other person's approval, it's not really a boundary — you're requesting permission.
The work is not to become cold. It's to become clear. Clear is compassionate. If we would just be honest about things, people could actually do something about it. So the work is to let your compassion include you.
Let's make this concrete. Imagine a physician is asked to pick up an extra shift, but she's already exhausted. She hasn't slept well. She's already worked too much. She's been short with her kids. Her body is screaming no. But the request comes in, and immediately the schema activates. Self-sacrifice says, "They need me. I don't want to let them down. Other people are working hard too." Subjugation says, "I don't really have a choice. If I say no, they'll think I'm not a team player. This is what's expected. It will create tension. I don't want to be a problem."
The coping style might be surrender — she says yes, but feels extremely resentful, maybe even gets sick. Or maybe it's avoidance — she ignores the message because she can't tolerate the guilt of answering. Or maybe it's overcompensation — she becomes irritated and harsh because she's overridden herself so many times that the only energy left is anger. She still does the thing, but she's angry about it.
A healthy adult response sounds different. It sounds like, "I care about my team, but I'm a human being — I also have limits." Surprising, right? It should be so obvious, but it's not. Maybe she says, "I do not have the capacity for this shift. Saying no doesn't mean I'm selfish — it just means I'm telling the truth." The actual response might be very simple: "I'm sorry, I'm not available for that shift." Period. That's it. No essay, no confession, no defense brief, no attempt to make everyone understand and be happy with your decision. Just a clean no.
I want you to notice where self-sacrifice or subjugation might be showing up for you. Where are you saying yes when your body is saying no? Where are you calling it compassion when it's actually more like compliance? Where are you overriding your limits and then feeling resentful? And if you don't know what resentment feels like, I invite you to notice — so that next time, you're aware. It's funny, because when I go into this with clients and ask, "What does resentment feel like?" everyone knows what anger feels like, but not always resentment. Then I bring up a situation that caused resentment, and they say, "Oh — this is what I did. I shut down," or, "I cussed under my breath." It's interesting — you may not notice resentment in the moment, but try this: notice whatever you felt when you said yes. That's it.
Okay — but where do you need permission to have a preference? Hmm, that's interesting. And where might your healthy adult say, "My needs matter too"?
So remember: compassion includes you. Your yes becomes cleaner when your no becomes available. Make your no just as available as your yes — it's an easy way to put it. A boundary is not a failure of love. It's one of the ways love becomes sustainable.
In the next episode, we're going to talk about emotional inhibition and emotional deprivation — the schemas that teach doctors to function beautifully while feeling profoundly alone.
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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.
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