riverside_edit_03 - schema therapy 5_the_whole physician
===
Welcome to the Drive Time Debrief with The Whole Physician, a podcast to burnout-proof your medical career with candor, humor, and encouragement. You've 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 Morrison, Cazier, and Dinsmore.
Hey, guys. Welcome back to Drive Time Debrief. I'm Amanda. I'm Laura. And I'm Kendra. And today is the finale of our series on schema therapy and the early maladaptive schemas that commonly show up in docs. In the last episode, we talked about emotional inhibition and emotional deprivation. Those are the schemas that teach many doctors to function beautifully while feeling profoundly alone.
So today, though, we're gonna talk about defectiveness, shame, and approval-seeking. Those are the schemas underneath so much of physician imposter syndrome. These are the schemas that make physicians look highly accomplished, competent, respected, and successful on the outside, but on the inside, if you were to look at them, they feel like they're only one mistake away from being exposed.
Defectiveness or shame says, "If people really knew me, they would think less of me." Approval-seeking says, "I'm okay if everyone else thinks I'm okay." When these two go together, you get the physician who's constantly performing, proving, pleasing, achieving, scanning to make sure everybody's okay, and trying to become finally, permanently safe from shame. So let's start by defining the two schemas.
Defectiveness or shame is the schema that says something is wrong with me, or I am not as good as everyone thinks, or if people really knew me, they would think less of me, or I am one mistake away from being exposed. Approval-seeking is the schema that says, "I am okay if other people think I am okay." It says, "I need the patient, the consultant, the colleague, the administrator, the evaluator, the audience, the partner, the family member—whoever—to approve of me before I can feel settled inside myself."
And when these schemas go together, the physician may become dependent on external reassurance but unable to fully absorb it. So praise might feel good for a moment, and then the schema kicks in and says, "Yes, but if they really knew..." Or achievement feels good for a moment, but then the schema says, "Yes, but what's next?"
Or approval feels good for a moment, but then the schema says, "Don't mess it up." This is why imposter syndrome is often not fixed by more evidence. The physician really has plenty of evidence. You have degrees and board certifications, years of practice, lots of patients who give you five stars, leadership roles, awards, a full schedule, an OR schedule booked out three months, whatever it is.
But shame doesn't ask what the evidence is. Shame asks, "What if they find out?" And this is why a lot of physicians are exhausted. They're not just practicing medicine, they're practicing worthiness through medicine, and we're trying to achieve our way into safety. And that's a problem, because when medicine becomes your identity, it's hard to separate that.
So we continue to try to be impressive enough that maybe, at some point, shame will quiet down. We're trying to be liked enough, useful enough, competent enough, productive enough, selfless enough, excellent enough, so that old fear finally says, "Okay, you're safe now." But shame rarely says that. Achievement can soothe shame temporarily, but it can't heal shame.
Approval can soothe shame temporarily, but it can't heal shame, because that schema is always going to ask for more. So where do defectiveness, shame, and approval-seeking come from? Like all schemas, they usually begin as adaptations that make a ton of sense. A child might learn that mistakes bring criticism, embarrassment, withdrawal, or maybe contempt.
Or maybe that child is compared to siblings, peers, or an impossible standard that... actually, I feel like doctors do this all the time, like, "I'm not the perfect doctor"—the one who, personally, I have never met. Mm-hmm. Who's a robot and has no human needs and all of that. Yeah, the comparison thing is a problem.
Maybe a child was praised for performance but not for being vulnerable. Maybe a child felt loved when they were impressive but ignored when they were just ordinary. Maybe they learned that approval, then, is safety. Maybe you picked up somewhere that being exceptional protects you from feeling defective.
Your nervous system learned, "I'm okay when I'm approved of," or, "I'm safe when I'm impressive," or, "If I make a mistake, people will see what's wrong with me." And again, this isn't about blame. Everyone is doing the best they can. This is about learning what your go-to adaptation is. And then that child grows up and becomes a physician, and here we are.
Medicine is almost perfectly designed to reinforce these schemas. From the beginning, you are evaluated constantly—your grades, your test scores, your exams. Then there are rotations, letters, match lists, rank lists, procedure numbers, patient satisfaction, RVUs, metrics. I mean, medicine is rife with comparison, and a lot of feedback in medicine is not at all given with tenderness. Some of it's brutal. Many physicians have had the experience of being corrected publicly in front of their peers, humiliated in training, pimped on rounds, put on stage for an M&M case about their practice, and it felt like a personal failure. So the shame schema most definitely gets reinforced in our culture in medicine.
The approval-seeking schema also gets reinforced. The doctor learns, "I'm only as safe as my last performance." So in physicians, defectiveness and shame can look a lot like feeling like a fraud despite years of evidence that you're competent, despite the diplomas on the wall, despite the years in practice.
It can look like obsessing over one mistake, one complaint, one awkward interaction, or a bad outcome. It can also look like feeling secretly relieved when someone praises you, and then needing the next hit of reassurance the next day. It can look like over-explaining to prove you're competent.
It can look like apologizing when you've done nothing wrong. That drives me crazy. I do that all the time, trying to stop myself. It can look a lot like avoiding new opportunities unless you already feel like you can look successful doing it. It can look like being unable to tolerate being seen as ordinary, or turning your CV into a worthiness document.
Approval-seeking can look like needing every patient to like you—and I mean, honestly, our jobs want us to do that, right? It can look like feeling destabilized by a consultant's tone and taking it personally. It can look like scanning the room to see if people are pleased with you, if they're nodding and smiling at you.
It can look like changing your answer, your boundary, your schedule, or your opinion to avoid disapproval. It can also look like saying yes to things you don't want to do because you can't tolerate someone thinking you're selfish, difficult, or letting them down. And this is important: shame is not the same as accountability.
Accountability says, "I did something that needs attention, repair, or correction." Shame says, "I am something that needs hiding." Accountability helps doctors grow, but shame makes doctors hide, get defensive, collapse, or overwork and perform trying to escape it. We don't need more shame in medicine. Not at all.
There's way too much. What we need is clean accountability without identity destruction. Feedback is important, but shame turns it into a verdict.
I know. When we're just so used to shame culture, I think just hearing this can be disorienting. So just think about it. And how do we then begin to heal these schemas of defectiveness, shame, and approval-seeking? Remember that these are adaptations we developed as young children, sometimes even before we were verbal—we learned these things.
So the first thing we need to do is address a fear that many doctors often have. If I do not feel shame, will I become careless? If I do not care what people think, will I become arrogant? If I stop needing approval, will I stop being kind? The answer is no, okay? No. You're not gonna suddenly become a psychopath, okay?
No. That's not what's gonna happen here. Shame is not what makes you an ethical person, and approval-seeking is not what makes you compassionate. It can actually make you less compassionate over time. Self-abuse is not what makes you excellent, and you can be accountable without shame. You can be kind without people-pleasing, and you can be excellent without outsourcing your worth.
The first step is separating what's actual data from the shame story. The data is what actually happened, and the shame story is what your schema says it means about you. For example, data: a patient complained. The shame story you might give yourself is, "I'm a bad doctor." Or data: a consultant sounded irritated. The shame story might be, "I am incompetent."
Okay, let's look at that. Is that consultant's irritation more about you or about them? Ninety-five percent of the time, it is about them. Data: I missed something on the first pass. Shame story: I should not be trusted, or I'm incompetent. No. Again, no. Data: someone disagreed with my decision.
Shame story: I am exposed as a fraud. I never should have even gotten into medical school. Again, no. The healthy adult is going to ask, "What are the facts? What actually needs accountability? Where did I actually mess up and need to make repair? And then what story am I piling on top of that?" Do not let shame narrate the whole story.
And the second step is really practicing clean accountability—taking ownership over what's actually yours and not anything else. Clean accountability says, "What happened? What is mine to own? What can I repair? What can I learn, and what support or system change is needed?" And shame is going to say, "How could you? How dare you have done this? What's wrong with you? You should have known better. You're not safe unless everyone approves of you again." Just listen to the tone of that. When you hear statements in your mind that begin with the word "you," I want you to really question that, 'cause they're accusations, and they're most likely not true.
Clean accountability leads to repair, and shame leads to hiding, defending, collapsing, over-functioning, over-performing, and burnout. It leads to burnout—that's the bottom line there. The third step is to build some tolerance for receiving disapproval, starting to care a little bit less about what people think.
This is really important and huge for approval-seeking doctors. If approval has felt like safety, then disapproval can feel like death, honestly. It can feel like you're about to be annihilated. And so a patient being unhappy, or a colleague misunderstanding you, or a family member being disappointed, an administrator pushing back, a consultant being irritated with you—these can feel far bigger than what they actually need to feel.
So our work there is not to become indifferent. It's to develop the capacity to say, "Someone can be displeased with me, and I can still stay connected to myself." The healthy adult is going to say, "Disapproval is uncomfortable, but it is not danger, it's not death, and I can consider feedback without surrendering my worth.
I can be misunderstood and still feel okay. I can still be grounded. I can disappoint someone and still be a good person, and not everyone has to approve of me for me to be okay." The fourth step is practicing understanding our internal worth, and it sounds, I don't know, it sounds kind of basic, but for doctors it often feels almost impossible, because many of us have spent decades practicing external worth, or earning worth through our actions—through grades, through our scores, through match results, productivity, patient approval, being helpful, being impressive, not needing much, being a team player, doing strong work.
Healing means learning to say, "My work matters, but it is not my worth. My worth is inherent and cannot be taken away. Feedback matters, but it is not my identity. Achievement is meaningful, but it is not what makes me lovable. I can be a growing, imperfect human and still belong." This is the work of healing shame and approval-seeking.
Not becoming careless or arrogant or indifferent, but becoming less dependent on external approval to know that we are okay. Because we're not better doctors when shame is running the show. We actually become more defended, more exhausted, more frightened, and, again, more burned out. And we actually become less honest, because shame makes truth feel dangerous.
So the goal is not to stop caring—it's to stop making everyone else's approval the place where our worth lives. And we have a little case example here. Imagine a physician gets a patient complaint. I know, I know—none of you guys have ever had this happen to you. For those of you who have, patient complaint.
The event: a patient was unhappy and submitted a complaint. The schema, or the story, might be defectiveness or shame. It says, "You failed. You are a bad doctor. They're gonna find out you are not as good as they thought." And that schema may also be approval-seeking, saying, "You're not okay until everyone is okay with you again."
And it might create a coping style like surrender, where you collapse into the shame and believe the complaint is a global verdict on your worth. Or you might avoid it and refuse to look at it, push it away, or numb out because it feels too threatening. Or you might overcompensate, become defensive, over-explain.
Over-explaining is a big one for me—obsessively reviewing the chart or needing to prove that you did nothing wrong. And a healthy adult response sounds different. It sounds like, "This feels painful and threatening because it touches an old shame template. I can review the facts. I can own what is mine. I can repair what needs repair.
I can learn what needs learning, and I do not have to turn this into making me worthless or a bad doctor." That's the difference between shame—and I'm gonna argue we have way too much shame going on—and clean accountability. Shame says hide or defend, and the healthy adult says, "Okay, I can stay present, I can tell the truth, and I can still remain on my own side."
So this week, we want you to notice where this defectiveness, shame, or approval-seeking may be showing up for you. Where do you feel like one mistake means something global about you? Where do you need approval before you can feel okay? Where are you turning feedback into a verdict? Or where are you practicing worthiness through achievement?
And where might your healthy adult say, "My work matters, but it is not my worth"? And as we close this series, remember: the goal is not to become schema-free. The goal is to notice when an old pattern has taken the wheel and to say, "Oh yeah, this is my unrelenting standards coming up. Oh yeah, here's where I'm self-sacrificing beyond measure.
This is my emotional inhibition. Welcome back. This is my shame." And then to ask, "What does my wise adult know now that my younger self did not know then?" Because remember, schemas were adaptations. At the time we learned them, they were helping us survive, and it probably got us where we are today. It definitely helped us become a doctor.
We've already established that. But it also helped you excel in all the areas you have so far. But now that you're aware, it doesn't have to be the thing that runs the rest of your life. 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 the button now and leave us a rating and review—five stars, of course.
It helps other physicians find the podcast and moves us up on the list. And if you do leave a review, take a quick screenshot and email it to [email protected], and we will send you a free e-book on emotional regulation, which is actually one of our most requested, impactful topics. And just before we go, we have a weekly newsletter called the Weekly Well Check—bites of encouragement straight to your inbox.
Plus, we include details of our upcoming master classes and all the goodness you definitely want to stay connected with us to find out about. Click the link in the show notes to sign up and get it this week. 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.
Thank you for joining us for the Drive Time Debrief. If this podcast has helped you, be sure to share it with others. Please subscribe and leave us a five-star review so other doctors can find us. If you want to know more about what we do or want to work with us, go to our website at thewholephysician.com and schedule a free 30-minute strategy session.
We'd love to help you create the life you dreamed of before things went awry. It's absolutely possible.
