Kendra: Hi, welcome back to the show. We're gonna have a great episode in store for ya. We're going to be talking about thoughts, circumstances, and what we can do about it as physicians.
Laura: So one of the things we really wanted to touch on at the beginning of our podcast series is the concept of metacognition. And you may or may not be familiar with metacognition. It is a term coined by a developmental psychologist named John H. Flavell. I think that's how you pronounce his name. In 1979. And it, in his words, it’s cognition about cognitive phenomena. So the prefix meta- comes from the root, beyond or above. Metacognition happens anytime we have awareness about our learning, thinking and other cognitive processes. But on a deeper level, metacognition involves meta-awareness, truly detaching from the mind to get the bird's eye view from above. So it's so interesting to think about our thoughts.
Amanda:I feel like it's such a fascinating idea that we are not our thoughts. We are not our brain. You are the watcher of those thoughts and just getting in the practice of that is what can make a huge difference in physician wellness. One thing that blew my mind when I first into- started down the path of coaching and getting coached myself- was that I always thought. The things that were happening outside of me were what made me angry or what made me sad or scared or whatever. You know, we're raised like that. Like, you know, don't hurt your brother's feelings as if that’s possible. Don't do that or you might upset somebody. That sort of thing. We're just taught as children that that's a thing, and it's because people don't know any better. I think eventually in this podcast, we'll show you that the circumstances outside of you don't have any, that's not what's giving you the feelings. It's the thoughts about it.
In the show notes, I'm going to include a picture of the brain because it kind of makes sense anatomically. You know, [some lower] animals just have a spinal cord and lower brain that just does action. And that is like 250 million years old (the action part of our brain). The emotional brain is 150 million years old. So then, higher orders of animals would get a feeling [like] scared, you know, fight or flight, that sort of thing, and that would control the rest of the brain and cause action. But we've evolved since then. The cortex of our brain is more like 2-3 million years old. So now when something happens outside of us, weather, or somebody says something or anything like that, it has to travel through the cortex.
The cortex is what talks to our emotional brain. Then when we have the emotion, that's what tells the action part of our brain, what to do. So there is a step between all of the things outside of us and our feeling, and that's our thoughts. And that was just a completely different idea that no one can hurt my feelings. I have to think something about what they did or said. Even the death of somebody, until you find out about it and have a thought about it, you don't have a feeling. It's just kind of a really interesting thing to think about.
Laura: Well, I think, honestly, if it took a while for me to buy into that. It really did. So for me, the first step was even getting outside of my own thoughts because I thought my thoughts, the feelings that I was having in my own thoughts, that was reality. I, you know, I might fight you over it. It was real. And I think that a lot of people have that experience. And unless you, unless we are practicing, getting outside of what we're thinking about and looking at it, in as objective a way as we can, we are kind of at the mercy of our primitive brain in a lot of ways.
Amanda: Well, a hundred percent too. And like, I would argue too, that the process of having the thought is so fast sometimes that you don't really have any sort of recognition, especially when your brain is very good at a habitual thought.
Like you may not take the time to think something and then feel the emotion. You feel it instantaneously. It's just like a well-oiled machine, you know, with just a super highway that you've thought that you've practiced so many times that it, you don't really have that moment of awareness, and that's something that takes so much practice to like, pause, wait a second.
I'm feeling something. So I wonder what it is that I'm thinking that's causing that, you know, feeling in my body.
Laura: Yeah. So, and it's so interesting if you think about all the reasons why it's important to be able to identify that because so much of what we do to ourselves, so much of the suffering we endure in our lives is just because of all these thoughts that we've got going on.
Amanda: Yeah. Well, what I started even before coaching, I started suspecting that there was something going on. We have two partners that were both older, about the same age. Both had similar kind of life stories. Each one of them had a little bit of a tragic death in the family, like many years before, but one was so happy and then the other one was not at all. And I just, I kept, I, I would talk to the scribes and stuff. How does one go down the happy path instead of, cause I felt like I was maybe traveling the not so happy path was like, what is the difference? Cause it's the same job. So how does somebody have such a different experience of the same job when, when it's the same circumstance, but that's the difference there.
There are thoughts that happen that you may not even be aware of, that gives you the feelings that you're experiencing throughout, you know, your experience of life. So I did kind of like have a suspicion there was something going on, but I didn't know what it was called or, you know, any of the things that we know now.
So I, I kind of came up with examples because it's easy to talk about, but it's a lot easier, I think, with examples to take a look at of, of like how this is true. We're scientists, right? So let's, let's prove this.
So one, one thing with this, is your circumstance. It has to be made as neutral as possible.Your circumstances is a fact that everyone agrees upon. So you can't even say my boss is a jerk. Even if you think 99% of people agree with that, the boss would also have to agree with it. So the circumstances are facts, provable facts in the court of law.
So that was a hard thing too, for me. Like, no, for real, you know, this person is [a jerk]. But that's not really a, that's not a fact. That's, that's an opinion. So getting to the actual fact is step one.
So, what we're going to do is practice.
Like what sort of thought might give you this feeling?
A: If your, if your kid got a D on their report card, what sort of thought would it be that would make you feel embarrassed?
L: So it could be any number of things like “I'm responsible for my kids' success.”
A: Yeah. I was kinda thinking like, if a parent was like, this is a reflection of me.
L: Yeah. “If the other parents knew they would totally judge.”
A: Yeah. So same situation, kid, kid gets a D on the report card, but the parent feels worried.
L: So my thought in that circumstance might be, “Is he depressed or has he gotten into drugs or does he have a learning disability that we don't know about? Is he being bullied? What's going on?”
A: Yeah, or I, even, my habitual thing is to catastrophize too. Like this D obviously means that he's going to wind up in a ditch, you know, as an adult, you know. Clearly like to just go way out there. That's my default is to make it a big deal.
And then a third one, so same, same situation. The kid gets a D on the report card. What sort of thought might make a parent feel unaffected? Like it's not that big of a deal. Actually, I just cheated there. Cause I just said, that's the thought, “it’s not that big of a deal.”
L: “Well, he can just stay home and smoke pot with me, I guess.”
A: Well, yeah. And even I've talked with other physicians that were like, I just want you to know, because these are concerns that I always have, like if my kid just isn't nailing it in school, they're like, you don't know. There's so many physicians that didn't nail it in school when they're in seventh grade or eighth grade, or, you know, whatever. I mean, so like that sort of parent that had that experience, isn't so bothered by it, you know, they know that it's still possible to do whatever they want to do.
So more practice. So a spouse doesn't arrive home with an item from the grocery. That was on the grocery list. What sort of thought might you think that would leave you feeling enraged?
L: That's a tough one. Cause I don't know that I, “I asked five times and told him our oldest child's life depended on it. And he forgot,” you know. like, or it could be the thought that “he never, or she never does what I ask her to do. Like they know they don't care about me. Like they just don’t give a rip.”
A: I think that if you thought that them forgetting the item was out of spite or something like that, that would leave you feeling enraged.
Same thing. They didn't get the right item. What would leave you feeling hurt? What sort of thought?
L: That they cared more about their own. You know, junk food snacks, and didn't get the item that, that I wanted. They don't think about me. They think about themselves first and again, like just the, they don't care about me.
Yeah. How about if you felt judgemental?
L: Like, how could you forget that? There was an actual list! Where is your brain? You know what I mean? Like
A: Yeah. Complete doofus. Yeah.
And then what about amazed?
L: I'm amazed, just like amazed. I mean, to me amazed is a positive feeling. So just shocked. Just dumbfounded, even just like tired. Gosh, really? Like how many times do I have to ask for that thing, you know?
A: I was even thinking. “It is truly phenomenal that they seem to be doing just fine in the world and, and can't follow the list.” That's amazing to me, but that one feels way better than the other ones, you know? It’s just the thought, the different thought than the others.
What about dishes are in the sink when you get home from work and you feel dread.
L: You might feel dread if you think that I have to do those dishes and I can't do the things I need to do because I have to do them all and nobody else will do them. And they have to be done right now. Yeah.
A: And like, dishes are the worst
L: or they're disgusting. Or gross.
A: Yeah. Could be caked on funk in there. Who knows?
What if you felt despair? When the dishes weren't done.
L: I think that would again, be related to some expectations I have for the other people involved with the dishes. Like I am like, I'm the only one who does this. Nobody cares. I am so exhausted. I don't, I just can't. I just can't do those dishes because they're gross and somebody else needs to be helping me.
A: I even thought of, like you could come home and be relieved that, oh, this means that they already had their dinner and I don't have to do dinner. You know what I mean? Just interesting. Like, just all depends on where you're going with it.
And then the last one, I was to bring it back to medicine. So this is a personal one that used to get me all the time. Patient comes to the ED for the 20th time with the same abdominal pain. What sort of thought would leave you feeling frustrated?
L: Oh, so many, so many that I’ve long tried to push out of my mind, but really it used to be like, “oh my gosh, How many times are we gonna do this? Like really you have been radiated 1 million times, and we have to do this again.”
A: Right. Why I would get frustrated too, like what do you think I'm going to be able to do here? You know? You've already seen every specialist, like what is going on?
What about a patient comes to the ED for the 20th time with the same abdominal pain and you feel disapproving?
L: Oh, I think a lot of us can relate to that. Is this person, you know, a malingerer? a loser? a drug seeker? You know, whatever name you want to call them in your head. You're judging that person as inappropriate.
A: Where I spent like a huge percentage of my time. I hate that, but I didn't know at the time. “You shouldn't be here; it shouldn't be this way.” Just arguing with reality. Like who am I to say? You know what I mean? But yeah, I got real judgy or disapproving at times. Never outwardly, but definitely inwardly.
And then what about, this was a little bit different, but like a patient comes to the ER for the 20th time with the same abdominal pain, what sort of thought might leave you feeling curious?
L: “I wonder why this person feels like they want to spend their time in the emergency department is what's going on really? Like is somebody abusing them? Is, like maybe they do have an undiagnosed celiac or some other issue that just has been missed, or maybe they're just depressed.”
A: You know, this actually takes me back to residency. I had a lady who came in. She had been undergoing workup for like three years or something and had already seen GI and all of that. And the only thing that struck me as very odd was she's very thin. And, but I was like, what? Again, you know, I was like, what is it that you're wanting me to do? You've already had every test that I have? Actually, I take that back. She had had almost every test that I had, and she was like, yeah. All right, fine. I'll just follow back up with GI. But as she was leaving, she puked, and I was like, I don't know, I don't love how skinny she is. And so I scanned her, she was having intermittent volvulus! Three years of workup! Yeah, so anyway. I mean, stuff happens. Who knows?
L: And you don't want to be the one who blew it off.
A: Yes, stuff's weird sometimes. Or just like you said, like, what is it that I'm missing? You know, that would be a good thought, if you, if you wanted to be in the state of being curious, instead of frustrated or whatever.
And the thing with metacognition, you get to pick whatever, if that feeling is working for you - feeling frustrated or disappointed or angry or whatever. No one's taking that away from you. It's your life, you get to do whatever you want to.
We all think that we want to be happy all the time. That's not true. There's many things in the world that you do not want to be happy about. Just think about that for two seconds. There's lots of things that you want to be angry about, upset about, sad about, especially if it motivates you to do something, but if you are the only one suffering, then it's just such a good practice. That's what we want you to do from this podcast is just start practicing. Like, you know, “I feel really T.O.d right now,” to quote Napoleon dynamite. But when you identify that feeling, the next step to practice is, “Ooh, I wonder what I'm feeling [actually, thinking] to make me feel so T.O.d.”
Laura: Wow. I think, you know, it's really interesting because we think that all these things annoy us. We think that patients annoy us, we think that people around us annoy us, but. You can have a day without being annoyed at all. And it doesn't mean that you have to be empathetic about your abdominal pain patient, either that like we were just talking about that person can still be a malingerer. They can still be a whiner. They can still be them and it doesn't have to affect us at all.
Amanda: Like that was the biggest mind blowing thing is that no longer does anybody have any access to what's in between my ears. Like only I get to let in whatever I want to let in. It just made me feel a lot more powerful because for, for forever, I felt like at the effect of everything, like everything was happening to me. And once I finally learned this, like, oh no, I see that thought and this time I'm going to choose something different because you don't get to bother me again. I don't know. I loved it.
Laura: So yeah, and it's a process learning how to do it. And I mean, we're all, everyone is still in the process of doing it. It's a constant. And that's why we all need coaching forever. But because we can't always, we can't always see it. And that's where if we can't see it, it's where it helps to have somebody help us tease it out.
Amanda : And habits, or those habitual thoughts are so sneaky and so easily available to us that it's, it is definitely, it's just something to start practicing because it can lead to amazing changes in your life.
Laura: Yeah. And even practicing, just observing the thoughts and observing the feelings. I was, I like to, I refer to this little video that is on, I think it's on Zen kids or something. I'll put the link in the show notes, but it's a little video called “Be the Pond’” and it shows a pond and it shows a bunch of fish that are different feelings swimming around. And it tells us to be the pond. We're not the feelings, we're the observers of the feelings where we're just watching it all happen. And when we start practicing doing that, then we can take control of the situation and change all of that.
Amanda: And another, I guess, another point too. The thoughts are not to be resisted. Like it's, it's okay to be aware of them. There's no forbidden thoughts. They're not good or bad. If they're getting you where you want to go, then keep it. If they're not getting you where you need to go, you can allow it to pass. Just like in the pond, you know, with the fish. And then intentionally choose a different one that's a little more helpful for you. But yeah, that's, that was another big thing with like, there is no more judging of yourself. You don't, it's just positive from here on out. We think that being critical of ourself, so like, “I can't believe I'm thinking that thought again. Oh my God.” Once you learn this stuff, then you go on the opposite side, like critical that you're having these critical thoughts. No, it's all fine. It's all good. It's all. It's all good. Awesome. Well, but we'll talk more about that.
Laura: Yeah. It's very, very powerful stuff. So, so interesting. I, in fact, I issued a challenge to my whole family. The other day after one of my family members became extremely annoyed that the TV remote, which couldn't be found, like so annoyed, it was ruining this person's night. I was like, “I’ve got a challenge. Let's choose a day next week where we don't get annoyed about anything all day long.” And they're all like, “how's that even possible?”
Amanda: Good times. Well, I think that hopefully we have kind of highlighted a little bit about awareness and metacognition and kind of the work of, you know, this is the basis of a lot of cognitive behavioral techniques and all of that, that is just so, so helpful, with a lot of the issues that we have as physicians, and that's a place where we can get started. And with that, I guess we'll close out. Anybody have anything else they want to say?
Laura: Nope. Just enjoy observing your thoughts. And write down what you find. Sometimes, if you're just writing down the thoughts, you can unearth a little bit more information and get a little more insight into why you are, where you are.
Amanda: Yeah. I think Jon Kabat Zinn is the mindfulness guy. He says the point is to be aware, on purpose, without judgment. It's just information. You're just gathering data and then we can work with it later, but hopefully you're getting close to home or close to work or wherever you're going or finishing your pile of laundry. But we just are here for you and want to just say, you're a champion, Thank you for all that you do, and we'll talk to you next time.
Laura: Have a great week.