Amanda: Okay guys. Welcome back to the podcast. I'm Amanda
Laura: I'm Laura
Kendra: and I'm Kendra.
Amanda: And you may be getting in your car after a particularly difficult shift. The whole idea of this podcast is to get you in a better mind frame before you get home. However, you might be folding laundry, you might be doing whatever. But thank you for joining us for this next few minutes to talk about physician wellness. Laura, what are we talking about today?
Laura: So we're continuing our discussion of self-determination theory that we introduced to you last podcast. And just as a reminder, this is a theory that was developed by some psychologists. They had a book that they put out about self-determination theory in 1985. And while we remember from our psychology classes, Skinner and his rats and Pavlov and his dogs, and extrinsic motivation for behavior like reward or punishment, reinforcement.
What we're talking about today is more the intrinsic motivation for behavior. That internal locus of control that we are looking to do things for personal growth and from reasons within us instead of reasons in our environment. So self-determination theory is a theory of human motivation and personality that suggests that people are able to become self-determined when their needs for three primary psychological areas are met. So that's what we're gonna talk about specifically today is these three primary psychological needs in self-determination theory. And they are competence, relatedness and autonomy.
And so competence means that we need to feel like we are effective in dealing with the environment to feel fulfilled. In medicine, we understand what competence means. It means that we are good at our jobs, that we know how to take care of our patients in a safe and sound way, that we are efficient with our resources and can show up as excellent doctors. And for us as physicians, it's very…it's very clear why this is a need for us.
We are all very self-motivated people. We're high achievers. Personal growth is paramount for us. And if we do not feel like the things that we do are reflective of competence, we have existential crises. We struggle. And, this is a thing that we deal with a lot with our clients is understanding our own value as human beings, outside of being doctors.
And if we don't feel like we're doing a great job at work, it can affect our, our sense of personal worth and worthiness. We see it a lot in terms of imposter syndrome, where we've done all the training. We have gotten excellent grades. We have passed our boards, and yet we may still feel like we didn't do that, that we don't belong in the position that we're in. And so, when we are struggling with imposter syndrome, it may be that we are struggling with this competence, this psychological need for competence, where we feel like what we're doing is meaningful and that we're doing it well. When we feel competent, we feel like we can interact effectively with our environment.
And so, we work in the emergency department, sometimes even if we're showing up as the very best doctor that we can be, just by the nature of chaos and the chaos that we experience in the emergency department, in the lives of our patients, in their decision whether to do what we ask them to do or not, in how many ambulances come in that day, or how many codes we have, we may not have this competence need met if, if we feel like too much is coming at us at one time.
So. I think it's probably a minority of shifts where we feel like we have complete mastery over our environment in the emergency department because, just because of the nature of the work. And if tasks are too challenging or if a person receives negative feedback- and unfortunately this is what happens a lot in medicine is that we hear all the negative Press Ganey reports and the negative comments, but we might not get as many positives from our patients. And I think if we get a thank you note from a patient, we wanna like frame it and hang it on the wall because it's such a rare experience. And when we're getting more negative feedback, that's affecting this need for a feeling of competence.
So we can see that in the emergency department and in all areas of medicine really, our need for competence is really challenged and kind of attacked. So. We have to find ways to help ourselves feel competence, regardless of whether we have true mastery over the environment, which in the ED is becoming less and less likely to happen. Our administration is not going to be giving us a bajillion warm fuzzies. We're not gonna be getting fan mail from our patients every day. We have to be able to fill this need ourselves, and we absolutely can do that through thought work.
Amanda: Yeah. I, actually this is a very common topic, I think, that comes up for our physician clients. And a lot of it stems from this bad, maladaptive tendency that has been ingrained and reinforced and reinforced and reinforced in medical school of perfectionism. There is this idea that somehow I was supposed to make every correct diagnosis, never miss a finding on a chest X-ray, all of this sort of stuff. And we're judging ourself against this imaginary perfect person, which will lead you to feel incompetent because this person does not exist. And so that is very powerful for thought work and speaking to a peer like us. Like, no, do you see that there is no one on the planet that would've picked up that diagnosis. That diagnosis was unknowable at that moment.
Let's reframe this. There is like, let's look objectively at your training and the whole sum of your body of work. You are very competent. In fact, most people with imposter syndromes actually are in the higher portion of their class statistically, but you're just not framing it correctly. So thought work is huge for competence.
And, and then I do love this idea of like, if you're looking for external validation for the things that you're doing, that may not be there, people.
Laura: No, no.
Amanda: But tapping back into why you went into this in the first place is, “Oh yeah, I, this really isn't about anybody else. This is because this is my purpose. And, and I AM helping people.” There is objective evidence that you're helping people. So that's my 2 cents.
Kendra: The second one, the other psychological need, is relatedness and this idea that we long to have these kind of close affectionate relationships. It's an ability to feel a sense of attachment or belonging, whether it's in a group of people or in just a one-on-one relationship. There's something about just kind of going through it together.
It's very applicable in the ED. That connection that you have with your team. There's probably no other place in the hospital where you go through, or see, or take care of some horrific trauma. You do it together. And then you start to just have each other's backs, I guess, when you take care of some kind of bad trauma and then, whatever your hospital has implemented, some kind of debrief or anything. But anyways, I know for me, we'll come out of the room and of course there's still 500 patients for you to see, and you've gotta move on. But I would take the opportunity just to, before everyone disbanded from the room, ask for any other ideas or also just be like, “great job team.” Just to even more hit on the point that it was teamwork, that we just went through this and great job, and we're in this together kind of thing. That feeling of relatedness is enhanced when your team is respected and cared for. And as the team leader, as the physician in the room, you are that person that really can make an impact on the rest of your team when you call them out and say, “Great job team. We did everything we could do.” Or, “Great job team. Intense, but you all handled it like champions.” “Great job team. We had minimal time and you guys jumped on it and made the most of the seconds to minutes. And now that patient's in the cath lab and doing fine.” Or whatever. Those kind of, building of the teamwork that, that relatedness, that inclusion, that everyone's a part of this team and everyone matters. And everything that everyone did just now matters.
And really, I don't think is any more implicit than in the emergency department, cuz even my husband's a surgeon. And he has his teams in the OR, but I would argue that it's a different kind of team that sometimes everybody knows their role. You go and do your job, and it's sometimes a little monotonous or just automatic. And our teams in the ED, man, we have to be ready for anything at any time.
And so, it really calls on these people to just show up and at any time, during any code or trauma or anything, we have to pivot. And just knowing that you have their backs and you're constantly referring to it as the team.
Because as you know, I mean, just as much as we wanna take credit for all the patients that do well, we just can't. Because at any given time we could do all the right things, give all the right medicines, and act quickly, and the outcome of the patient is not what we expect at all. And so we can't take credit for those either. Even though those sometimes hit the team just as hard, but really having that need for relatedness for feeling a part of a group or feeling a part of a team. And both the successes and failures is definitely a part of this.
It can also be on the flip side. Sometimes can be undermined if there is competition within groups or inability for cooperation between groups. So you get some cliques when you're in school. And even in the hospital, you feel there's a little bit of competition between specialties that can really undermine that and create kind of a negative outcome from that feeling of relatedness. And there's almost a competition in receiving negative feedback or criticism. Then you start having that we versus them mentality, and that really fires up, especially in the emergency department. Cuz I know there was many, many times when the attitude was us versus them. And it's the emergency department versus ICU or ER versus OR. And it's the cliques that can form. And us in the ER is like, “Well, they don't know what it's like down here. They don't know we just had six ambulances, and we're doing the best we can. And so what if we missed the protonix given before they hit the floor,” or whatever. Something got missed or didn't get given until the floor or whatever. And so the floor's like, “well, the ER, didn't do anything.” And you know, you start to, then you start to kind of band together as like this, The Outsiders, and you've got gangs now, and they're us versus them.
So it can, it can create a little bit of undermining of this relatedness, but, all in all, the positive side, or the need for those close affectionate relationships where you do feel a part of something for the good, is definitely one of those things that helps us as the team leader's ability to manage ourselves and our team.
Laura: Yeah. So I'd say, if you're feeling burned out or you're feeling dissatisfaction in your work, it, this may be one of the things that needs attention. And we, this is absolutely in our control to be able to cultivate this relatedness with the people that we work with. And it can improve our own satisfaction when we reach out and connect with our coworkers.
Amanda: Yeah. And the ER is a natural place for teams. However, I've seen it disintegrate too, when it became doctors versus nurses, and nurses versus techs, and all of that sort of stuff, too. It is a completely different feeling from when we were all working together. Alternatively, I've seen beautiful cases of like, the cath lab team celebrating together, and the OR team celebrating together. Even, like in a clinic, it would be very easy to establish a group mentality.
And it kind of goes back to our podcast on the Roseto Effect. There is just something that's vitally important about social connection and interconnectedness. That may be one of the very most important things on the planet. I don't know.
Laura: Absolutely it is. There's no question.
Amanda: Yes. So that takes us into the third psychological need, which is autonomy, the need to feel self-governing and independent. So we need to be able to feel like we're in control of our own behavior and destiny. It involves self initiation and self-regulation of our own behavior and being able to make our own decisions and feeling independent. It's enhanced whenever we are given a choice, and able to govern our own behavior, and when others acknowledge our feelings,
I, this was huge for me as a parent to, I don't know what even book it was, but give your kids two choices that you're equally fine with. And that takes all of the pressure, cuz at least they get to choose it. Instead of, “you need to do this right now,” giving them two options, both of which are totally fine. You can go brush your teeth or you can finish your homework. You know what I mean? Two choices that are fine, lets that child have that feeling of autonomy, and it's a game changer, for parenting at least. And well, and just interactions with humans in general. Nobody loves to get a finger wagged in their face and, “you need to do this right now.” Nobody does. When an individual lacks autonomy, they feel controlled and threatened, and that puts you in a different mind frame. That puts you in a defensive mind frame, as opposed to your best self.
The most interesting thing about this article is that tangible rewards can actually reduce your feelings of autonomy. If you're only doing things to get the gold star, if you're only doing things to check the box, then we are taking away from your own individual autonomy, your own intrinsic reward. And in the end, it is less satisfying than when you're doing things for the pure reason that you want to. And as that's repeated, it becomes increasingly controlled. Your intrinsic motivation is diminished, and then people start to feel both a different source for their motivation and less belief in their own personal qualities.
And I will say the perfect example of this. At one point in my career, I felt so incredibly stuck. I felt like I was at the affect of whatever administration had made a decision about. I felt like I had done this ER residency, and there was absolutely nothing else I could do. I had kids, so I couldn't go back and do another residency. I was married, so I couldn't just up and move, with an employed spouse who liked their job. So I just, there were so many things that I was telling myself that I was stuck, and feeling at the affect of everything was miserable, and it was all untrue.
It was all this story I had created in myself. But this is so important, you guys. You don't have to go to work. You don't have to stay married. You don't have to even raise your own children. There are plenty of people in the world that say, “Peace out. Deuces.” And walk away. The fact of the matter is you, on some level, would like to go to work. You don't want to abandon your coworkers. It is a very reliable paycheck. You like your kids, actually, if you really get down to it. Maybe you don't, but, but you know what I mean? There's a very good reason why you are parenting, staying married if you want to, going to this job that you want to.
Unless somebody is handcuffing you, and chaining you, and dragging you in somewhere, you are getting in your car on your own and going in there. It is a choice. Why haven't you quit? There are good reasons why you haven't quit so far. But just even reframing it that “I don't have to do anything. It just makes the most sense right now that I actually show up for my shift that I'm scheduled for.”
Okay! It's fine, but stop telling yourself that you have to do this. This is still a choice always. And so even, even just a simple mind shift, like that, gave me a lot of the autonomy feeling that I was needing when I was telling myself that I was so stuck. There were things that I couldn't change, but there was so much I could, and I just had shut my mind off to that because I was so stuck in the story of how stuck I was.
Laura: Yeah, just changing that one word I HAVE to go to work to I GET to go to work. It sounds so corny, but it changes the feeling that you have, and it can be a complete game changer.
Amanda: Yeah. And if “get to” is too wildly optimistic for you right now, I'm “choosing to” go to work right now. Like, even that is different than “I have to.” You do not have to. You're gonna be really hard pressed to convince me that you absolutely have to.
Laura: Yeah. No, you literally could pack up a backpack and go live in the woods right now. If you wanted.
Amanda: Yeah. You don't have to pay taxes. You absolutely can go to jail. It’s a choice! Totally fine. Up to you.
Kendra: Well, and I think another thing too, like feeling. I felt the same stuck too, Amanda, at some point. But I think one of the things that kept, maybe me going? I don't know, looking back, I still had a choice. But that- when I was talking about that relatedness- at some point I felt like, almost like I would be abandoning our group. We had such a strong, amazing group of colleagues. We had some BAFERDS in our group. And so, you just have camaraderie, cuz you're kind of going through this drudgery together. You feel that camaraderie, and you feel like, “I can't quit because I'll be walking out all these amazing docs. And that's why I come to work is because I get to work alongside of these awesome people.’
And so, for a time, that- even when I realized it was a choice and I wasn't stuck- I still felt that pull. Like “I can't.” It took me a long time finally to hand my resignation because I was like,”oh, I just don't wanna, you know. I love these colleagues. I love my coworkers. This is such a strong group. It made me feel so fulfilled to work alongside our group.” And that was not enough.
Amanda: So there, there may be some people that don’t know what BAFERDS is. It's B A F E R D S. It's Bad Blank Blanking ER Docs. Just, so, if you wanna know how we speak to each other.
Kendra: So, yeah, so this self determination theory and figuring out what makes you tick, how to manage yourself, how to make confident choices, to think on your own, to really become truly self fulfilled. These last two podcasts, I think, has been an amazing awakening and awareness in what drives us, why we do the things we do, why we feel the things we do, why we make the choices. But just hoping to be able to shine a little bit of awareness on, kind of, why we think the way we do and why we've made the choices that we've made. But hopefully, you're equipped now with a little bit of awareness and a little bit of a push to move forward in the right direction.
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