Amanda Dinsmore:
Hey guys, welcome back to the podcast, I'm Amanda.
Laura:
I'm Laura.
Kendra Morrison:
and I'm Kendra.
Amanda Dinsmore:
And just a reminder to be sure to rate and review this podcast so that other doctors like you who are surviving in their careers in medicine can get a little better by finding our podcast. And the rating and review does help the algorithm so that the people who need us can actually find us. Today, Laura is going to introduce a special topic.
Laura:
So we're going to talk today about forgiving ourselves. You know, we try to forgive other people of things that they do wrong, but our ability to forgive ourselves really also is very important to our progress. Sometimes things have happened in our past that we aren't proud of. You know, we can't get through a medical career without making some mistakes and errors. So we may have had something happen or had something embarrassing happen or we may have said something that we regretted. We may have yelled at our kids, something has happened for all of us that is in our past that we're not proud of. So we often carry the remnants of these with us in our subconscious, allowing them to create a negative narrative about who we are that can affect. our lives now and into the future. So it's really important for us to learn how to forgive ourselves. It's crucial to our wellbeing and our ability to progress and become the best version of ourselves, that version that we really want to become. We're bringing this up today because it's a common theme we see among our clients. So we just wanted to address it and equip you with some strategies to make it easier to forgive yourself.
Amanda Dinsmore:
This reminds me of the four agreements, you know, it struck me when he said that I think it's in his section of be impeccable with your word Humans are the only one that punishes themselves thousands of times for a single mistake I'm like I most definitely have done that and so many of our clients and it's also very appropriate with current events when people's mistakes get broadcast across all of social media, all of news outlets. It's like my goodness, I can't even imagine like thank God I grew up in the 90s where there weren't cell phones and all of the dumb things I did in college weren't recorded. But
Laura:
Yeah.
Amanda Dinsmore:
I mean, it can get out of control.
Kendra Morrison:
Yeah, and I think too this is a good follow up to our podcast we did on shame and guilt when we talked about that because this is one of the things that really feeds that shame monster is
Amanda Dinsmore:
Mm-hmm.
Kendra Morrison:
living in unforgiveness. More about living in forgiveness of ourselves in the past mistakes we've made, but also it just leads to judgment for others too and can affect. many of our interpersonal relationships as well. But I think we'll also do a follow-up podcast talking about humiliation and embarrassment. And that's kind of one of the first things that happens is maybe something happens and you're feeling a little embarrassed. And embarrassment's okay, that's kind of light work, but it's when it gets down to that deep-rooted humiliation. And then you kind
Amanda Dinsmore:
Mm-hmm.
Kendra Morrison:
of start making decisions based on that and going forward in your career and you start to make even medical decisions mistakes that are still haunting you in that humiliation realm that's why it is so important that we learn how to forgive ourselves. Research says that not forgiving ourselves is actually one of the things that puts us at the highest risk for depression and of course we all know that the moral injury and feelings of burnout that we have now are just those feelings, but it definitely if left untouched will go into that fulminant depression and that is where you know we're seeing our own colleagues take their own lives at the root of probably something simple that started out as maybe an embarrassment or humiliation. Also not forgiving ourselves is essentially holding on to very negative emotions about ourselves. Once again, if left undealt with can open the door to some major depression and anxiety. And once again, those negative emotions, yes, they're thoughts and feelings in our brains and our bodies, but if left undealt with can manifest in some pretty severe even physiologic changes that manifest in some, you know, even some medical conditions, illnesses not just mental health but also, you know medical illnesses and conditions So when we can't forgive ourselves and acknowledge that we are more than our past errors or mistakes, we can get really stuck in that identity that made those mistakes. So you know, I can think of several times that I absolutely practice or perform in a way on shift if it's a patient case where I've known I've made a mistake before and I am very rigid in the way that I practice today because of that mistake when honestly it could have happened at any time and honestly has never happened since but it affected me so much that it definitely affects my medical decision making. Plus minus for the patient safety but I will tell you, I mean it was something I think of.
The strongest one that I can think back in my training is I was a first year out of residency training and I had a lady come in with a swollen knee. So I'm trying to figure out she's nice grandma walkie talkie 70 something year-old grandma comes in with a swollen knee. So we're trying to of course work down the differential and is this a septic joint? Is this just from her anticoagulation that an arcuminant level ended up being an INR of like six or seven? So is she a spontaneous hemarthrosis? As we're trying to work through some of this, I'm thinking, okay, I'm gonna just try to tap the knee and like get a definitive diagnosis. Well, for some reason, the tap was very, very difficult and I was unable to really get and a significant amount of fluid. And so I thought, okay, her INR is a little high, it's not life-threatening bleeding, we'll just hold the Coumadin and let me give her a dose of antibiotics and we'll send her home and have her fall up with ortho and maybe they can tap it in the office. This wasn't something that I was thinking, it was like anything major. So I go in there and I say, okay, we'll cover for the most likely orgs. And I ask her, what is, do you have any allergies? And she's like, oh, well, one time my mom said way back when I had an allergy to penicillin, that honestly I've never had any obvious reactions that I can remember. And so it was just something my mom said. So I was like, okay. So I wrote for Rocephin IM, she didn't have an IV or anything. So I wrote for Rocephin 1 gram IM. Well, the nurse took it upon herself to put an IV in and decide to give it the Rocephin IV, which. may or may not have been pertinent to the outcome, but anyways, she had a severe anaphylactic reaction to the Rocephin within five or six drops of that medicine going into the IV and she coded and that was we got her back. She went to the ICU, she survived. The outcome was okay, but I to this day ask very specific questions to anyone that's allergic to anything that could possibly cause anaphylaxis like penicillin. to the point where I'll go to great extents not to give that. And it was based on that is where I felt like I made a mistake, not clarifying the allergy and maybe not realizing that, you know, could this have happened with the IM injection versus IV? I mean, there were so many things going through my brain. But until I got to a place where I forgave myself for possibly because my brain wanted to offer up that I caused harm to this patient and knowing that we took an oath to do no harm, That was kind of one of those things where I had to get to a place of forgiving myself. And one of the things I did was write a letter to the family. Like it was enough for me to have to go into that room after we coded and say, I'm admitting your mom and grandma to the ICU because she just had anaphylactic reaction and now she's going to the ICU when two minutes ago we were discharging home with oral antibiotics. So working through some of that, one of the things that helped me forgive myself and heal myself. was writing a letter to the family. I never actually gave it to the family, but it was so good for me to just write it all out, write to them, like, you know, what I experienced as a physician and how that experience has impacted me was one of the ways or the first steps I took to forgiving myself for what I thought was a very grave mistake.
Amanda Dinsmore:
That is so incredible because You know it flags it whenever somebody's allergic to penicillin. I've never once in over 20 years so I've been just sitting there like I have no thoughts whatsoever about it I'm like, I think this is even a fake allergy cross reactivity thing, but now obviously
Laura:
Yeah,
Amanda Dinsmore:
it's
Laura:
well, I mean the research, I would say research would bear out that you did not make a mistake.
Amanda Dinsmore:
You didn't make a mistake.
Laura:
you know,
Amanda Dinsmore:
You couldn't have known.
Kendra Morrison:
Right.
Amanda Dinsmore:
Right.
Kendra Morrison:
But that's how my brain, that's how I initially process.
Amanda Dinsmore:
yeah.
Kendra Morrison:
I was a young doctor, my first year out. This was very, very traumatic for me knowing that like, I ordered this medicine, this lady was walkie talkie, she was here for a swollen knee. I was going to discharge her. I mean, it was just all the thoughts that you naturally just come to mind right away. You take full responsibility because you wrote the order. Like, that's why it processed so much as that mistake because I'm like, Oh, you know what I the allergy said this, you know what, but yeah, looking back, did I make a mistake? Probably not. But that outcome happened regardless. It could have happened really at any time with any med allergy for anybody, you know, it just happened to be her
Laura:
Right.
Kendra Morrison:
and I was just so fresh out that was immediately where my brain went.
Amanda Dinsmore:
Qhat is so particularly devastating-that's what's so particularly devastating about the culture of medicine where we're not allowed to talk to each other. We're supposed to have never made a mistake. And so I never knew that. I've known you for a long time. I never knew that story. But we all have these sorts of stories and we think we're the only ones who have ever Questioned their decisions and it's so crazy. And that's why I love that. We're physician coaches because our clients can--I mean I can just tell you like there's no way that you could have possibly known that I've been ordering Rosephin on people with penicillin and allergies daily
Laura:
Yep.
Amanda Dinsmore:
for 20 whatever years
Kendra Morrison:
Yeah, for sure.
Amanda Dinsmore:
We're but Laura and I are PGY 23's have you ever had one Laura, but you
Laura:
Nope.
Amanda Dinsmore:
see what I'm saying like Like, I'm telling you, you couldn't have known that. But like, we don't, and I've had similar cases too, but anyway, I'm gonna make this podcast way too long if I don't move on. So.
Laura:
Well,let me just I'm gonna make it a little longer right here.
I'm gonna just argue that like sometimes we need the mistakes to make us be the doctors We need to be like I teach
Amanda Dinsmore:
Absolutely.
Laura:
med students They come through and invariably like the they'll give a differential Like a kid comes in with a headache and they're like, oh, you know, he's probably faking, doesn't want to go to school. I mean, like they come in and their first things on the differential are like the things that need to be the last. And I'm like, this, you're here someplace where people, you know, people think they're dying when they're coming here. You assume that they think they're dying or that something really bad is wrong. So the things that are going to kill somebody need to be at the top of your differential. And then you rule them out, but you need to think about them or you will never catch them. And the reason we think about them is because of mistakes that we or other people have made that have changed our brains so that we're like, okay, we got to think about these things.
Amanda Dinsmore:
Well, 100% and Kendra and I work in the same shop and I was way overworking up this person and ended up having to check out the CAT scan or whatever it was but it's like it's my person. It's my person that went south
Laura:
Mm-hmm.
Amanda Dinsmore:
revisiting me. This is why I'm going way over.
Laura:
Yeah.
Amanda Dinsmore:
I'm fully aware that this is out of control, but I'm trying to make the outcome different this time.
Laura:
Yeah, it's so interesting.
Amanda Dinsmore:
But also, just acknowledging that there is no perfection in medicine. Despite what you've been told and despite what the culture says, none of us make it out. And so just being prepared with some of these things, like being able to forgive yourself when you did your best is such an important skill to have. doesn't mean you're not shooting for excellence. I don't want crappy doctors, I just don't. But there is no such thing as a perfect doctor. And so that being your comparison can be super dangerous. A 2021 study from psychology research and behavior management found that tolerance of negative feelings in confrontation with one's behavior. part of the self-forgiveness process. Self-forgiveness requires you to have a cognitive reframing of your own views of yourself. Reflecting and saying that you did the best that you could with what you knew at the time can be incredibly healing and in that particular case I did have to come to the true facts that The girl, the woman, the doctor who was treating that patient at that time couldn't have possibly known the outcome. And to judge her otherwise isn't fair. And now I know better and I'll do better the next time, but me continually judging the person who didn't have the information of the outcome and couldn't have possibly had the information of the outcome. That hurt so badly, that voice in my head that was just incessantly like you failed, you were this person's last chance. Everything rides on you. That's that internal control fallacy that the entire world rests on me and my decisions. But that's what my brain believed, you know? just being able to step away from that and, and revisiting, like if you had the same information that you did at the time, you probably still would choose it because it's the best you knew. And that's how we learn is when stuff goes wrong and the failure is just like you were saying, Laura, Dr. Rick Hanson in his book, Just One Thing addresses this topic by pointing out that we have many sub-personalities in our minds. There's one, the critic, who's always "yammering away looking for something to find fault with," that is one that at least myself and most of my clients are very familiar with this voice. The one is like, "I can't believe you did that. I can't believe that you didn't know that this was gonna happen. I can't believe you are who you are." I can't believe you know all that sort of stuff. Super familiar with that one.
Kendra Morrison:
Yeah, that voice was my voice. It was saying, I can't believe you're in charge of taking care of patients.
Amanda Dinsmore:
Yeah.
Kendra Morrison:
After that happened, I'm like, you are in charge of taking care of patients. Who allowed you to graduate? How did you even get here? Like that was the constant struggle for me. I did kind of go to a dark place there.
Amanda Dinsmore:
But if we can just realize that there is part of our brain that does not like failure, that if they can convince you to step out of the arena and go back into your cave and stay safe, it's just wanting you to be safe. Medicine's
Laura:
Mm-hmm.
Amanda Dinsmore:
scary sometimes. Medicine is a high-risk field, right? And so yeah, of course our brain that wants to be perfect, like this is a no-win situation. Maybe we need to run and hide, you know. That's all it's doing. It comes across so malignant but that's all it's trying to do is to keep you safe. Just knowing that it's not trying to hurt you but the but the delivery is bad. It's real bad. But knowing that there's a critic, but there's also a sub personality in your mind which is the inner protector and that's the one that maybe we should spend some more time cultivating. To forgive ourselves we need the inner protector to stand up and stick up for ourselves. to put past mistakes and misdeeds in perspective. And to tell the inner critic, listen, I see you, I know what you're trying to do, you're a toddler with a knife, but I'm gonna take the knife away. What we need right now is a hug for crying out loud. Something already went wrong. We don't need you to step it up. We need you to step down and just give this poor doctor who just got traumatized a hug, okay? It's just,
Laura:
Yeah.
Amanda Dinsmore:
we have those available, we just tend to rush to the critic rather than the protector.
Laura:
Yeah and that's natural because our brain just wants--it really does just wants us to not do anything risky, just stay in the cave on the couch watching Netflix and eating ice cream--that's the most comfortable safe place but that's not where we find our fulfillment. So we've got to forgive ourselves so we can get back out there and keep taking care of our patients. So how do we do it? How do we forgive ourselves?
I love Dr. Hanson cause he is, he's a positive neuroplasticity researcher. He's always giving awesome tips about how to rewire your brain. So this is how he says how to rewire your brain to forgive itself. He says, start with that feeling of being cared about. Think about somebody who cared about you or cares about you currently and how you feel around them or when they are saying kind things to you. He's suggesting that we're building up this inner protector. Think about how that inner protector may have been influenced by these people in your past who cared about you like my mom. I think about my mom and that I always knew she loved me no matter what. And she was very, she still is very good at giving me unconditional love. So think about whoever you have in your past or present, who loves you, cares about you, how you feel in their presence. So think about those characteristics and those feelings adding to your inner protector.
So while you're feeling that feeling of being cared about, then think about some of your own good qualities. Think about some of the good things about you. You know, you don't have to flatter yourself, but actual facts that everyone would agree about you. Are you hardworking? Are you kind? Are you determined? Ask your inner protector what it knows about you to help you gain some perspective. and kind of override some of what that inner critic is telling you. So these steps help you face whatever mistake you've made. So that's you want to do that to kind of get ready for processing whatever mistake the mistake was. So what he says is if you lied, if you yelled at a child, if you lied at work, let a friend down, or did something else, maybe you were just secretly glad at someone else's downfall. Think about what it was and then all the facts surrounding it and just notice what is actually true about the situation. I yelled at my kid because he didn't get his homework done. And it was the 10th time in the last two months that he got a zero because he didn't turn in his homework. And I yelled at him about it. So think about the things that are hard to face, like maybe the look on your child's face when you were yelling at them, or think about how it felt when you heard about, heard those words, "Hey, remember that patient you saw the other day?" Just think about all the things that were hard to face about it.
And then he says to put them into three piles, moral faults, unskillfulness and everything else. So moral faults, something that you did against your own moral compass, you're going to have guilt and remorse over that. But unskillfulness is just, you know, you didn't have the skills that you needed. And then once you have sorted these and assigned whether you need to have feelings of guilt or remorse over the things that went against your own moral compass, then just take responsibility for them. Like maybe say something like, I'm responsible for this. And let yourself feel it. And then think about what you've already learned from the situation. Think about what you have done to make amends. And think about what else you might like to do to make amends in this situation? If it's the child yelled at the child, have you apologized? Have you asked about their feelings about the situation? Have you given additional positive interactions to help offset the negative? And then check in with your inner protector. Is there any, the inner protector, not the critic. inner protector, is there anything else that I need to do to make this right? And then just acknowledge that you've learned something from the situation and actively forgive yourself. And that may come from you actually saying, I forgive myself for yelling at Johnny this morning. I've taken responsibility and I've done what I could to make things better. And then ask the inner protector to forgive you if that feels right. And he says, you may have to go through these steps more than one time to get your brain to this, the brain, those neural pathways that, especially if this was something that happened long ago and you've ruminated over it for years and years, you've got a super highway going in there. So it may take time of doing this over and over again to rewire and help your brain realize that you've already forgiven yourself. But the key is Dr. Hanson says when we're rewiring our brain is to tap into the emotions related to what is happening. And so tapping into the emotion of feeling cared about and engaging with that inner protector is what's gonna help rewire our brains and help us forgive ourselves. And I would add ultimately the past is in the past. It only has the control over us that we allow it to have. And if it is not serving us even in the present, it's not going to serve us into the future. So we want to make sure that we can forgive ourselves so that we can move on and be the best version of ourselves we can be. If for no other reason, then to even model it for our kids or the other people we care about. It is not healthy to go around with stuff in our past that we haven't forgiven ourselves of. It's not healthy and we want to be healthy and happy and be our best selves. So we've got to let go of the stuff in the past that we've messed up and just forgive ourselves.
Kendra Morrison:
Yeah, that's a great wrap up of this because I know that was one of the things that helped me move past feeling like I made a mistake because I took complete ownership with it. But not only that, but just allowing myself to say, this isn't the first time and this isn't the last and how I recover and overcome and rebound from this is going to set the stage for the future. And just that acceptance and knowing that, I love how we talk about that more. want to be that high achiever. Every situation that we come in context with that we feel like we make a mistake is something to be learned and so I just learned like what not to do really and really trying to shift to that more adaptive high achiever.
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