What You Need is Internal Autonomy
We think we need external autonomy, control of our surroundings and activities (and other people) in order to be happy, but what if awakening internal autonomy is all we need to shift to a more positive mental and emotional state?
I had a recent blog post on autonomy, or rather the lack thereof, that so many physicians experience at work and even at home. It reminds me of a great scene in the movie “Parenthood(1989)” where Steve Martin’s character exclaims “My whole life is HAVE TO!”.
When I first watched the movie, I was a married orthopedic resident with two stepchildren, and that line really resonated with me, in a way that was both affirming and aggravating. But if my whole life is “have to” it’s because I’m letting it be that way.
When the Autonomy blog was posted on KevinMD I attached this quote from Atomic Habits by James Clear, “We don’t rise to our goals. We fall to the level of our systems.”. It was a quote I wanted to put in front of every single medical administrator in the country and jab my finger with it.
But here’s the thing. That quote also applies to our internal systems and our internal autonomy.
Because the truth is that’s where real autonomy and power lie. And always has been.
It’s not out there waiting for an administration or boss or spouse to give them back. Autonomy lives inside you and you can either feel like your whole life is “have to” or that your whole life is “choose to”.
Autonomy ultimately isn’t something you're given. It’s something you make and you take. And it starts by changing your internal systems.
You can choose. We all have parts of our jobs or life that aren’t our favorite, but we do in fact choose to do them, because we don’t choose to do something else.
Quitting the job is an option, leaving the profession is an option, refusing to do certain things is an option. Now when we argue and say, “I can’t quit because of X, Y, Z”. When that happens, realize that there has been a choice not to quit. We chose not to quit because the quitting option doesn’t look so great either.
There has been a choice. You have chosen to do the thing by choosing not to quit.
You get to decide if “you have to” or “you choose to”. When you choose to (or choose not to), that’s where your autonomy lives. Try out this new language with something you “have to” do today and see how it feels.
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More Musings
Recently, I read a post by another physician online about an experience he had decades ago, soon after he first became an attending in the ER. The experience still troubled him significantly.
The anecdote was one of so many in a long career on the front lines of healthcare, where life and death are often part of the daily events, amidst the otherwise mundane and ordinary.
Last week I drove to my favorite trails in Point Defiance Park. The roads seemed oddly empty and quiet, even for “the time between the years” as I’ve heard it called. Perhaps I hadn’t noticed it before, since in medicine it’s always been just another week when most people don’t work, but we always had a full schedule.
The day was overcast, as it so often is during winter in the PNW. The trails seemed unusually quiet and dark as well, with fog surrounding the woods and blanketing the Sound.
I was asked recently to give a talk on leadership at a pre-meeting before the annual conference of the Orthopedic Trauma Association. A friend, also both an orthopedic surgeon and coach, is putting on this half-day symposium. I was, of course, honored to be asked and saw it as a great opportunity to do some networking, gain a new audience, and also get more experience in public speaking.
Summer marked the start of medical school, with July being when clinical rotations commenced in the third year and when the transition to the fourth year occurred. July was when internship began, followed by each new year of residency. Fellowships began later but still in the summer. Each year brought advancement and a new role commenced, finally culminating in graduation to being an attending. An independent practitioner. Free to practice medicine out in the real world. With each advancement, I found myself thinking, “I’m not ready for this. And yet, I can’t imagine what would have prepared me further.” This makes me wonder, did I receive informed consent for medical education and training? Did you?
Doctors have been conditioned since childhood to experience not knowing information as a trigger. Daily messages telling you you're not doing it right bring back memories of implied or overt criticism from school and training. There are steps you can take to minimize this effect.
There have been changes to how residents are taught, with the hours they work. There has traditionally been a lot of pushback to this.
The unhealthy pushback goes like this: “I was trained that way. I’m fine. I survived, they can survive too!”
The healthier pushback also has concerns: “If they work fewer hours, they’ll see less patient care, participate in fewer surgeries, and not see the same evolution of a patient’s condition, following the clinical course from beginning to end. This could hurt their eventual knowledge base and clinical acumen.”
I recently read a story written by a friend and business coach about a time when she volunteered at an event. During the event, she had given away all her food to support others. Now she was hungry and the event was still going on. Instead of being praised (as she had expected) by one of the more senior volunteers, she was told “If you don’t take care of yourself you can become an emergency someone else needs to tend to.”
That’s what has happened to our healthcare system.
It’s become an emergency that someone else has to tend to.
Acceptance means taking stock of the situation and not fighting it. Instead of judging it or having a strong emotional reaction to it, take a deep breath. Stop arguing with yourself or others about how it “should” be. You can easily argue that you’re right about how it should be. But being right won’t really help you. It just keeps you stuck fighting an illusion. How it “should” be is a distraction. It is different from the reality you are actually facing.
What if I told you there was a medicine that would improve your wellbeing, productivity, and creativity while decreasing your risks of heart disease, stroke, and chronic illnesses caused by stress?Because that medicine exists. It’s called vacation. It’s not exactly free, but the money you spend on it is well worth it for your longevity in work and in life.
You already know how to round on patients. Now you need to learn how to round on yourself. Self awareness is critical to your health and effectiveness as a physician. Your physical, emotional and mental health.
One of the biggest lessons I’ve learned about perfectionism is that done is better than perfect. In my medical school and residency, we learned about “The Enemy”, a shortened version of “The enemy of good is better.” This is a well-known aphorism that originated in the 1700s and not in medicine.
Perfectionism seems to help physicians succeed in school and in training. Chasing perfection appears to be the acceptable standard during that time. But after we arrive at our intended destination–medical practice–it can make our life miserable if we continue to adhere to it. Not just work life. All life. It is no way to create a happy life because it adversely affects our relationships, both with ourselves and with others.
World events have me thinking about boundaries. Boundaries are created over time and they often change for a variety of reasons. So too are our human boundaries. Physicians need boundaries as well to function at their best. We can mean the physical boundaries of our skin or the cell’s boundaries of membranes. Or we mean the psychological or social boundaries that we live with, and sometimes without. These boundaries can protect us from burnout and enhance our sense of well-being.
Recently I’ve been sharing some coaching tools that can help doctors experience more of what they want in life and less of what they don’t. But just like in medicine, it’s not enough to memorize facts or steps in a procedure. Practice is necessary to really make progress.
Since I’ve retired from practicing medicine, people ask if I miss surgery. It’s certainly been a big life adjustment. But what I’ve realized is that while I’m no longer doing physical surgery, I now do a kind of thought surgery in my new career as a coach.
Many people who work in healthcare were burned out even before Covid made it so much worse. Guilt and shame arise when we judge ourselves for the things we think and feel. It’s important to differentiate between guilt and shame. Let's delve into the differences, and why they matter in solving burnout and cultivating calm for physicians.
Did you know that the ancient Greeks had the ability to drain lung infections? People got lung infections but there were no antibiotics. Sometimes the infection would get so bad that pus would build up in the lung cavity and drainage was required to save the person’s life.
When a child is born with clubfoot, parents naturally have many concerns. Topping their list is, “Will he/she walk?”. Understandably, they are concerned that the deformity will keep their precious baby from reaching that important and exciting milestone.
Last year I had the opportunity to hear Gabor Mate, MD speak over several days at a conference. He is the epitome of the compassionate witness, the person you’d want sitting in a confessional.
I first learned about the art of triage watching MASH with my parents growing up. I also learned about the critical timing of one-liners. Both followed me into a career in pediatric orthopedic surgery, which I practiced for 21 years.