Have you ever had a situation where afterward you repeatedly questioned the choice you made at the time? You chewed on it, perseverated on it, kept coming back to it? If you are a clinician, there is an amplifier to this because someone else’s life is also involved – the patient’s. You worry about their health, you worry about whether they or their family may sue you – you worry worry worry. I think most of us have been there to varying degrees. In this episode, we will discuss one strategy to manage these fears: the letter to your future self.
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The letter;
- A tool to approach perseverating worry in the moment is what I call “A letter to my future self”. This comes from one of my clients who shared this idea during a coaching session. It had such a profound impact that I asked her if I could share it and she graciously agreed (thank you!!).
- This client came to coaching with several goals – one of them was to experience less of what she called ‘the afterburn’.
Afterburn;
- Afterburn is this: that day or days after a shift, going down the rabbit hole of… what I should have done, the decision I should have made…ahhh, why didn’t I do X?!? It’s so obvious that was the right choice, and then I really worry about the patient, and on and on.
A little afterburn is probably good;
- Some degree of this is natural, even healthy- to consider how an event played out and what you might do differently in the future and also… being concerned about a patients’ welfare. Afterburn, however, takes this to the next level.
Afterburn can be completely consuming and bleed into the next work day, leading to pre-work dread and ending up in a downward spiral.
The pinnacle can be lonely;
- YOU have high standards. You trained well, and you are trying to do your best. You are doing your best. You are not going to work with the clear intent of doing things poorly and making some really questionable choices. You are going there to rock it and take on the world. You are bringing to bear a skill set unparalleled in the history of humanity.
You are at the pinnacle of knowledge and skill in the entire history of medicine.
Living in the gray;
- Even with all of that expertise, there are moments in the day when you are in the gray- when it’s not clear which way to go. The decision rules, textbooks, and algorithms just don’t spit out the answer. It all comes down to your judgment. You are in the gray.
The tunnel;
- Here is the thing about any moment when you are making a decision and you’re actually “in it” looking forward. It’s like you’re in a tunnel. You see a fairly narrow path forward where one decision clearly follows the next in the straight line. The choice moving forward, RIGHT THEN and THERE, makes sense. The tunnel is the reality of how you make decisions in real time.
The tree;
- When you look back, however, and see all of the possibilities, it’s no longer a tunnel, it’s a branched tree. There are infinite branches where so many different choices could have been made where, “Of course this was the obvious answer or truth all along!”
- When you play back these cases in your mind, during the afterburn or in a public forum like a morbidity and mortality conference, it’s from the perspective of looking back, seeing all those potential tributaries, seeing the tree, not the tunnel. It’s rarely from the perspective of you in the moment.
The blame;
- Another aspect of how this is often approached both from the systemic as well as a personal standpoint is blame. Blame adds such toxicity to this because we also turn it on ourselves. We ask “Who’s to blame for this?” rather than, “What do we learn from this and how do we move forward and be better?” Our inner critic loves to look back at that tree and just stroke its chin and shake its head.
- It doesn’t even have to be a bad outcome, just a retrospective questioning with a side dish of self flagellation. For the clinician who is probably coming from this from the perspective of being a perfectionist, it then leads to the afterburn.
Say hello to afterburn;
- How do we approach the afterburn? The first step is to notice. Take note of what situations are associated with afterburn. What are the patterns for you? Who are the patients? What are the situations that seem to come up in your mind during the afterburn moments? It will not be the same for every person. The only way for you to know is to pay attention to what you keep coming back to when the day has ended. What are your afterburn moments?
Identify when it’s happening in real time and pause;
- In those moments that you have identified as high potential for afterburn, take a pause and, if possible, be fully present when making an important decision. The tumult of the day is a perfect substrate for suboptimal decision making.
When you have entered a critical moment in a potential afterburn situation, pause, be present, and take a moment to reflect on the decision.
Put a stamp on it;
- When you’ve made the decision, put a mental stamp on it, something like “I’m OK with this decision. At this moment, in the tunnel, this makes sense. I’m doing the best that can be done with the information I have right now.”
Letter to my future self;
- As promised, here is the tool my client developed. After noting the afterburn moments, after the pause, after the mental stamp, comes the letter to her future self. She silently says, “Dear future self, I am fine with this decision, right now, at this moment.”
- That’s it. Doing this, she acknowledges the imperfection of what might be happening at this point in time, but also the reality of the tunnel. When she thinks about the case later, she’s able to refer back to her silently spoken letter,
“Dear future self, I am fine with this decision, right now, at this moment.”
It doesn’t always work;
- Does this always work? No. Sometimes you are overtaken by events of the day. No plan or approach is foolproof, or even universally applied to every situation.
- I’ve found “letter to my future self” to be incredibly impactful, not just professionally but personally. Sometimes I use the letter to remind myself that at this moment I’m in the tunnel, this decision makes sense right now. When I look back and feel that tinge of anxiety or regret or blame, I can see the tree as a learning tool rather than confirmation of my ineptitude.
Shownotes by Melissa Orman, MD
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